Cardiovascular Disease 2

Categories of risk: normal

< 150 mg/dL

Categories of risk: very high

>500 mg/dL Risk of pancreatitis, may lack LPL

Lipoprotein profile

Total cholesterol: >200 mg/dL LDL cholesterol: >130 mg/dL HDL cholesterol: <40 mg/dL Triglycerides: >150 mg/dL

Bariatric surgery

Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health Bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue Present guidelines advise that weight loss surgery only recommended for patients with extreme obesity (BMI > or equal to 40) or in patients that have a BMI ≥35 in addition to a chronic health condition

Categories of risk: borderline high

150-199 mg/dL Familial dyslipidemias

2013 guidelines in obesity, cholesterol, risk assessment, lifestyle

1. Obesity should be managed and treated like a disease 2. More Americans could benefit from statins 3. New risk equations add African-Americans and stroke risk 4. New guideline outlines the best dietary pattern and exercise for heart health

Guideline recommends statin therapy for:

1. People without cardiovascular disease who are 40-75 years old and have a 7.5% or higher risk for heart attack or stroke within 10 years 2. People with a history of heart attack, stroke, stable or unstable angina, peripheral artery disease, transcient ischemic attack, or coronary or other arterial revascularization 3. People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher) 4. People with Type 1 or Type 2 diabetes who are 40-75 years old

Categories of risk: high

200-499 mg/dL Familial dyslipidemias

Familial hypercholesterolemia: cholesterol

250-500 mg/dL present at birth (360 average)->early atherosclerosis Screen 2-10 year olds--considered unreasonable to treat before 2 years old No safety data on statins before 8-10 years old Statins improve arterial function and structure

Heart-healthy lifestyle

Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest: Eating a diet rich in vegetables, fruits, and whole grains; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats. Getting regular exercise; check with your health care provider about how often and how much is right for you. Maintaining a healthy weight Not smoking or getting help quitting. Staying on top of your health, risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

Your treatment plan

Before develop specific treatment plan, care provider talks with client about options for lowering your blood cholesterol and reducing personal risk of atherosclerotic disease; likely include discussion about heart-healthy living and potential benefits from a cholesterol-lowering medication

Pharmacological management: types

Bile acid sequestrants (e.g. cholestyramine) Nicotinic acid HMG CoA reducatse inhibitors (statins) (e.g. lovastatin, pravastatin) Fibric acid derivatives (e.g. clofibrate, gemfibrozil) Probucol

Lipoproteins found in blood

Chylomicrons LDL HDL Type of hyperlipidemia depends upon portion of particles present

TG rich lipoproteins

Chylomicrons VLDL VLDL remnants

New guidelines: diet

Diet is a vital tool for lowering cholesterol and blood pressure levels, two major risk factors for cardiovascular disease. Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats. Many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate. Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat. Patients with high blood pressure should consume no more than 2400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. Reducing sodium intake in one's current diet by 1000 mg each day can help lower BP. Important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Create eating patterns that are realistic and sustainable.

Dietary factors

Dietary cholesterol—no longer recommended to restrict dietary cholesterol Fiber—high intake associated with lower incidence of CVD Antioxidants—high in diets rich in fruits and vegetables Stanols and sterols—known to lower cholesterol by blocking absorption Omega-3 fat—showed decreased risk of CVD in some studies. May lower triglyceride levels and raise HDL levels Weight •Obesity is associated with increased risk of all CVD •ACC/AHA guideline specific to obesity •CVD risk related to obese years

Nw risk equations add African-Americans and stroke risk

Doctors can now calculate cardiovascular risk in African-Americans for the first time ever. New equations offer greater accuracy in predicting the chances of heart attack or stroke in African-Americans whose risk levels are higher than whites Also, for the first time, stroke risk has been added to the equation, giving patients a two-in-one assessment of their future cardiovascular health

1988

Exclusive focus on LDL-C

Familial defective apo B-100 hypercholesterolemia: symptoms

Found in > or equal to 2 family members LDL-C above 90th percentil Elevaed serum cholesterol, normal TG Tendon xanthomas, premature CHD

Familial defective apo B-100 hypercholesterolemia

Hepatic overproduction of apo B-100 (VLDL) or defect in hepatic lipase production gene which facilitates TG removal from blood Treatment: TLC diet with drug therapy

Obesity should be managed and treated like a disease

Included in new guidelines to help lose weight and keep it off Claculate at least once a year every American's body mass index BMI of 30 or higher are considered For overweight, new guidelines found that more people can reap rewards from weight loss than previously thought

Familial hypercholesterolemia: diagnosis

LDL >90th percentile in > or equal to 2 family members, xanthomas Genetic defect in the LDL receptor--absent or nonfunctional Monogenetic disorder (14-34 M worldwide)

If triglycerides > or equal to 200 mg/dL

LDL cholesterol: primary target of therapy Non-HDL cholesterol = total cholesterol - HDL cholesterol

Familial combined hyperlipidemia (FCHL)

