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102 Cards in this Set
- Front
- Back
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atherosclerotic plaque is a result of what
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causes lipids to accumulate by passing through dysfunctional endothelium at the site of the artery wall
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is instability of plaque related to plaque size
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no - thin capsules that are friable and increase the risk of breaking off
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what is the major vasodialator in the body
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nitric oxide
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what are the three lipid groups
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cholesterol, triglyceride, phospholipids
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what is cholesterol function
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manufacture and repair the cell membrane
used for adrenal and gonadal steriods - base of hormones synthesis of bile acids in liver -why fatty liver is common |
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atherosclerotic plaque is a result of what
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causes lipids to accumulate by passing through dysfunctional endothelium at the site of the artery wall
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how is cholesterol synthesized
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in most tissue, by HMGCoA
major core lipid of LDL and HDL |
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is instability of plaque related to plaque size
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no - thin capsules that are friable and increase the risk of breaking off
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what is the major vasodialator in the body
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nitric oxide
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what is TG function
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used to serve as energy substrates in liver and muscles
excess is stored in adipose tissue central obesity increases visceral fat which is fat around organs - bad!! |
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what are the three lipid groups
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cholesterol, triglyceride, phospholipids
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how is TG synthesized
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small intestines and liver, its a glycerol backbone with three fatty acids
visceral easily gets into bloodstream |
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what is the function of lipoprotiens
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transport cholester and TG from sites of absorption and synthesis to sites of utilization
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what is cholesterol function
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manufacture and repair the cell membrane
used for adrenal and gonadal steriods - base of hormones synthesis of bile acids in liver -why fatty liver is common |
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what is the make up of lipoprotiens
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lipid portion is TG, cholesterol and phospholipids
protien portion - apolipoprotiens - transports cholesterol and TG from sits of absorption to utilization |
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how is cholesterol synthesized
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in most tissue, by HMGCoA
major core lipid of LDL and HDL |
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what is TG function
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used to serve as energy substrates in liver and muscles
excess is stored in adipose tissue central obesity increases visceral fat which is fat around organs - bad!! |
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how is TG synthesized
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small intestines and liver, its a glycerol backbone with three fatty acids
visceral easily gets into bloodstream |
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what is the function of lipoprotiens
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transport cholester and TG from sites of absorption and synthesis to sites of utilization
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what is the make up of lipoprotiens
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lipid portion is TG, cholesterol and phospholipids
protien portion - apolipoprotiens - transports cholesterol and TG from sits of absorption to utilization |
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what are the six classifcations of lipoprotiens
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LDL
HDL VLDL IDL Chylomicrons Lp(a) |
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What are apolipoprotiens
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provide structural stability
act as cofactors to specific enzymes serve as ligands to receptors involved in lipoprotien metabolism |
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what is pattern B LDL
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are small dense LDL, cholesterol carrying particle that is prone to oxidation and endothelial uptake
most atherogenic if present high risk of elevated LDL - usually with DM - why DM is CV risk |
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what is the size difference in LDL
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small dense B LDL can easily invade the arterial wall
large pattern A LDL carry a lot of cholesterol but do not invade the artery wall, the liver disposes the cholesterol |
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Pattern B Particles are likely present with what TG and HDL
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TG 180 - 200 and HDL under 35 or women under 45
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what is Lipoprotien A
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modified LDL partical with an apoprotien attached
this is abnormal thrombosis is encouraged with this |
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what level do you want lipoprotien A under
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20
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why would you check a lipoprotien a level
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strong family history of CV disease, young patient with HL
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what medication lowers lipoprotien A
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Niacin
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what non-lipid causes endothelial dysfunction
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homocystiene
fibrinogen smoking chronic infections |
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what is homocystiene
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independent RF for atherosclerosis
famililal amino acid byproduct promotes atherothrombosis by injuring the endothelium and promotes thrombosis |
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what level should homocystiene be under
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less than 10
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this marker is thought to play a role in the progression of plaque and acute cardiac events
independent RF for atherothrombotic event |
fibrinogen
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this is an inflammatory marker
inflamed plaque are the more vulnerable to rupture strong independent risk factor for CVD |
CRP - HS
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aspirin decreases which markers
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fibrinogen and CRP
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should you given HRT for women who have CV risk factors
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not unless it is as soon as they start menopause, it will increase CRP
will increase thrombus event |
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what are some secondary causes of HL
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DM
nephrotic syndrome hypothyroidism toxins - ETOH, Dioxin Liver disease - cannot metabolize cholesterol Meds - steroids, thiazides, BB |
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what is the lifetime risk of CHD by total cholesterol in men verses women based on age
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lower in women until menopause then will catch up to men.
