Cardiovascular Hyperlipidemia HTN Obesity
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| Identify cardiovascular risk factors for hyperlipidemia (Slide #31 & Cecil Page 87 Table 8-1, ATPIII Step3) | Cigarette smoking
Hypertension--BP>140/90 or on medication
Low HDL cholesterol--<40 mg/dL
Family history of premature CHD
CHD in male first degree relative <55 years
CHD in female first degree relative <65 years
Men > 45 years
Women > 55 years
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| Describe epidemiology, of hyperlipidemia. (Slide #3) | CAD risk increased by 5 if cholesterol >209
For every 10mg/dL elevation in cholesterol there is a 10% increase in heart disease
For every 5 mg/dL increase in HDL, heart disease risk decreased by 10%
Fewer than 10% of women with heart disease utilize
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| Describe pathophysiology of hyperlipidemia. (Slide 5, 6, | - Serum elevations of the lower density particles are correlated with cardiovascular disease
LDL lipoprotein is most strongly correlated with INCREASED CV disease
- VLDL -increase cardiovascular risk. Mostly triglyceride
- HDL -elevations are corre
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| Describe clinical findings of hyperlipidemia (Slide 12-16) | - Xanthomas (Tendinous, Tuberous, Eruptive, Planar)
- Opthalmologic (Corneal arcus <40y, lipemia retina,)
- Cardiovascular (Atherosclerosis, Aortic Stenosis-genetic)
- Gastrointestinal (Pancreatitis-elevated triglycerides, cholelithiasis)
- Musculosk
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| *** Describe methods of diagnosing hyperlipidemia | Fasting total cholesterol, triglyceride and lipoprotein assessments are required for diagnosis, page 691 Cecil.
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| Classification of LDL cholesterol (Slide 27) | <100 -Optimal
100-129 -Near or above optimal
130-159 -Boderline high
169-189 -High
>/=190 -Very high
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| Classification of total cholesterol (Slide 27) | <200 -Desirable
200-239 -Boderline high
>/=240 -High
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| Classification of HDL cholesterol (Slide 27) | <40 -Low (associated with increased risk)
>/=60 -High (associated with less risk)
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| *** Construct a treatment plan for different clients with hyperlipidemia (Slide 28) | Risk Assessment
Primary Prevention
Secondary Prevention
LDL-Lowering Therapy
Therapeutic Lifestyle Changes (TLC)
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| Risk Assessment (Slide 29) | All adults age > 20 need fasting lipoprotein profile once every 5 years
Total cholesterol
LDL cholesterol
HDL cholesterol
Triglyceride
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| Pediatric Risk Assessment (Slide 30) | Children and adolescents who have a family history of elevated cholesterol and/or heart disease
Children whose family history is unknown
Children who have risk factors-such as DM, obesity, htn
(Nelson Essential of Pediatrics, 6th ed., pg. 27)
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| Primary Prevention (Slide 40) | Clients without established CHD
- Reduce intake of saturated fat and cholesterol
- Increased physical activity
- Weight control
- Drug therapy in some selected clients
All patients with elevated LDL cholesterol or other form of
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| Secondary Prevention (Slide 42) | - Clients with established CHD or CHD equivalents
- Goal of therapy is < 100 mg/dL with < 70 mg/dL as an option
- Therapeutic lifestyle changes
- Drug therapy
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| LDL Lowering Therapy (Slide 43) | Two modalities of LDL-lowering therapy
TLC--therapeutic lifestyle changes
Drug therapy
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| Update ACC/AHA Guidelines, 2013. NIH 2011 screening recommendations Major changes (Slide 44) | For very high risk -LDL goal of < 70 mg/dL is an option.
For moderately high risk -LDL goal is 130, but < 100 mg/dL is an option
Drug therapy in high risk/moderately high risk -Try to achieve 30-40% reduction in baseline LDL levels
No changes for l
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| Therapeutic Lifestyle Change (TLC) (Slide 45) | Nutrition
Weight reduction
Physical activity
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| Role of nutrition (Slide 45) | Transfatty acids (saturated fats)-reduce/eliminate
Role of omega-3 oils (cold H20 fish/fish oil)-add to diet
Soy protein-add to diet
Plant stanol/sterol margarines (Benecol) –add to diet
Viscous fiber sources (soluble fiber)-add to diet
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| CHD risk equivalents (know these!) (Slide 34) | Other forms of atherosclerotic disease
- peripheral vascular disease
- abdominal aortic aneurysm
- symptomatic carotid artery disease
Diabetes
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| Name major drugs for treating hyperlipidemia | Statins (non-statins are not recommended in most cases)
Bile acid sequestrants
Nicotinic acid
Fibric acid derivatives
Adjunctive agent that acts of brush border of gut (Zetia)
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| High dose Statin (average LDL reduction about 50% or higher) (retrieved from Guidelines prescriber's letter) | - Atorvastatin 80 mg once daily (40 mg if
80 mg not tolerated).
