Cardio II - HTN and Cholesterol

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Snooze
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Cardio II - HTN and Cholesterol
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2015-03-12 16:15:13
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HTN and Cholesterol
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  1. HTN is considered as having a BP>__________. Its a major modifiable risk factor for wut 2 things?
    HTN is considered as having a BP>140/90

    Modifiable RF for CV dz and stroke
  2. Primary or essential HTN occurs 90% of the time where theres no identifiable cause. What are 5 causes of 2ndary HTN?
    1. Primary aldosteronism aka hyperald-

    2. Renal parenchymal dz

    3. Pheochromcytoma (tumor of adrenal glands to inc E/NE)

    4. Thyroid or parathyroid dz (hyper, more rare)

    5. Meds (NSAIDs, cyclosporine, sympathomimetics)
  3. Benefits of lowering BP include decreasing risk of what 3 dz?
    • Dec risk of:
    • 1. Stroke
    • 2. MI
    • 3. HF
  4. Wut r 5 lifestyle modifications to help decrease BP (2-20mmHg reduction)? [Be specific]
    Think DASH (Dietary approaches to stop HTN, but think diet, alcohol, sodium intake, habits (phys activity n wt loss)

    1. DASH diet, rich in fruits and veggies, low-fat dairy products, reduction of saturated (and total) fat (FYI 8-14mmHg reduc)

    2. Alcohol intake reduction - 2 drinks/d (men), 1 drink/d (women) [24oz beer (2bottles), 10oz wine (1 glass), 3oz of whiskey (2 shots)] - FYI 2-4mmHg reduc

    3. Na intake - <2.4g/d, better is <1.5g/d [fyi 2-8mmHg reduct]

    4. Phys activity - 30 mins/d (brisk walk) most days of wk [fyi 4-9mmHg reduct]

    5. Wt reduc - maintain BMI<25kg/m2 [fyi 5-20mmHg per 10kg wt loss]
  5. At wut BP should 2 anti-HTN meds be considered?
    BP: SBP>160 or DBP>100
  6. According to JNC8, which pt populations have the following BP goals:
    1. <150/90
    2. <140/90
    3. <130/80
    4. SBP<140
    5. SBP 140-145
    6. 110-129/65-79
    1. <150/90: Gen'l pop >60yo

    2. <140/90: Gen'l pop<60yo, DM, CKD

    3. <130/80: Better for DM and CKD


    4. SBP<140: HF in 55-79yo

    5. SBP 140-145: HF>=80yo

    6. 110-129/65-79: Pregnant with DM
  7. For stage 2 HTN, which is defined as ________, what are the initial 2 drug class recommendation? Wut about add-on choices if 2 drugs arent sufficient?
    Stage 2: SBP>160 or DBP>100

    Recommend: ACE/ARB plus CCB/Thiazide

    Add-on: ACE/ARB plus CCB plus Thiazide
  8. For stage 1 HTN, which is defined as ______________, whats the initial drug recommendation for blacks? What about add-on if 1 drug isnt sufficient?
    Stage 1: SBP>140-159 or DBP>90-99

    Recommend: CCB or Thiazide

    Add-on: CCB plus Thiazide OR add-on ACE/ARB to above
  9. For stage 1 HTN, which is defined as ______________, whats the initial
    drug recommendation for non-blacks, ages<60 and ages>60? What about add-on if 1 drug isnt
    sufficient?
    Stage 1: SBP>140-159 or DBP>90-99

    Recommend:

    Age<60: ACE or ARB, add-on CCB or Thiazide

    Age>60: CCB or thiazide, add-on ACE/ARB
  10. Initial med choice for HTN depends on disease state. Explain the drug choices for:
    1. DM (in blacks and non-blacks)
    2. CKD
    3. Stroke or TIA
    4. Coronary dz
    5. HFrEF
    6. HFpEF
    1. DM (in blacks and non-blacks): ACE or ARB; Blacks use CCB or Thiazide

    2. CKD: ACE or ARB

    3. Stroke or TIA: ACE or ARB

    4. Coronary dz:: BB plus ACE/ARB

    5. HFrEF: ACE/ARB, BB, Ald Antagonist, diuretic


    6. HFpEF: ACE/ARB, BB, diuretic
  11. In terms of s/e, BB have inc'd risk of developing DM compared with what 3 drug classes? Wut r 2 other s/e that warrants caution?
    Inc'd risk of DM of BB over: ACE, ARB, CCB

    Also masks hypoglycemia in DM

    Causes depression
  12. In addition to BB, thiazides also inc risk of developing DM compared to what 3 drug classes? Wut other dz should be used w/caution with use of thiazides?
    Inc'd risk of DM of thiazide over: ACE, ARB, CCB

