HTN FINAL EXAM

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jaimee781
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HTN FINAL EXAM
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2011-05-15 22:25:28
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  1. When were the first cholesterol drugs available? What were they?
    • 1960s
    • Bile sequestrans
  2. When did NCEP release it first report?
    1970s
  3. What does NCEP stand for?
    National Cholesterol Education Program
  4. When did NCEP issue its second report?
    1993
  5. When did NCEP issue its third report (Adult Treatment Panel III)?
    2001. Called for more aggressive evaluation and treatment of lipid levels
  6. Effect of hypothyroidism on lipid levels.
    Screening tests
    • INCREASE TC
    • INCREASE TG

    TSH
  7. Effect of DM and Metabolic Syndrome on lipids levels.
    Screening tests
    • INCREASE TC
    • INCREASE TG
    • DECREASE HDL

    HgbA1C, glucose
  8. Effect of obstructive liver disease on lipid levels.
    Screening tests
    Increase TC

    LFT
  9. Effect of CRF on lipid levels.

    Screening tests.
    • Increase TC
    • Increase TG

    Serum creat, GFR, CrCl
  10. Effect of nephrotic syndrome on lipid levels.

    Screening tests
    Increase TC

    UA for increase protein, Serum albumin (decrease)
  11. Effect of cushings disease on lipid levels

    Screening tests
    • Increase TC
    • Increase TG

    24 urine collection for cortisol levels
  12. Effect of pregnancy on lipid levels
    Increase TC (measure 3-4 months postpartum)
  13. Effect of obesity on lipid levels
    • Increase TG
    • Decrease in HDL
  14. Effect of ethanol on lipid levels
    • Increase TG
    • Increase HDL
  15. Effect of sedentary lifestyle on lipid levels
    Decrease in HDL
  16. Effect of illness (eg MI, CVA, sx, trauma, malignancy, infection) on lipid levels
    Decrease TC (by equal to or less than 40%)

    Must be measured within 12h of the event
  17. Factors that can increase TG
    • 1) Not fasting
    • 2) ETOH. Ask to abstain 3 months before testing
    • 3) DM with poor glycemic control
    • 4) High amts of added sugar or fructose
  18. How often do you screen healthy adults for lipids?
    every 5 years
  19. Lipoprotein levels as part of bld test. Must fast 12h for accurate TG levels
  20. Why would you test LFT?
    • 1) Could indicate liver dysfxn
    • 2) Baseline needed for statins, niacin, and fibrates
  21. Why would you test glucose?
    To screen for DM. Can affect LDL goal
  22. Why would you test serum creatinine
    It affects dosing of fibrates
  23. Why would you test uric acid?
    Niacin may increase uric acid levels and gout
  24. RISK FACTORS:
    (There are five)
    • 1) Age (Men > or equal to 45, Women > or equal to 55)
    • 2) Smoking
    • 3) HDL (<40mg/dl). Subtract one RF if HDL is > or equal to 60.
    • 4) HTN or treatment (> or equal to 140/90)
    • 5) Family hx of CHD in first degree relative. MI or sudden cardiac death
  25. CHD
    • 1) MI
    • 2) Angina (stable or unstable)
    • 3) Angioplasty
    • 4) CABG
  26. CHD Risk Equivalent
    • 1) DM
    • 2) PAD
    • 3) AAA
    • 4) Symptomatic carotid disease (e.g TIA)
    • 5) > or equal to 2 RF and a 10year risk for CAD that is >20%
  27. What is categorized as HIGH RISK?
    What is the LDL goal?
    When do you start TLC?
    When do you start drug rx?
    • 1) CHD, CHD risk equivalent, > or equal to 2 RF and a 10 year risk >20%
    • 2) < 100, but optimal < 70
    • 3) > or equal to 100
    • 4) > or equal to 100

    Start rx and TLC at same time
  28. What is categorized as MODERATE HIGH RISK?
    What is the LDL goal?
    When do you start TLC?
    When do you start rx?
    • 1) > or equal to RF and a 10yr risk 10-20%
    • 2) < 130, but optimal <100
    • 3) > or equal to 130
    • 4) > or equal to 130. Consider if 100-129.
  29. What is categorized as MODERATE RISK?
    What is the LDL goal?
    When do you start TLC?
    When do you start rx?
    • 1) > or equal to 2RF and a 10 year risk of <10%
    • 2) <130
    • 3) > or equal to 130
    • 4) > or equal to 160
  30. What is categorized as LOW RISK?
    What is the LDL goal?
    When do you start TLC?
    When do you start rx?
    • 1) 0-1 RF and a 10 year risk of <10%
    • 2) <160
    • 3) > or equal to 160
    • 4) > or equal to 190. Consider if 160-189
  31. When should you consider optimal LDL goals?
    • 1) Multiple RF, esp DM
    • 2) Severe, or poor controlled RF, esp smoking
    • 3) ACS
    • 4) Metabolic syndrome
  32. Criteria for Metabolic Syndrome
    • 1) Waist (Men >40 and women >35)
    • 2) TG > or equal to 150
    • 3) HDL (Men <40 and women <50)
    • 4) BP > or equal to 130/85
    • 5) FBS > or equal to 100
  33. Recommended cholesterol intake and its sources
    • <200mg/day.
    • Animal products
  34. Recommended saturated fat intake and its sources
    • <7% of total calories
    • Coconut, palm, animal fat
  35. Recommended polyunsaturated intake and sources
    • <10% of total calories
    • corn, sunflower, cottonseed oil
  36. Recommended monounsaturated fat intake and sources
    • <20% of total calories
    • Olive, Canola, Peanut oil, Avocados
  37. Recommended total fat intake
    25%-35% of total calories
  38. Recommended protein intake and sources
    • 15% of total calories
    • Lean fat meats
  39. Recommended fiber intake and sources
    • 20-30g/day
    • Grains, legumes, fruits, veggies
  40. Recommended carbs intake and sources
    • 50-60% of total calories
    • Whole grains, pasta, brown rice, oatmeal, beans, peas
  41. Non- dietary TLC
    • Wight management
    • Exercise
    • Stop smoking
  42. Primary focus is to achieve LDL goal unless...
    • TG is > or equal to 500. At risk for pancreatitis
    • Begin Niacin or Fibrate