women have different symptoms: fatigue, neck pain and do not think of cardiac issue |
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what percent of patients have less than 50% occlusion with MI
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50
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why is intravascular US better then angio
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plaque builds up in wall of artery but may not always look narrowed by angio
angio and stress test cannot detect non-obstuctive atherosclerosis |
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what stenosis is the majority of MIs caused by
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under 50%
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what percent of stenosis causes CP or ischemia
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over 70% which 86% of MIs are less than 70% and 64% have under 50% stenosis
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is cholesterol a good predictor of heart disease risk
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no - 80% have same levels as those who never develop CAD
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who to treat for atherosclerosis
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personal history of known MI, DM, HTN or smoker
family history PE - bruit Framingham score 10 yrs over 20% |
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what signs and symptoms are with atherosclerosis
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history of MI CVA or angioplasty
has aortic knob calcification Bruits decreased pedal pulses - PAD retinal changes has intimal thickening or plaque on carotid US |
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what are the atherosclerosis RF
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smoker
HTN HDL under 40 Family History of premature CHD Age Men over 45 and women over 55 |
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what is the 10 year risk of CHD with 0-1 risk factors
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10%
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what is the LDL goal for low risk of 0-1 RF
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160
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what is the 10 year risk for CHD in moderate high risk
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10-20%
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what is the target LDL for moderate risk
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130
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what is the target LDL for moderate high risk
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130
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what is the target LDL for High risk
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100
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what is the target LDL for very high risk
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70
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what are the criteria for metabolic syndrome
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over 3:
waist circ over 102cm TG >150 HDL <50 BP >135/85 glucose >110 |
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what is the prevelence of metabolic syndrome for age and race
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even amoung races, increases with age
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what is xanthomas
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thickened nuckles and cartilage areas meaning increased TG
check Lp (a) |
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what is the goal of cholesterol
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under 200
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what is borderline and high cholesterol
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200 - 239
over 240 |
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what is the goal of TG
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under 150
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what is borderline TG
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150-199
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what strategies lower TG
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lower simple surgars and carbs
increase fiber limit fat avoid alcohol fish oil 1gram BID |
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what is the goal of HDL
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over 60, under 40 is low
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what is optimal LDL
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under 100
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what is the TLC diet
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sat under 7
poly under 10 mono under 20 carbs 50-60 fiber 20-30g protien 15 cholesterol under 200 |
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what lifestyle changes can decrease cholesterol
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BMI <28
smoking cessation plant based fat moderate ETOH use moderate physical activity 30 minutes 5x per week |
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how much omega 3s needed to treat TG
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2-4 grams
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what foots have omega 3s
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olive oil
walnuts canola oil flaxseed |
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what do plant sterols reduce
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LDL by 10-15%
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what are the benefits of dietary fiber
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reduce LDL
glucose control reduce BP |
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what are solube fiber foods
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oatmeal
psyllium |
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what medications are best for elevated LDL and TG - pattern B
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statin
niacin gemfibrozil or fenofibrate omega 3s |
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what factors would you treat with medications LDL for primary prevention
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LDL >150
LDL >140 with 1 - 2 RF LDL >130 >2 RF Any HDL <40 |
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what factors would you treat with medications for secondary prevention - LDL
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LDL >130
Any pattern B LDL HDL <40 |
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How do Bile Acid Resins reduce cholesterol
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LDL 15-30%
HDL increase 3-5% |
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when would you avoid resin medications
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TG >200 because it increases VLDL
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if a patient is on a bile acid sequestrant how would you teach to take the medication