    May worsen gout d/t inc'd uric acid levels
  13. In add'n to pregnancy CI in ACE/ARB, for Aliskiren, it should be avoided in combination w/what 2 drugs?
    Avoid combo w/ cyclosporine or itraconazole
  14. Although in AA, ___ and _____ drug classes are less effective as monotherapy in white pts, they should still be used if comorbid conditions dictate. However, combination therapy with ______ drug class improves effectiveness.
    • Although in AA, BBs and ACE drug classes are less effective as
    • monotherapy in white pts, they should still be used if comorbid
    • conditions dictate. However, combination therapy with thiazide drug class
    • improves effectiveness.
  15. Although most anti-HTN meds are safe to be continued in pregnancy, if a HTN med must be initiated in the pregnant women, what 2 drugs r recommended?
    Methyldopa

    Hydralazine
  16. Wut r the 5 POSITIVE RF's for dyslipidemia? [HINT: 2 are non-modifiable]
    • Non-mod:
    • 1. Age: Men 45yo & older, women 55yo & older
    • 2. CHD in 1st deg relative: Men 55yo or younger, women 65yo or younger

    • Modifiable:
    • 3. Cigarette smoking
    • 4. HTN (BP>140/90 or taking anti-HTN)
    • 5. HDL<40mg/dl [FYI HDL>60 is main NEG RF]
  17. Wut r the 4 major statin benefit groups according to ACC/AHA cholesterol guidelines?
    1. Individuals w/ASCVD (includes CAD, stroke, PAD)

    2. Individuals w/LDL 190 or greater

    3. Pt w/DM, ages 40-75, LDL 70-189

    4. Pt w/LDL 70-189, 10-yr ASCVD risk of 7.5% or greater
  18. Which patients should have their 10-yr ASCVD risk score recalculated q4-6yrs? (5)
    1. Pt 40-75yo

    2. No clinical ASCVD

    3. No DM

    4. LDL 70-189

    5. No statin therapy
  19. Describe the following statin groups next path to distinguish who receives hi vs mod intensity statins:
    -ASCVD
    ASCVD --> Age 75yo and less: Hi-intensity

    ASCVD --> Age >75yo: Mod-intensity
  20. Describe the following statin groups next path to distinguish who receives hi vs mod intensity statins:
    -LDL 190 or greater
    LDL 190 or greater --> Automatically HIGH intensity
  21. Describe the following statin groups next path to distinguish who receives hi vs mod intensity statins:
    -DM, ages 40-75, LDL 70-189
    DM, ages 40-75, LDL 70-189-->10-yr ASCVD 7.5% or higher: Hi-intensity

    DM, ages 40-75, LDL 70-189-->10-yr ASCVD <7.5%: MOD-intensity
  22. Describe the following statin groups next path to distinguish who receives hi vs mod intensity statins:
    -LDL 70-189, 10-yr ASCVD risk 7.5% or greater
    LDL 70-189, 10-yr ASCVD risk 7.5% or greater --> Ages 40-75yo: Mod-Hi intensity

    LDL 70-189, 10-yr ASCVD risk 7.5% or greater -->Ages <40 or >75: Statin benefit unclear
  23. Wut r the 2 high-intensity statins, which lower LDL>50%?
    1. Atorvastatin 40-80mg

    2. Rosuvastatin 20-40mg
  24. Wut r the 8 moderate-intensity statins, which lower LDL 30-50%?
    1. Fluvastatin 40mg BID

    2. Fluvastatin XL 80mg daily

    3. Pravastatin 40-80mg daily

    4. Lovastatin 40mg

    5. Simvastatin 20-40mg

    6. Atorvastatin 10-20mg

    7. Rosuvastatin 5-10mg

    8. Pitavastatin 2-4mg
  25. The 10-yr ASCVD risk assessment is bassed on the pooled cohort equation, and takes into consideration which 9 factors? [HINT: 3 non-modifiable, 2 factors related to a dz, another 2 factors related to a dz]
    • Non-modifiable:
    • 1. Sex
    • 2. Age
    • 3. Race

    • Chol:
    • 4. TC
    • 5. HDL

    • BP:
    • 6. SBP
    • 7. Taking Anti-HTN meds

    • 8. DM
    • 9. Smoker
  26. A fasting lipid panel is preferred. However, a non-fasting non-HDL>______ may be indicative of genetic hypercholesteremia (warrants further eval). If non-fasting TG>________, a fasting lipid panel is needed.
    • A fasting lipid panel is preferred. However, a non-fasting
    • non-HDL>220mg/dl may be indicative of genetic hypercholesteremia
    • (warrants further eval). If non-fasting TG>500mg/dl, a fasting lipid
    • panel is needed.
  27. Besides pharmacological therapy, dietary changes, and physical exercise, what is another way to manage TG>500mg/dl? Whats the primary goal to reduce this?
    Wt loss (FYI 5-10% wt loss results in 20% reduction in TG)

