Atherosclerosis

Question 1

CAD is? and means?

Answer 1

-Coronary Artery Disease (CAD): Most common cause is atherosclerosis

Question 2

Arteriosclerosis

Answer 2

hardening of arteries (common used term)

Question 3

-Atheromas:

Answer 3

intimal wall plaques that consist of raised lesion with soft, yellow grumous core of lipid covered by firm, white fibrous cap.

Question 4

Hyperlipidemia:

Answer 4

High lipid levels in the blood

Question 5

-LDL cholesterol

Answer 5

Low Density Lipoprotein Bad cholesterol

Question 6

HDL cholesterol

Answer 6

High Density Lipoprotein Good Cholesterol

Question 7

etiology

Answer 7

What causes and origins of disease

Question 8

pathophysiology

Answer 8

disturbance that a disease causes in an organ

Question 9

Etiology of Atheroslcerosis

Answer 9

cholesterol and lipids on intimal wall of the artery

-Endothelial lining altered as a result of inflammation and injury

Question 10

-Pathogenesis of Atheroslcerosis

List the steps

Answer 10

Injury to endothelium
Accumulation of lipoproteins
Monocyte Adhesion to the endothelium
Platelet Adhesion 
Smooth Muscle proliferation 
Lipid Accumulation
Inflamation

Question 11

-C-reactive protein (CRP)

Answer 11

marker of inflammation

Question 12

Where is CRP found?

Answer 12

• Marker is found in patients with CAD

- CRP is found with unstable plaques and oxidation of LDL cholesterol

Question 13

What is the most common heart disease?

Answer 13

-CAD is most common heart disease

Question 14

What age groups are effected by CAD?

When are they diagnosed?

Answer 14

• Mainly effects ages between 40-60
• Men risk increases after 45 years old
• Women risk increases after 55 years old (estrogen may protect), post menopausal

Question 15

What are death rates due to CAD?

Answer 15

25% of population

Question 16

Modifiable Risk Factor associated with development of atherosclerosis (4)

Answer 16

• Hyperlipidemia: Can be treated, life style change
• Hypertension: There are drugs for that
• Cigarette Smoking: Toxins that damage Intima
• Diabetes: Increased Risk

Question 17

Nonmodifiable Risk Factor associated with development of atherosclerosis (4)

Answer 17

• Genetics: Due to several conditions, hypertension, diabetes, pro-inflammatory state
• Age: 40 – 60 is critical threshold
• Gender: possible effect estrogen protects
• Family History

Question 18

Additional Risk Factors associated with development of atherosclerosis (4)

Answer 18

• Inflammation: Increases risk of plaque formation and rupture, a marker for inflammation, CPK is shown to be a risk factor for MI, stroke, PAD and cardiac death
• Hyperhomocystinemia: Homocysteine levels correlate to increased CV disease
• Metabolic Syndrome: central obesity, insulin resistance, HTN, high LDL and low HDL, hypercoagubility, and pro inflammatory state
• Lipoprotein a: altered LDL, associated with CAD and CVD.

Question 19

Identify signs and symptoms of atherosclerosis

in various arteries

Answer 19

• Coronary arteries – angina, shortness of breath, arrhythmias, MI
• Carotid arteries – sudden weakness, paralysis, confusion, trouble speaking, problems breathing, sudden headache
• Peripheral Arteries – numbness, pain, infections
• Renal arteries – fatigue, loss of appetite, nausea, edema, itching

Question 20

Hyperlipidemia

• How does it pertain to atherosclerosis?
• What is a component of risk?
• What causes reduced risk?

Answer 20

Major risk factor for atherosclerosis

LDL is major component associated with increased risk

Higher HDL correlates with reduced risk

Question 21

What can cause a negative affect on lipid levels

3

Answer 21

High dietary intake of cholesterol and saturated fats (egg yolks, animal fats, butter…)

Trans-unsaturated fats produced by hydrogenation of polyunsaturated oils (baked goods, margarine)

Obesity and smoking lower HDL levels

Question 22

What can cause a Positive affect on lipid levels

3

Answer 22

Diets low in cholesterol and/or higher ratios of polyunsaturated fats

Diet high in Omega-3 fatty acids (found in fish oils) appear to be beneficial

Exercise and moderated consumption of ethanol both raise HDL levels

Question 23

Pharmacotherapy for Hyperlipidemia

4

Answer 23

Statins
Fibrates
Bile acid sequestrants
PCSK9 inhibitors

Question 24

What do Statins do??

