Podcast
Questions and Answers
What is a potential risk associated with using non-statins in combination with statins?
What is a potential risk associated with using non-statins in combination with statins?
Which of the following patients should avoid using non-statin medications?
Which of the following patients should avoid using non-statin medications?
What is a common side effect of Niacin as a treatment for triglycerides?
What is a common side effect of Niacin as a treatment for triglycerides?
When is it recommended to consider the use of Bile Acid Resins?
When is it recommended to consider the use of Bile Acid Resins?
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What does the term 'primordial prevention' refer to in cardiovascular health?
What does the term 'primordial prevention' refer to in cardiovascular health?
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What is the consequence of using a blood pressure cuff that is too small for the patient's arm?
What is the consequence of using a blood pressure cuff that is too small for the patient's arm?
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Which of the following actions should be avoided immediately before taking a blood pressure reading?
Which of the following actions should be avoided immediately before taking a blood pressure reading?
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What does ambulatory blood pressure monitoring allow for?
What does ambulatory blood pressure monitoring allow for?
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What is a common issue with using wrist blood pressure cuffs compared to upper arm cuffs?
What is a common issue with using wrist blood pressure cuffs compared to upper arm cuffs?
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What is the goal when starting treatment for hypertension according to guidelines?
What is the goal when starting treatment for hypertension according to guidelines?
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What does the validateBP.org website verify?
What does the validateBP.org website verify?
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Why are at-home blood pressure measurements considered more closely related to left ventricular mass?
Why are at-home blood pressure measurements considered more closely related to left ventricular mass?
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What is the significance of nocturnal blood pressure readings?
What is the significance of nocturnal blood pressure readings?
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Which statins have longer half-lives and higher bioavailability, posing lower interaction risk with 3A4 inhibitors?
Which statins have longer half-lives and higher bioavailability, posing lower interaction risk with 3A4 inhibitors?
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What is the mechanism of action of Ezetimibe?
What is the mechanism of action of Ezetimibe?
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In the IMPROVE-IT trial, what was the average LDL level achieved in the group treated with Ezetimibe plus statin?
In the IMPROVE-IT trial, what was the average LDL level achieved in the group treated with Ezetimibe plus statin?
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What does PCSK9 do in relation to LDL receptors in the liver?
What does PCSK9 do in relation to LDL receptors in the liver?
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What is the primary effect of PCSK9 inhibitors?
What is the primary effect of PCSK9 inhibitors?
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Which of the following is a combination drug of Simvastatin and Ezetimibe?
Which of the following is a combination drug of Simvastatin and Ezetimibe?
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What is a significant benefit of Ezetimibe when used in conjunction with statins?
What is a significant benefit of Ezetimibe when used in conjunction with statins?
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How does genetic polymorphism affect PCSK9 activity?
How does genetic polymorphism affect PCSK9 activity?
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Which diuretic is considered a 1st line medication and is well-tolerated for hypertension management?
Which diuretic is considered a 1st line medication and is well-tolerated for hypertension management?
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What is a more potent alternative to HCTZ when it is not achieving the desired blood pressure goal?
What is a more potent alternative to HCTZ when it is not achieving the desired blood pressure goal?
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What condition is contraindicated for using all calcium channel blockers?
What condition is contraindicated for using all calcium channel blockers?
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Which of the following beta antagonists is cardioselective?
Which of the following beta antagonists is cardioselective?
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Which medication class is effective in treating hypertension resistance or primary aldosteronism?
Which medication class is effective in treating hypertension resistance or primary aldosteronism?
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What is a major side effect to monitor when initiating treatment with HCTZ?
What is a major side effect to monitor when initiating treatment with HCTZ?
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Which beta blocker is most likely to cause bronchospasm in patients with asthma?
Which beta blocker is most likely to cause bronchospasm in patients with asthma?
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Which condition can worsen with the use of non-cardioselective beta blockers?
Which condition can worsen with the use of non-cardioselective beta blockers?
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What is the primary effect of blocking the activity of PCSK9 with monoclonal antibodies?
What is the primary effect of blocking the activity of PCSK9 with monoclonal antibodies?
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What was the median LDL level decrease in the FOURIER Trial when comparing statins alone to statins plus a PCSK9 inhibitor?
What was the median LDL level decrease in the FOURIER Trial when comparing statins alone to statins plus a PCSK9 inhibitor?
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What reduction in LDL-C is anticipated when using bempedoic acid as an adjunct therapy?
What reduction in LDL-C is anticipated when using bempedoic acid as an adjunct therapy?
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Which condition is characterized by dysfunctional LDL cholesterol receptors leading to severely elevated LDL levels of over 600 mg/dl?
Which condition is characterized by dysfunctional LDL cholesterol receptors leading to severely elevated LDL levels of over 600 mg/dl?
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What is the mechanism of action of ACL inhibitors, such as bempedoic acid?
What is the mechanism of action of ACL inhibitors, such as bempedoic acid?
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What are the recommended parameters for prescribing fibrates to lower triglyceride levels?
What are the recommended parameters for prescribing fibrates to lower triglyceride levels?
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What potential side effect should be monitored when using bempedoic acid?
What potential side effect should be monitored when using bempedoic acid?
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Which medication combination is noted for achieving a higher LDL reduction when used maximally with a statin?