LDL-C and/or TG levels above 90th percentil in at least 2 family members, both abnormalities seen in family members (1/200) Type IIA-increased LDL, normal TG Type IIb-increased LDL, increased TG Type IV-increased VLDL Small dense LDL often present All cause premature disease; often accompanies obesity, HTN, diabetes, metabolic syndrome Defect = hepatic overproduction of apo B-100 (increased VLDL) or problems with enzyme that removes TG from blood or hepatic lipase Treatment: lifestyle factors, weight reduction, diabetes control, increased activity, meds if needed, avoid alcohol with increased TG

Benefits of weight loss

Losing just a little bit of weight can result in significant health benefits For adult who is obese, losing 3-5% of body weight can improve BP and cholesterol levels and reduce the risk for cardiovascular disease and diabetes Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits

2004

Lower LDL-C threshold for therapy initiation in very high risk patients

2001

Lower LDL-C threshold or therapy initiation in high risk patients

New guidelines outlines the best dietary pattern

Maintaining an overall heart-healthy dietary patterns according to a new lifestyle management guideiline from the AHA/ACC Just 40 minutes of moderate to vigorous aerobic exercise 3-4x/week found to be sufficient for most, walking will do Dietary patterns that emphasize fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. Red meat and sugary foods and beverages should be limited. Many diets work, including the DASH eating plan and plans suggested by the USDA and the AHA "It's about the overall diet" Less sodium, the guideline recommends an initial step-down to no more than 2400 mg/day of sodium. Currently 3600 mg/day Americans can lower BP even further by getting sodium down to 1500 mg/day

Definition of obesity

Medical condition Excess body fat accumulated to extent that it can have an adverse effect on one's health Diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference Obesity = BMI of 30 or greater Abdominal obesity = waist circumference greater than 40 inches for men or 35 inches for women

Familial hypercholesterolemia: extra

Men develop CVD before women Xanthomas on Achilles tendon IDs most FH patients (ultrasound)

High TG levels with:

Metabolic syndrome (most common) Acute-phase response Uncontrolled diabetes Untreated hypothyroidism Chronic renal disease Liver disease Obesity and overweight Certain medications Excess alcohol intake Physical inactivity Cigarette smoking Low-fat, high refined CHO diets Estrogens Genetics--dyslipidemias

Polygenic familial hypercholesterolemia

Multiple gene defects Apo E allele common Diagnosis: > or equal to 2 family members with LDL cholesterol > 90th percentile with absence of tendon xanthomas High risk of premature disease Treatment: lifestyle change, drug treatment

Weight loss strategies

No single diet or weight loss program works best for all patients Reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss Weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss

Medical intervention

Percutaneous coronary intervention (PCI) Coronary artery bypass graft (CABG)

Prevention

Primary: assessment and management of risk factors in asymptomatic (hyperlipidemic) persons (diet, exercise, lifestyle) Secondary: treatment of hypercholeseterolemia in patients who already have CHD

Lowering LDL cholesterol

Reduce calories from saturated fat Reduce consumption of trans fat Eat appropriate calories Follow diet therapy for other diseases (e.g. diabetes) Emphasize fruit, vegetables, legumes, whole grains, fish, nuts, nut oils, low-fat dairy Limit intake of red meat Limit intake of sweets, especially sugar-sweetened beverages Achieve through DASH diet or USDA MyPlate food pattern

LDL treatment

Proven that reducing level of LDL cholesterol reduces risk of having cardiovascular event; benefit proportional to CVD risk More intensive treatments are more effective in preventing clinical events Low LDL-C is safe Statins are the cornerstone of LDL-C lowering Addition of ezetimibe to a statin reduces ASCVD events Large clinical ASCVD outcomes trials of PCSK9 inhibitors showed that these agents reduce ASCVD risk Intensive treatments

New guidelines: physical activity

Regular PA helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease. In general, adults should engage in aerobic physical activity 3-4x times a week with each session lasting an average of 40 minutes. Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.

1993

Risk assessment guides therapy

Familial dysbetalipoproteinemia (type III hyperlipoproteinemia)

Uncommon (1/10,000 in US) Catabolism of VLDL remnants, IDL and chylomicron remnants delayed due to apoE2 replacing epo E3 and 4 Diagnosis: TC = 300-600 mg/dL and TG = 400-800 mg/dL + increased age, hypothyroidism, obesity, diabetes, or other dyslipidemias (FCHL) must be present for diagnosis + ID of apo E Increased risk of premature ASCVD and peripheral vascular disease Treatment: weight loss, hyperglycemia control, diabetes control, dietary restriction of cholesterol and SF, meds if needed

2013

Use of moderate- or high-intensity statin therapy for patient across 4 major groups at risk for ASCVD

The Mediterranean Diet (MedDiet)

Was not specifically recommended in ACC/AHA guideline Studies did not have a consistent definition of the MedDiet Recent studies have supported the general pattern Tools have been developed for assessment of MedDiet pattern

Hypertriglyceridemia treatment

Weight loss if overweight Low saturated fat-low cholesterol diet Decreased refined CHO intake Increased physical activity Stop smoking Manage diabetes Restrict alcohol Drug therapy may be indicated, especially with genetic forms