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HLD Tx & AHA/ACC Guidelines
Megan Chan, PGY-2 UHCMC 2015
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HMG-CoA reductase inhibitors: “Statins” ↓↓↓ ↑ ↓
Drug Effect on LDL Effect on HDL Effect on TG Mechanism of Action Side Effects HMG-CoA reductase inhibitors: “Statins” ↓↓↓ ↑ ↓ Inhibits rate limiting step of cholesterol precursor formation Hepatotoxicity Rhabdomyolysis (esp in combo with fibrates & niacin) Niacin (Vit B3) ↓↓ ↑↑ Inhibits lipolysis in adipose tissue; Reduces hepatic VLDL synthesis Flushed face (vasodilation, ↓ w/ ASA) Hyperglycemia (↑ insulin resistance) Hyperuricemia Bile acid resins: Cholestyramine Colestipol Colesvelam Slight ↑ Prevents intestinal reabsorption of bile acids; livers uses cholesterol to make more Bad taste GI upset ↓ absorption of fat-soluble vitamins Cholesterol gallstones Cholesterol absorption blockers: Ezetimibe -- Prevents cholesterol absorption in small intestine Rare ↑ LFTs Diarrhea Fibrates: Gemfiborzil Fenofibrate Clofibrate Upregulate LPL gene ↑ TG clearance Myositis Cholesterol gallstones (esp with bile acid resins) Stop statin when LFTs are 3x upper limit of normal
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HMG-CoA reductase inhibitors: “Statins” ↓↓↓ ↑ ↓
Drug Effect on LDL Effect on HDL Effect on TG Mechanism of Action Side Effects HMG-CoA reductase inhibitors: “Statins” ↓↓↓ ↑ ↓ Inhibits rate limiting step of cholesterol precursor formation Hepatotoxicity Rhabdomyolysis (esp in combo with fibrates & niacin) Niacin (Vit B3) ↓↓ ↑↑ Inhibits lipolysis in adipose tissue; Reduces hepatic VLDL synthesis Flushed face (vasodilation, ↓ w/ ASA) Hyperglycemia (↑ insulin resistance) Hyperuricemia Bile acid resins: Cholestyramine Colestipol Colesvelam Slight ↑ Prevents intestinal reabsorption of bile acids; livers uses cholesterol to make more Bad taste GI upset ↓ absorption of fat-soluble vitamins Cholesterol gallstones Cholesterol absorption blockers: Ezetimibe -- Prevents cholesterol absorption in small intestine Rare ↑ LFTs Diarrhea Fibrates: Gemfiborzil Fenofibrate Clofibrate Upregulate LPL gene ↑ TG clearance Myositis Cholesterol gallstones (esp with bile acid resins) Stop statin when LFTs are 3x upper limit of normal Statins are teratogenic
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https://classconnection. s3. amazonaws
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2013 AHA/ACC Prevention Guidelines:
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2013 AHA/ACC Prevention Guidelines:
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2013 AHA/ACC Prevention Guidelines:
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Framingham’s 10 year CV Risk Score
Online Calculator: Calculates patient’s risk of an MI in the next 10 years. Low risk < 10%, Intermediate risk 10-20%, High risk >20% Factors: Age Gender Total Cholesterol HDL Cholesterol Smoker Systolic BP Taking any anti-hypertensive agents
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High-Intensity Statin Moderate-Intensity Statin
Low-Intensity Statin Lowers LDL by ≥ 50% Lowers LDL by 30% to <50% Lowers LDL by <30% Atorvastatin 40-80mg Rosuvastatin 20-40mg Atorvastatin 10-20mg Rosuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lovastatin 40mg Fluvastatin 40mg BID Simvastatin 10mg Prvastatin 10-20mg Lovastatin 20mg
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Statin Interconversion
LDL Reduction Atorvastatin Lovastatin Simvastatin Pravastatin Rosuvastatin 20-30% -- 20mg 10mg 30-40% 40mg 40mg, 80mg 40-45% 80mg 5mg 45-50% 50-55% 55-60%
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2013 AHA/ACC Prevention Guidelines
Follow Up: 2013 AHA/ACC Prevention Guidelines
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Secondary Causes of HLD
High LDL High TG Diet Saturated fats Weight gain Anorexia nervosa Very low fat diets High carb diets Excessive ETOH Drugs Diuretics Glucocorticoids Amiodarone Cyclosporine Oral estrogens, tamoxifen Bile acid sequestrants Protease inhibitors Beta blockers (not carvedilol) Thiazides, Sirolimus Diseases Nephrotic syndrome Biliary obstruction Chronic renal failure Lipodystrophies Disorders of altered states of metabolism Hypothyroidism Obesity Pregnancy Uncontrolled DM Treatment with statins, niacin, & ezetimibe are contraindicated during pregnancy & lactation.
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References First Aid Stone NJ, Robinson JG, Lichtenstein AH, et al ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B): Trevor AJ, Katzung BG, Kruidering-Hall M, et al. Katzung & Trevor’s Pharmacology Examination & Board Review, 10th ed Mc Graw Hill. New York, NY. Wilson PW, D'agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):
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