Hyperlipidemia

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Information about Hyperlipidemia
Science-Technology

Published on July 26, 2008

Author: margaret33

Source: authorstream.com

Hyperlipidemia Screening : Hyperlipidemia Screening Margaret Hines RN BSN CCRN Take - Home Information : Take - Home Information Calculate global risk to determine overall strategy for cholesterol mgmt. Emphasize the benefits of (TLC) therapeutic lifestyle changes- diet, exercise and wt. control Use Statins as 1st line drugs to lower LDL-C in those at risk for CHD Determine if new, lower optional goals for LDL-C (<70mg/dl or 100mg/dl) are reasonable in those at high to moderately high risk respectively. Guidelines are only useful if they are used! Our opportunity to save lives and make a difference! : Our opportunity to save lives and make a difference! 93 million adults have LDL-C ≥ 130mg/dl which would make them eligible for lipid lowering drug therapy if they have CHD or a 10 yr risk of CHD of 10-20%. ♥ 64 million Americans (1 in 5) have at least one form of CVD. ♥ Elevated lipid levels are not being aggressively managed, and patient compliance with prescribed therapy is often inadequate. Who should be screened for Hyperlipidemia? : Who should be screened for Hyperlipidemia? Adults ≥ 20 yrs. q 5 yrs. Adolescents, young adults who have a positive family hx of early CVD. Adolescents who have a BMI ≥ 85th percentile. Step 1: Determine Lipid Levels : Step 1: Determine Lipid Levels Complete lipoprotein profile preferred Fasting total cholesterol, LDL, HDL, TG Secondary option Non-fasting only total cholesterol and HDL will be usable. If TC  200 mg/dL or HDL <40 mg/dL , a follow up fasting will be needed to determine LDL-C and appropriate Tx. Step 2: Determine CHD or CHD Risk Equivalents : Step 2: Determine CHD or CHD Risk Equivalents Established CHD ♥ MI ♥ Angina-stable & USA ♥ Revascularization procedures ♥ Myocardial Ischemia- clinically significant CHD equivalents ♥ Peripheral arterial disease ♥ Abdominal aortic aneurysm ♥ Symptomatic carotid artery disease ♥ Diabetes ♥ 10 yr risk ≥ 20% Step 3: Determine Presence of Major Risk Factors (other than LDL) : Step 3: Determine Presence of Major Risk Factors (other than LDL) Smoking • Age (≥ men 45 & women ≥55) • Family Hx of premature CVD ♥ (CHD in male 1st degree relative < 55; female <65) • HTN (BP ≥ 140/90 or on anti-HTN med) •  HDL (< 40mg/dl)* *HDL ≥ 60mg/dl counts as a “negative” risk factor; it’s presence removes one risk factor from the total count. Step 3a : Step 3a Total up Major Risk Factors ♥ 2 or more risk factors – Do a 10 yr. Risk Assessment using the Framingham ♥ 0-1 risk factor – No risk assessment needed unless has CHD/CHD risk equivalent Step 4: If 2 or more Major Risk Factors assess 10 yr. CHD risk using Framingham Table : Step 4: If 2 or more Major Risk Factors assess 10 yr. CHD risk using Framingham Table Framingham predicts the probability of having a CHD event in 10 yrs based on 4 factors: ♥ Age, HDL, Smoking, SBP Determines risk level based on # of points in appropriate group- male or female Low/Optimal = < 10% Intermediate = 10-20% High = > 20% Go to: http://hp2010.nhlbihin.net/atpiii/riskcalc.htm to download free risk calculator for your PDA Step 5: Determine Risk CategoryEstablish LDL goal, Determine if TLC, Rx’s are needed : Step 5: Determine Risk CategoryEstablish LDL goal, Determine if TLC, Rx’s are needed Risk Category LDL-C Goal (mg/dL) LDL-C Level for Initiation of TLC (mg/dL) LDL-C Level for Consideration of Drug Therapy (mg/dL) CHD or CHD Risk Equivalents (10-y risk > 20%) 2 + Risk Factors (10-y risk  20%) 0-1 Risk Factor < 100 < 130 < 160  100  130  160 130 (100-129: drug optional) 10-y risk 10%-20%:  130 10-y risk < 10%:  160  190 (160-189: LDL-C-lowering drug optional) NCEP, Adult Treatment Panel III. JAMA. 2001;285:2486-2497. Step 6: Initiate TLC if LDL is above goal : Step 6: Initiate TLC if LDL is above goal Weight Management  Physical Activity TLC diet ♥ Saturated fats < 7% of calories ♥ Cholesterol < 200mg/day ♥ Fiber (soluable) to 10-25g/day ♥ Plant Stanols/Sterols 2g/day Step 7: Consider adding Rx if LDL exceeds levels shown in Step 5 Table : Step 7: Consider adding Rx if LDL exceeds levels shown in Step 5 Table Consider drug simultaneously with TLC for CHD and CHD equivalents Consider adding drug to TLC after 3 months for other risk factors. Step 8: Identify Metabolic Syndrome & Treat : Step 8: Identify Metabolic Syndrome & Treat Dx: 3 or more of the following: ♥ Waistline ≥ 40” men, 35” for women ♥ BP ≥ 130/85 ♥ TG ≥ 150mg/dl ♥ FBG ≥ 110mg/dl ♥ HDL-C < 40mg/dl for men & < 50mg/dl Step 9: Treat Triglycerides : Step 9: Treat Triglycerides Treat if ≥ 150mg/dl ( 1st reach LDL goal) Intensify weight management & physical activity If TG’s are ≥ 200mg/dl after LDL goal reached, set another goal for non-HDL-C (TC- HDL) 30mg/dl higher than LDL goal. TG treatment (cont’d) : TG treatment (cont’d) IF TG’s 200-499 after LDL goal reached ♥ Add drug to reach non-HDL goal by LDL lowering drug, ♥ Add Niacin or fibrate to further lower VLDL. Elevated Triglycerides : Elevated Triglycerides Management of Very High Triglycerides (500 mg/dL) Goal of therapy: prevent acute pancreatitis Very low fat diets (15% of caloric intake) Triglyceride-lowering drug usually required (fibrate or nicotinic acid) Reduce triglycerides before LDL lowering Clinical Criteria for Hyperlipidemia = lipids : Clinical Criteria for Hyperlipidemia = lipids Total Cholesterol ≥ 200mg/dl HDL < 40mg/dl LDL ≥ either 160mg/dl, 130mg/dl, 100mg/dl or 70mg/dl depending on Risk Factor Category ATP III Lipid and Lipoprotein Classification : ATP III Lipid and Lipoprotein Classification LDL Cholesterol (mg/dL) <100 Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189 High 190 Very high ATP III Lipid and Lipoprotein Classification (continued) : ATP III Lipid and Lipoprotein Classification (continued) Total Cholesterol (mg/dL) <200 Desirable 200–239 Borderline high 240 High Classification of Serum Triglycerides : Classification of Serum Triglycerides Normal <150 mg/dL Borderline high 150–199 mg/dL High 200–499 mg/dL Very high 500 mg/dL Differential Dx: Causes of Primary Hyperlipidemia : Differential Dx: Causes of Primary Hyperlipidemia Familial Hypercholesterolemia (FH) autosomal dominant disorder caused by a mutation in the LDL receptor protein. Present in 1 in 500 people making it very common. Familial Combined Hyperlipidemia (FCHL) autosomal dominant disorder accounts for ½ of familial causes of CAD. Familial Hypertriglyceridemia (FHTG) common autosomal dominant disorder (1% of population). Slide 23: Familial FH manifestations Tubero-eruptive xanthomata Eruptive xanthomata Corneal arcus Differential Dx: Causes of Secondary Dyslipidemia : Differential Dx: Causes of Secondary Dyslipidemia Diabetes = TG, HDL Hypothyroidism =LDL, HDL Obstructive liver disease Chronic renal failure TG Protease Inhibitors = TG Beta Blockers, HCTZ =  HDL Prednisone=TG Tamoxifen = TG Differential Dx: Causes of Increased Triglycerides : Differential Dx: Causes of Increased Triglycerides Excessive ETOH intake Obesity; Carbohydrate Intake Insulin Resistance Hypothryroidism Estrogens, Steroids Differential Dx: Causes of Low HDL-C : Differential Dx: Causes of Low HDL-C Causes associated with insulin resistance Hypertriglyceridemia (reciprocal relationship) Overweight/obesity Physical inactivity Type II diabetes Other causes Cigarette smoking Very high carbohydrate intake (> 60% of calories) Drugs (anabolic steroids, progestational agents) Drug Therapy for Primary Prevention : Drug Therapy for Primary Prevention First Step Initiate LDL-lowering drug therapy (after 3 months of TLC) Usual drug options Statins Bile acid sequestrant,nicotinic acid or Zetia®(cholesterol absorption inhibitor) Continue TLC Return visit in about 6 weeks Drug Therapy for Primary Prevention : Second Step Intensify LDL-lowering therapy (if LDL goal not achieved) Therapeutic options Higher dose of statin Statin + bile acid sequestrant Statin + nicotinic acid Statin + Zetia® Return visit in about 6 weeks Drug Therapy for Primary Prevention Drug Therapy for Primary Prevention (continued) : Third Step If LDL goal not achieved, intensify drug therapy or refer to a lipid specialist Treat other lipid risk factors (if present) High triglycerides (200 mg/dL) Low HDL cholesterol (<40 mg/dL) Monitor response and adherence to therapy Q 4-6 months Drug Therapy for Primary Prevention (continued) Better Living through Chemistry : Better Living through Chemistry Slide 32: Progression of Drug Therapy in Primary Prevention If LDL goal not achieved, intensifyLDL-lowering therapy If LDL goal not achieved, intensify drug therapy or refer to a lipid specialist Monitor response and adherence to therapy Start statin or bile acid sequestrant, or nicotinic acid or Zetia® Consider higher dose of statin or add a bile acid sequestrant or nicotinic acid or Zetia® 6 wks 6 wks Q 4-6 mo If LDL goal achieved, treat other lipid risk factors Initiate LDL-lowering drug therapy Secondary Prevention: Drug Therapyfor CHD and CHD Risk Equivalents : LDL-cholesterol goal: <100 mg/dL Most patients require drug therapy First, achieve LDL-cholesterol goal Second, modify other lipid and non-lipid risk factors Secondary Prevention: Drug Therapyfor CHD and CHD Risk Equivalents What’s New for High-Risk Patients? : What’s New for High-Risk Patients? ATP III LDL-C goal: <100 mg/dL For very high risk: optional goal <70 mg/dL For LDL-C 100 mg/dL, start LDL-lowering drug simultaneously with lifestyle changes For LDL-C <100 mg/dL, LDL-lowering drug is a therapeutic option For high TG/low HDL-C, consider fibrate or nicotinic acid in combination with LDL- lowering drug Three Categories of Risk that Modify LDL-Cholesterol Goals : Risk Category CHD and CHD riskequivalents Multiple (2+) risk factors Zero to one risk factor LDL Goal (mg/dL) <100 <130 <160 Three Categories of Risk that Modify LDL-Cholesterol Goals LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents : LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline LDL Cholesterol: 130 mg/dL Intensive lifestyle therapies Maximal control of other risk factors Consider starting LDL-lowering drugs simultaneously with lifestyle therapies LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents : LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline (or On-Treatment) LDL-C: 100–129 mg/dL Therapeutic Options: LDL-lowering therapy Initiate or intensify lifestyle therapies Initiate or intensify LDL-lowering drugs Treatment of metabolic syndrome Emphasize weight reduction and increased physical activity Drug therapy for other lipid risk factors For high triglycerides/low HDL cholesterol Fibrates or nicotinic acid LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents : LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline LDL-C: <100 mg/dL Further LDL lowering not required Therapeutic Lifestyle Changes (TLC) recommended Consider treatment of other lipid risk factors Elevated triglycerides Low HDL cholesterol Ongoing clinical trials are assessing benefit of further LDL lowering LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk 20% : LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk 20% 10-Year Risk 10–20% LDL-cholesterol goal <130 mg/dL Aim: reduce both short-term and long-term risk Immediate initiation of Therapeutic Lifestyle Changes (TLC) if LDL-C is 130 mg/dL Consider drug therapy if LDL-C is 130 mg/dL after 3 months of lifestyle therapies LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk 20% : LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk 20% 10-Year Risk <10% LDL-cholesterol goal: <130 mg/dL Therapeutic aim: reduce long-term risk Initiate therapeutic lifestyle changes if LDL-C is 130 mg/dL Consider drug therapy if LDL-C is 160 mg/dL after 3 months of lifestyle therapies LDL-Lowering Therapy in Patients With 0–1 Risk Factor : LDL-Lowering Therapy in Patients With 0–1 Risk Factor Most persons have 10-year risk <10% Therapeutic goal: reduce long-term risk LDL-cholesterol goal: <160 mg/dL Initiate therapeutic lifestyle changes if LDL-C is 160 mg/dL If LDL-C is 190 mg/dL after 3 months of lifestyle therapies, consider drug therapy If LDL-C is 160–189 mg/dL after 3 months of lifestyle therapies, drug therapy is optional A Model of Steps in Therapeutic Lifestyle Changes (TLC) : Reinforce reductionin saturated fat andcholesterol Consider addingplant stanols/sterols Increase fiber intake Consider referral toa dietitian Initiate Tx forMetabolicSyndrome Intensify weightmanagement &physical activity Consider referral to a dietitian 6 wks 6 wks Q 4-6 mo Emphasizereduction insaturated fat &cholesterol Encouragemoderate physicalactivity Consider referral toa dietitian A Model of Steps in Therapeutic Lifestyle Changes (TLC) MonitorAdherenceto TLC Visit N Populations that need TLC ♥! : Populations that need TLC ♥! TLC should be encouraged in all populations (adolescents, geriatrics, adults that have exceeded their LDL goal.) Prosper Trial- Pravastatin in Elderly Individuals (70yrs+) at risk of Vascular Disease found significant benefits for statin therapy to prevent death or MI.. Some people thought it would not be worth it to treat the elderly! HIV infected people may have TG due to Protesase Inhibitors. Unfortunately not many trials that include women. Continue to follow guidelines and use good judgement. HMG CoA Reductase Inhibitors (Statins) : HMG CoA Reductase Inhibitors (Statins) Reduce LDL-C by 18–55% & TG 7–30% Raise HDL-C 5–15% Major side effects Myopathy Increased liver enzymes Contraindications Absolute: liver disease, pregnancy Relative: use with certain drugs (CYP450 34A) Nicotinic Acid : Nicotinic Acid Major actions Lowers LDL-C 5–25% Lowers TG 20–50% Raises HDL-C 15–35% Better at decreasing TG than decreasing LDL, good at raising HDL. Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity Contraindications: liver disease, severe gout, PUD Fibric Acids : Fibric Acids Major actions Lower LDL-C 5–20% (with normal TG) May raise LDL-C (with high TG) Lower TG 20–50% Raise HDL-C 10–20% Side effects: dyspepsia, gallstones, myopathy Contraindications: Severe renal or hepatic disease Zetia® (Ezetimibe) : Zetia® (Ezetimibe) Inhibits intestinal absorption of cholesterol Can be used as monotherapy or in combination with a statin to reach LDL goal Reduces LDL by 15-20% Alternative Therapies : Alternative Therapies Garlic- 6 out of 10 studies found garlic to be effective TC24.8mg/dl, LDL 15.3mg/dl & TG38mg/dl Can not be recommended due to low methodological quality of studies. Omega 3 Fatty Acids- 10 studies found TC 11.6%, LDL32.5%, TG11.6%. Not recommended to replace lipid lowering medications. Methodology of studies was weak. Specific Dyslipidemias:Very High LDL Cholesterol (190 mg/dL) (continued) : Specific Dyslipidemias:Very High LDL Cholesterol (190 mg/dL) (continued) Management LDL-lowering drugs Statins (higher doses) Statins + bile