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one hour before or two hours after other medications because it will decrease the absorption of others
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what is the affect of cholesterol absorption blockers and what is an exampl
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Zetia
decreased LDL 18% with monotherapy has no affect on vasculature, does not reduce CV risk |
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what are the benefits of statin medications
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best at lowering LDL 18-60%
increase HDL 5-15% decrease TG 7-30% |
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does statins convert pattern b LDL to pattern a
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no
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what medications convert pattern b LDL to pattern a
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Niacin
Firbrates - Tricor, Triglide, Antara TZDs - which have a lot of SE Metformin Also lifestyle changes and decrease saturated fat |
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which statin medications need to be adjusted based on GFR under 30
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all but lipitor and pravastatin, zocor only on 5mg
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when is the full effect of statins seen
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3-4 weeks
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what are the major SE of statins
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HA, insomnia, muscle pain, myopathy and eleveated LFTs
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this is defined as muscle ache or weakness without CK elevation
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myalgia
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this is defined as muscle symptoms with increased CK
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myopathy
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this is defined as muscle symptoms with marked CK elevation, and creatnine elevation with brown urine and urine myoglobin
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rhabdo
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what factors will increase the risk of myopathy with statin medicatons
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increased age
RI hepatic dysfunction hypothyroidism Diet high in grapefruit polypharmacy |
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which statin has the lowest and highest risk of myopathy
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lowest - lipitor, safe at any doese
highest - zocor and is dose dependent |
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CYP3A4 inhibitors (azoles) are now contraindicated in this statin
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zocor
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how does niacin affect cholesterol
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blocks VLDL synthesis and release of lipoprotien lipase
decrease LDL 15-25% decrease TG 25-35% increase HDL 15-30% Best for Lp(A) |
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what are the major SE of niacin
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flushing, reduced with NSAID, will go away after 2 weeks - use ER tab or start at low dose
abdominal cramping, nausea, diarrhea, dry skin, high glucose, itching |
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what is niacin contraindicated in
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gout, liver dysfunction, DM, high uric acid, PUD
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how do Fibrates lower cholesterol
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reduce TG 25-40%
stimulate lipoprotein lipase which decreases VLDL revert pattern B to pattern A |
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if a patient is on a statin, when would you consider combination therapy
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HDL <35/ 45 in females
TG >150 in primary prevention TG >100 in secondary prevention or DM if pattern B LDL present |
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what combination therapy should be started on pattern B LDL
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statin and niacin/fibrate/or zetia
Niacin alone Fibrate or gemfibrozil add metformin or TZD if DM |
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What is ther EBP treatment for atherosclerosis
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ASA
Plavix for secondary prevention vitamin E strick BP control strict glucose control - metformin aggressive lipid control |
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a 56 year old male presents with no hisotry of atherosclerosis or DM
He is a non smoker FMH of father with MI age 45 BMO 28 BP 128/82 on ACE and HCTZ Lipid panel: TC 196;LDL 133; HDL 42; TG 110. What other questions would you ask What is your plan Is this primary or secondary prevention |
Ask: Dietary habit, ever see a nutritionist
Plan: discuss ways to increase HDL Start lipitor 10mg for goal LDL <100 Primary prevention |
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If a women in her 30s presents with no PMH but has a FMH of mother with MI at 45 years, LDL 132 what is your plan
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lifestyle modification for 3-6 months, hold off on statin as long as child bearing if you can
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47 year old women with PMH of DM taking metformin BID
Last HgA1C 7.2% BP 135/80 on ACE and Diuretic nonsmoker mother died at 54 from MI Does not exercise BMI 33 Lipid panel: TC 189 LDL 118 HDL 38 TF 165 What is your plan and is this primary or secondary prevention |
secondary prevention
Plan: refer to nutrition, encourage exercise and diet weight loss goal HgA1C elevated, may increase metformin which will lower TG start on statin goal LDL <100 |
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76 year old man with PMH of HTN, previous MI, HL
on exam: BMI 25 BP 120/85 HR 50 BMI 28 Labs: LDL 112 HDL 44 TG 160 on lipitor 20 enalapril 10, metoprolol 50mg, ASA 325 what is your plan |
secondary prevention
increase lipitor to 40 check BMP - may be pre-DM increase enalipril goal LDL <70 |
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48 year old male with previous MI, HTN and smoker
PE 144/90 HR 50 BMI 28 Labs: LDL 143 HDL 36 TG 190 fasting glucose 120 what is your plan for this patient meds: lipitor 40 enalipril 10 metoprolol 50 ASA 325 |
rule out metabolic syndrome, get HgA1C - if over 6.5 - DM
start metformin Niacin to lower LDL and TG and increase HDL or double lipitor to 80 Diet and exercise start on amlodipine/lipitor combo or diuretic |
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67 year old women with CHD afib HTN and mother died from MI at 48 years old
PE 122/80 HR 70 BMI 28 murmur Labs: LDL 88 TG 90 HDL 49 INR 2.5 Meds: Warafin 7 Lipitor 40 Lisinopril 40 HCTZ 50 Atenolol 50 what is your plan |
continue regimen,
encourage diet and exercise for HDL >50 LDL <70 |