- Rosuvastatin 20 mg to 40 mg once daily.
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| Moderate-dose Statin (average LDL reduction about 30 to <50%): | - Atorvastatin 10 to 20 mg once daily.b
- Fluvastatin 40 mg twice daily or 80 mg
(XL) once daily.
- Lovastatin 40 mg once daily.
- Pitavastatin 2 to 4 mg once daily.b
- Pravastatin 40 to 80 mg once daily.b
- Rosuvastatin 5 to 10 mg once daily.b
- S
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| Low-dose Statin (average LDL reduction <30%): | - Fluvastatin 20 to 40 mg once daily.
- Lovastatin 20 mg once daily.
- Pitavastatin 1 mg once daily.
- Pravastatin 10 to 20 mg once daily.
- Simvastatin 10 mg once daily.
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| Indication for high-dose statin (retrieved from Guidelines prescriber's letter) | - Secondary prevention in adults 75 years of age and younger.
(Level A)
- Primary prevention in adults with LDL 190 mg/dL (5 mmol/L) or
higher. (Level A)
- Primary prevention in adults 40 to 75 years of age with LDL 70 to
189 mg/dL (1.8 to 4.9 mmol/L
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| Indication for moderate-dose statin (retrieved from Guidelines prescriber's letter | - Secondary prevention in adults older than 75 years. (Level A)
- Patients who cannot tolerate a high-dose statin.
- Primary prevention in adults 40 to 75 years of age with LDL 70 to
189 mg/dL (1.8 to 4.9 mmol/L) and an estimated 10-year risk of
ather
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| Indication for Nonstatin | - Triglycerides 500 mg/dL or higher (use omega-3 fatty acids [e.g.,
fish oil], niacin, or fenofibrate).
- Patients who cannot tolerate the recommended statin dose or do not
achieve the expected statin response and are high-risk (i.e., patient
with LDL
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| What to do before initiating nonstatin | - Reinforce statin adherence and lifestyle changes, and check for secondary causes before adding a non statin.
** Do not add gemfibrozil to statin therapy.
**No proof adding a non statin to a statin
further reduces cardiovascular risk.
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| What is the side effect of statins (retrieved from ATP III Guideline) | Myopathy
Increased liver enzymes
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| What is the side effect of bile acid sequestrants (Cholestyramine, Colestipol, Colesevelam) | Gastrointestinal distress
Constipation
Decreased absorption of other drugs
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| What is the side effect of nicotinic acid (Crystalline, Niaspan) | Flushing
Hyperglycemia
Hyperuricemia (gout)
Upper GI distress
Hepatotoxicity
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| Side effect of fibric acids (Gemfibrozil, Fenofibrate, Clofibrate) | Dyspepsia
Gallstones
Myopathy
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| Define Obesity | Excess of adipose tissue
Manifested by body weight in excess of 20% or a BMI of 30 or higher.
Two types: Upper body (apple-shaped-greater risk for DM2, CAD, CVA, early death; lower body (pear-shaped)
In pediatric obesity is equal to or greater than 9
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| Morbidity associated with obesity (Obesity slide 5) | National Health and Nutrition Exam Survey III reports
59.4% of men are overweight
49.9% of women are overweight
Almost 20% of men and 25.1% of women are obese
Incidence of obesity is higher in lower socioeconomic classes
Higher incidence in African A
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| Mortality associated with obesity |
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| Risk factors associated with obesity | Type 2 DM
CAD
CVA
Early deathcd
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| Prevention, treatment and teaching related to obesity |
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| Pneumonic for secondary HTN causes (ABCDE) | Accuracy, aldosteronism, apnea
Bruits, bad kidneys
Catecholamines, Cushing’s, Coarct
Drugs, diet
Endocrine, erythropoeitin
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| Meds that can elevate BP | Oral contraceptives
Cyclosporine
Tricyclic antidepressants
Sympathomimetic decongestants
Appetite suppressants
Corticosteroids
NSAIDs
Erythropoietin
Anabolic steroids / corticosteroids
MAOI
Norepineprine reuptake inhibitors
Stop drugs if can be
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