acid sequestrants Statins + bile acid sequestrants + nicotinic acid Specific Dyslipidemias: Elevated Triglycerides : Specific Dyslipidemias: Elevated Triglycerides Non-HDL Cholesterol: Secondary Target Primary target of therapy: LDL cholesterol Achieve LDL goal before treating non-HDL cholesterol Therapeutic approaches to elevated non-HDL cholesterol Intensify therapeutic lifestyle changes Intensify LDL-lowering drug therapy Nicotinic acid or fibrate therapy to lower VLDL Interventions to Improve Adherence : Interventions to Improve Adherence Focus on the patient Simplify medication regimens Provide explicit patient instruction and use good counseling techniques to teach the patient how to follow the prescribed treatment Encourage the use of prompts to help patients remember treatment regimens Use systems to reinforce adherence and maintain contact with the patient Interventions to ImproveAdherence (continued) : Interventions to ImproveAdherence (continued) Focus on the patient (continued) Encourage the support of family and friends Reinforce and reward adherence Increase visits for patients unable to achieve treatment goal Increase the convenience and access to care Involve patients in their care through self-monitoring References : References Baron, R.B. (2005). Lipid Abnormalities. In L.M. Tierney, S.J.McPhee, & M.A. Papadakis (Eds.). Current medical diagnosis and treatment 2005 (pp.1202- 1213). New York: Lange Medical Books/McGraw Hill. Berra, K. (2003). Treatment options for patients with the metabolic syndrome. Journal of the American Academy of Nurse Practitioners, 15 (8), 361-368. Brunzell, J., Failor, R. (2006). Diagnosis and treatment of dyslipidemia. Retrieved January 28, 2006 from http://www.medscape.com/view article/521683_print. References : References Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497. Retrieved January 20, 2006 from National Heart, Lung and Blood Institute Web site: http://www.nhlbi.gov/guidelines/cholesterol/index. htm. References : References Grundy, S.M., Cleeman, J.I., Bairey Merz, C.N., Brewer, H.B., Clark, L.T., Hunninghake, D.B., et al. (2004). Implications of recent clinical trials for the national cholesterol education program adult treatment panel III guidelines. Circulation, 110, 227-239. Retrieved January 20, 2006 from http://circ.ahajournals.org/cgi/content/ab stract/110/227 References : References Hagarty, A., Schmidt, C., Bernaix, L., Clement, J.(2004). Adolescent obesity: current trends in identification and management. Journal of the American Academy of Nurse Practitioners, 16 (11), 481- 488. Harmel, A., Berra K., (2003). Impact on the new cholesterol education program guidelines on patient management. Journal of the American Academy of Nurse Practitioners, 15 (8) 350-360. References : References Holcomb, S.(2005). An update on cholesterol guidelines. The Nurse Practitioner, 30 (3), 55-57. Loscalzo, J. (2001). Lipid Disorders: Diagnosis, Management, and Controversy. In Noble, J. (Ed). Primary Care Medicine. (pp.634-651) References : References Lookinland, S., Adler, R., Berry, J.A., Williams, M.(2003). A systematic review of the effectiveness of garlic as an anti-hyperlipidemic agent. Journal of the American Academy of Nurse Practitioners 15 (3) 120. References : References Mason, C.M.(2005). The nurse practitioner’s role in helping patients achieve lipid goals with statin therapy. Journal of the American Academy of Nurse Practitioners 17 (7), 256-262. References : References O’Rlordan, M.(2006). Race and genetics influence the prevalence of protease inhibitor related lipid abnormalities. Retrieved February 2, 2006 from http://www.theheart.org/printArticle. do?primaryKey=633613.

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