    Primary goal is to prevent pancreatitis
  28. Wut r 4 drugs/drug classes that could increase LDL?
    1. Glucocorticoids

    2. Amiodarone

    3. Diuretics

    4. Cyclosporine
  29. Wut r 4 dietary influences that could increase LDL?
    1. Saturated fats

    2. Trans fat

    3. Wt gain

    4. Anorexia
  30. Wut r 5 dz states/med conditions that could increase LDL?
    1. Nephrotic syndrome

    2. Biliary obstruction

    3. Hypothyroidism

    4. Obesity

    5. Pregnancy
  31. Wut r 12 drugs/drug classes that could increase TG's?
    1. Glucocorticoids

    2. Thiazide diuretics

    3. Sirolimus

    4. Hormone therapy

    5. Anabolic steroids

    6. Bile acid sequestrants

    7. BBs

    8. PI's

    9. Retinoic acid

    10. Atypical AP's

    11. Raloxifene

    12. Tamoxifen
  32. Wut r 4 dietary influences that could increase TG's?
    1. Very low fat diets

    2. High carb intake (refined)

    3. Excess EtOH

    4. Wt gain
  33. Wut r 7 dz states/med conditions that could increase TG's? [HINT: 4 out of 5 of these that increase LDL also inc TG's]
    1. Nephrotic syndrome

    2. Hypothyroidism

    3. Obesity

    4. Pregnancy

    5. Poorly controlled DM

    6. Chronic renal failure

    7. Lipodystrophies
  34. When selecting a statin, consider the % of LDL reduction needed by the following equation:
    [(Current LDL - goal LDL)/Current LDL] x 100
  35. Statins' MOA include inhibiting enzyme for converting HMG-CoA to _________ which is the.....?
    Statins' MOA include inhibiting enzyme for converting HMG-CoA to mevalonate which is the rate-limiting step in production of cholesterol
  36. The main adverse efx of statin is _______, which requires one to check which labs and when?
    The main adverse efx of statin is myopathy


    Check CK at baseline, and then only if muscle sx's occur (no regular monitoring)
  37. Wut r the 4 absolute CI to using statins?
    1. Active liver dz (unexplained persistent elevations in hepatic transaminases)

    2. Pregnancy

    3. Nursing mothers

    4. Certain meds (DDIs)
  38. Wut 2 drugs/drug classes for cholesterol interact greatly with statins to inc risk of rhabdo/myopathy? Be specific.
    Fibrates (risk gr8er w/gemfibrozil than fenofibrate)

    Niacin (doses greater than 1g/day, although risk is lower than w/fibrates)
  39. Among all of the statins, which 2 statins have a max dose limit with amiodarone? Wut is the dose?
    W/amiodarone:

    Lovastatin daily dose DNE 40mg

    Simvastatin daily dose DNE 20mg
  40. Among all of the statins, which statin has a max dose limit w/amlodipine? Whats the dose?
    W/amlodipine:

    Simvastatin 20mg (same dose restriction w/amiodarone)
  41. Although atorvastatin has a dose limit with use of one of these - boceprevir or telaprevir (whats the dose?), what 2 other statins are CI w/their concomitant use?
    With boceprevir or telaprevir:

    Atorvastatin 40mg (with boceprevir), CI w/telaprevir
  42. Cyclosporine is CI with concomitant use of what 3 statins? What other 3 statins have a dose limit with cyclosporine (and what are their doses)?
    • Cyclosporine CI w/LAS (strong 3A4 inhibitors):
    • 1. Lovastatin
    • 2. Atorvastatin
    • 3. Simvastatin

    • Daily dose limits (think weak and/or super low dose!):
    • 1. Pravastatin 20mg
    • 2. Fluvastatin 20mg
    • 3. Rosuvastatin 5mg
  43. Diltiazem, Verapamil have a similarity of DDI with dronedarone use, in that there are daily dose limits of ____ and _____ in what 2 statins? [HINT: Same 2 drugs in amiodarone but half the dose limit]
    Diltiazem, Verapamil, and dronedarone:

    • Dose limits:
    • 1. Lovastatin 20mg
    • 2. Simvastatin 10mg
  44. When it comes to macrolides (erythromycin, clarithromycin, telithromycin), what are 2 statins that are CI w/concomitant use? What 3 statins can be used with dose restrictions (and w/which macrolide)?
    Macrolides (erythromycin, clarithromycin, telithromycin):

    CI w/: Lovastatin, simvastatin

    • Dose limits:
    • 1. Pravastatin 40mg with clarithromycin
    • 2. Atorvastatin 20mg with clarithromycin
    • 3. Pitavastatin 1mg with erythromycin [FYI only 1 of 2 dose limits with any other drugs]
  45. Grapefruit juice in consumption of >1 quart per day, should be avoided in what 2 statins? Which statin may be used but has a limitation on grapefruit consumption of...?
    Grapefruit juice:

    Avoid in lovastatin and simvastatin

    Can be used in atorvastatin, but DNE >1.2L per day
  46. Azole antifungals (itraconazole, ketoconazole, posaconazole) and voriconazole are CI in which 2 statins?
    • Lovastatin
    • Simvastatin
  47. The SSRI, nefazodone, and all HIV PI's are CI in which 2 statins?
    • Lovastatin
    • Simvastatin
  48. Niacin >1g/day should be avoided in ALL statins except...?
    Atorvastatin
  49. Only 1 statin has a DDI in rifampin, that warrants a daily max dose. Which statin is it, and wuts the dose?
    With Rifampin, daily limit of:

    Pitavastatin 2mg
  50. Only 1 statin requires NO renal dose adjustments in renal impairment. Which 1 is it?
    Atorvastatin
  51. 1 statin requires renal dose-adjustment <60ml/min (eGFR), but is the same dose range throughout renal impairment. What is it, and whats the dose range?
    Pitavastatin 1-2mg MAX

    Fyi pitavastatin max dose in non-renal impairment is 4mg
  52. 1 statin has NOT been studied in eGFR<15ml/min and therefore is the only one not recommended in that population. Which 1 is it? Wuts the dose range recommendation for eGFRs 30-59, and 15-29ml/min?
    Rosuvastatin

    eGFR 30-59: 5-40mg

    eGFR 15-29: 5-10mg
  53. Besides the 3 newest statins, the rest of the 4 statins have proportional dose reductions in renal impairment. Name the statins and their dose range suggestions for the following eGFR: 30-59, 15-29, and <15ml/min.
    In all: Mild impairment remains same, anything <30ml/min is the same as <15ml/min

    • Fluvastatin:
    • 30-59ml/min: 10-80mg
    • 15-29ml/min: 10-40mg
    • <15ml/min: 10-40mg

    • Pravastatin:
    • 30-59ml/min: 20-80mg
    • 15-29ml/min: 10-40mg
    • <15ml/min: 10-40mg

    • Lovastatin:
    • 30-59ml/min: 20-80mg
    • 15-29ml/min: 10-40mg
    • <15ml/min: 10-40mg

    • Simvastatin:
    • 30-59ml/min: 20-80mg
    • 15-29ml/min: 10-20mg
    • <15ml/min: 10-20mg
  54. Bile acid sequestrants (cholestyramine, colestipol, colesevelam) have 2 main adverse efx, which are...?
    • GI distress
    • Constipation
  55. Bile acid sequestrants (cholestyramine, colestipol, colesevelam) can decrease absorption of what 2 drugs/2 drug classes? Therefore, the recommendation is to....?
    • Decreases absorption of:
    • 1. Warfarin
    • 2. Levothyroxine
    • 3. BBs
    • 4. Thiazides

    Recommend to administer drugs 1-2hrs BEFORE BA sequestrants OR 4hrs AFTER BA sequestrants
  56. Bile acid sequestrants are contraindicated in dz's like dysbetalipoproteinemia and raised ____ levels of >_________.
    Bile acid sequestrants are contraindicated in dz's like dysbetalipoproteinemia and raised TG levels of >400mg/dl.
  57. The MOA of niacin for cholesterol is....? Therefore must monitor LFTs at baseline, q6-12wks, and then yearly.
    Niacin:

    Inhibits mobilization of FFA's from peripheral adipose tissue to the liver --> Reduces VLDL synthesis (into LDL and TG)
  58. Which formulations of Niacin is more likely to cause hepatotoxicity? Which formulation is more likely to cause flushing? Give examples.
    Hepatotox: Sustained release (i.e. Slo-Niacin OTC or BID generic Niacin OTC)

    Flushing: Immediate release (i.e. Niacin OTC, or Niacor Rx)
  59. Niacin is CI in what 3 dz states/conditions?
    • Liver dz
    • Severe gout
    • Active peptic ulcer
  60. How can one minimize flushing with use of niacin (4)? Which 2 types of formulation of niacin are less likely to cause flushing?
    Take ASA 325mg or ibu 200mg 30-60mins before niacin, take HS, avoid hot beverages and spicy foods, and avoid hot showers around time of admin.

    Less likely for flushing: ER and SR formulations (ER: Niaspan Rx; SR: Slo-Niacin OTC)
  61. Wut r the 2 main adverse efx of ezetimibe?
    • HA
    • Rash
  62. Omega 3 FA's (Lovaza) is used for....? At what dose?
    Used to tx hyperTG >500mg/dl as adjunct to diet for adults

    Dose: 4g/day in single/2 divided doses

    FYI MOA is unknown.

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