    • When TG down, goal is to achieve LDL
    • Begin -statin
  43. Cannot calculate LDL when TG is greater than
    400
  44. Dietary ways to decrease TG
    Limited added sugar, fructose, trans fat, ETOH
  45. If TG is still elevated (200-499) after LDL goal is achieved, then set non HDL (eg VLDL) goal 30mg/dl higher. EX: LDL goal <100, then non HDL goal <130
  46. What is your drug of choice when you want to lower your LDL <20%
    Statin, niacin, or BAR
  47. What is your drug of choice when you want to reduce your LDL by > 20%
    Statin
  48. Statins effects on lipids
    Primary: Decrease LDL and increase HDL

    Also: Decreases TG
  49. Niacin effect on lipids
    Primary: Decrease TG

    Also: Decrease LDL and Increase HDL
  50. BAR effect on lipids
    CAUTION: Increase TG

    Also: Decrease LDL and increase HDL
  51. Fibrate effect on lipids
    Primary: Decrease TG

    Also: Increase HDL
  52. Ezetimibe effect on lipids
    Decrease LDL
  53. Omega 3 effect on lipids
    Primary: Decrease TG 25-30%
  54. Omega 3 recommendations
    • 1) With CAD: 1g daily
    • 2) Without CAD: 2 servings oily fish a week
    • 3) With TG> or equal to 500: 2-4gms/day
  55. Action and peak of statin
    Inhibits enzyme of cholesterol synthesis, which causes an increase clearance of LDL

    Peak at MN so take at night
  56. Contraindications to statins
    Active hepatic disease (increased LFTs), heavy ETOH use, breast feeding, pregnancy

    Temp d/c with conditions predisposing to rhabdo
  57. SE of statins
    • 1) GI complaints, sleep problems (nightmares), HA
    • 2) Increase AST/ALT by 3x (nml AST: 10-30 ALT: 11-45)
    • 3) Myalgia
    • 4) Myopathy. CK may be > 10x nml (nml: 38-174) STOP if 350-400
    • 5) Rhabdo
  58. When to d/c statins
    • 1) >2-3x AST and ALT
    • 2) > 2-3x CK. Generally >400
    • 3) Unexplained muscle pain/tenderness, weakness, lethargy, fever, decreased urination, dark urine, sever NV, abd pain
  59. When and what to monitor for statins
    AST/ALT, Lipids, CPK esp if in combo therapy

    • Baseline and 3 months after starting or changing dose
    • Every 6 months for first year
    • Annually when stable for a year
  60. Niacin action
    Lowers hepatic VLDL secretion and lowers HDL clearance. Increased hepatic glucose output and may worsen insulin resistance
  61. Niacin contraindications
    • Active PUD or active liver disease
    • Relative contraindications: DM and gout
  62. Niacin SE
    Flushing, tingling, itching, rash, gastritis, hyperglycemia, hyperuricemia, hepatotoxicity, aggravation of peptic ulcers

    Rare: myopathy. worsens with combined with statin or fibric acid
  63. Niacin monitoring. What and when?
    AST/ALT, lipid, CPK esp in combo therapy

    • Baseline and every 3 months after starting or changing. Also check glucose and uric acid at baseline
    • Every 6 months for first year
    • Annually after stable for one year
  64. Bile Acid Sequestrans (BARS) action
    Anion exchange resin that binds to bile acids in the gut and inhibits cholesterol absorption.
  65. Niaspan SA dosing
    • 500mg qHS for one month
    • then 1000mg qHS for one month with food
    • titrate every month by 500mg. Max is 2000mg/day
    • once daily dosing
  66. Cholestyrimine and Colestipol Rx 1gm
    • Wk 1: 4 tabs po daily before PM mean
    • Wk 2: 4 tabs po BID before meals
    • Wk 3: 8 tabs po BID before meals
    • WK 4: 12 tabs po BID before meals
  67. Monitoring for BARS
    • Lipid panel 6-8 weeks after starting or adjustment.
    • No need to check LFT
  68. Fibric Acid Derivatives action
    complex procress that results in TG lowering and HDL synthesis
  69. Fibrates meds and dosing
    • 1) Tricor 48-145mg daily with meals
    • 3) Lopid 600mg po bid before meals
  70. Fibrates contraindications
    Severe renal, hepatic and gall bladder disease
  71. Fibrates SE
    Flatulence, gallstones (abd discomfort, pain, bloating, belching, food intolerance), increase LFTs, myoptahy
  72. When to dc fibrates
    • AST/ALT > 3x nml
    • CK >2-3x nml
    • persistent LDL elevation
  73. When and what to monitor fibrates
    • baseline and 3 months after starting and changing
    • every 6 months for first year
    • annually after stable for one year
    • if used in combo with statin, check LFT and CK every 6 months

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