Answer 24

– HMG CoA reductase inhibitors

Question 25

What do Fibrates do?

Answer 25

– lower triglycerides and raise HDL

Question 26

What do Bile Acid Sequestrants do?

Answer 26

inhibit enterohepatic reuptake of intestinal bile salts which increase fecal loss of LDL cholesterol

Question 27

PCSK9 inhibitors

Answer 27

Proprotein converstase subtilisin kexin 9 inhibitors.

Question 28

According to the 2013 ACC/AHA Cholesterol Guidelines who should be assessed for Cardiovascular Risk?

Answer 28

For patients without atherosclerotic cardiovascular disease: - Assess traditional risk factors (e.g., lipids, blood pressure, diabetes) every four to six years in patients 20 to 79 years of age.2,3 - In patients 40 to 75 years of age not receiving cholesterol-lowering therapy, and with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L),

Question 29

According to the 2013 ACC/AHA Cholesterol Guidelines who should be treated with a Statin?

Answer 29

- Patients with clinical atherosclerotic cardiovascular disease. - Patients with LDL 190 mg/dL (5 mmol/L) or higher. - Patients age 40 to 75 years of age with diabetes (but without clinical atherosclerotic cardiovascular disease) and LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L). - Patients without clinical atherosclerotic cardiovascular disease or diabetes with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L), with an estimated 10-year risk of atherosclerotic cardiovascular disease of 7.5% or higher.

Question 30

What are 5 Key points of Statin therapy

Answer 30

Check ALT (alanine aminotransferase) at baseline. Repeat only if symptoms of hepatotoxicity Document pre-existing muscle pain and monitor for increases in muscle pain Check creatine kinase if symptoms of muscle pain or fatigue. Concern of rhabdomyolysis but it is rare. Check lipid levels at 12 weeks Monitor adherence before making dose adustments

Question 31

What are some limitation to 2013 ACC/AHA Cholesterol Guidelines?

Answer 31

Increased use of statin drugs especially in patients considered at lower risk. Overtreatment? Risk calculator relies heavily on age and sex and not on other factors such as triglyceride levels, family history, CRP Do not address patients younger than 40 or older than 75 No LDL targets for patients to have goals to achieve

Question 32

Who be helped by High-dose Statin (average LDL reduction about 50% or higher): Atorvastatin 80 mg once daily (40 mg if 80 mg not tolerated). Rosuvastatin 20 mg to 40 mg once daily.

Answer 32

Secondary prevention in adults 75 years of age and younger. Primary prevention in adults with LDL 190 mg/dL (5 mmol/L) or higher (VERY HIGH) Primary prevention in adults 40 to 75 years of age with LDL 70 to 189 mg/dL Primary prevention in diabetes patients 40 to 75 years of age with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L)

Question 33

Who be helped by Moderate-dose Statin (average LDL reduction about 30 to 50%)

Answer 33

Secondary prevention in adults older than 75 years. 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 Primary prevention in diabetes patients 40 to 75 years of age, with LDL 70 to 189 mg/dL

Question 34

Who be helped by | Low-dose Statin (average LDL reduction 30%)

Answer 34

For patients who cannot tolerate a high- or moderate-dose statin

Question 35

Who be helped by | Nonstatin

Answer 35

Patients who cannot tolerate the recommended statin dose or do not achieve the expected statin response and are high-risk

Question 36

What are other recommendations about keeping statin levels down?

Answer 36

Reinforce statin adherence and lifestyle changes, and check for secondary causes before adding a nonstatin

Question 37

What should not be added to statin therapy? Why?

Answer 37

Fibrates | -it may cause muscle breakdown

Question 38

Adding a non statin to a statin ?

Answer 38

No proof adding a nonstatin to a statin further reduces cardiovascular risk.

Question 39

What are LDL Ranges?

Answer 39

Optimal Below 100 Near Optimal 100-129 Borderline High 130-159 High 160-189 Very High above 190

Question 40

What are total Cholesterol Ranges

Answer 40

Desirable >200 Borderline High 200-239 High >240

Question 41

What are HDL Ranges

Answer 41

Low below 40 and High above 60