Which medication combination is noted for achieving a higher LDL reduction when used maximally with a statin?
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Study Notes
Blood Pressure Measurement
- Manual blood pressure cuffs need to be calibrated, and human interpretation can introduce errors.
- Automated blood pressure machines can have varying fidelity, validateBP.org can be used to check the fidelity.
- Correct cuff size is essential for accurate blood pressure readings:
- A cuff too small will lead to a falsely high reading.
- Avoid caffeine, smoking, or exercising within 30 minutes of taking blood pressure.
- Do not talk during the reading.
- The cuff should cover 80% of the upper arm, with its bladder being ~40% of the arm circumference.
Home Blood Pressure Monitoring
- Automated blood pressure machines make at-home monitoring easier.
- Home measurements are more closely related to left ventricular mass than in-clinic measurements.
- CPT codes 99473 and 99474 are used for interpretation of out-of-office BP readings.
- Home BP readings are generally lower than office readings.
- Nighttime readings are more accessible with ambulatory 24-hour monitoring.
- Nocturnal BP readings have stronger predictive power for cardiovascular events.
Wrist Cuffs
- Radial systolic BP is generally 5.5 mm Hg higher than brachial systolic BP, with >20% of individuals having a difference of >10 mm Hg.
- Currently, there's no validation procedure to translate radial BP to brachial BP.
- At-home measurement using wrist BP cuffs can be unreliable.
Choosing a Treatment Target
- The first step for treating hypertension is choosing a blood pressure target.
- For most patients, including those with high cardiovascular risk, the target should be <130/80 mm Hg.
- If a patient doesn't respond to the maximum dose of a single medication, add another agent.
- Combining medications with different mechanisms of action is more effective in lowering BP.
- Maxing out on single medications can lead to more side effects without achieving the BP goal.
Diuretics
- Hydrochlorothiazide (HCTZ) is a commonly used first-line diuretic, well tolerated.
- HCTZ inhibits sodium and chloride reabsorption in the distal convoluted tubule, leading to decreased blood volume, sodium, potassium, and magnesium, resulting in reduced peripheral vascular resistance (PVR).
- Chlorthalidone (thiazide-like) is useful when HCTZ isn't achieving the goal, as it's more potent and has a longer half-life.
- Monitor potassium levels closely, especially with initiation.
- Lasix isn't a first-line antihypertensive diuretic for patients with intact renal function.
Calcium Channel Blockers (CCBs)
- CCBs are modest negative inotropes, reducing contractility of the heart.
- Commonly used CCBs include:
- Amlodipine
- Diltiazem
- Verapamil
- Red Flags: Contraindicated in heart failure (HF), renal or hepatic impairment.
Beta-Adrenergic Antagonists
- Beta-blockers commonly used for hypertension:
- Atenolol
- Metoprolol
- Carvedilol
- Labetalol
- Bisoprolol
- Propranolol
- Block beta-1 adrenergic receptor sites, blunting catecholamine response.
- This decreases cardiac output and sympathetic outflow.
- Commonly used for post-myocardial infarction patients.
- Carvedilol and labetalol block beta-1, beta-2, and alpha-1 receptors, decreasing heart rate, stroke volume, and PVR.
- Non-cardioselective agents (beta-1 & beta-2) include propranolol and nadolol.
- Avoid non-cardioselective agents in asthma, COPD, pulmonary lung disease, and peripheral artery disease (PAD).
- Red Flags: Sinus bradycardia, depression, HF decompensation. Avoid abrupt cessation.
Aldosterone Antagonists
- Aldosterone antagonists commonly used for hypertension:
- Spironolactone
- Eplerenone
- Useful for hypertension resistance or primary aldosteronism.
- Consider spironolactone for a higher dose (150-300mg).
- Spironolactone has an androgen-blocking effect.
- Red Flags: Risk of hyperkalemia.
Statins
- Atorvastatin and rosuvastatin have longer half-lives and higher bioavailability.
- Diltiazem and grapefruit juice are 3A4 inhibitors, which can interact with some statins.
Association vs. Causation
- Emphasize diet and lifestyle modifications to avoid type 2 diabetes progression.
- Consider the risk-benefit ratio when making treatment decisions.
Ezetimibe (Zetia)
- Ezetimibe can further lower LDL cholesterol by about 17% on top of statin therapy.
- It's a selective cholesterol absorption inhibitor.
- Anticipated LDL-C reduction is 15-20%.
- Well tolerated, no drug-to-drug interactions, and no renal or hepatic dysfunction.
- Drug combination: Simvastatin + Ezetimibe = Vytorin.
- IMPROVE-IT trial showed that ezetimibe plus statin lowered cardiovascular events compared to statin plus placebo.
PCSK9 Inhibitors
- PCSK9 is a proprotein convertase involved in the degradation of LDL receptors in the liver.
- PCSK9 inhibitors:
- Evolocumab (Repatha)
- Alirocumab (Praluent)
- Excess cholesterol is primarily cleared by liver cells' receptors, but PCSK9 blocks this action by destroying the receptors.
- PCSK9 inhibitors block the action of PCSK9, allowing more receptors to function and lowering LDL cholesterol.
- Can further reduce LDL-C by ~60% for patients already on optimized statin therapy.
- FOURIER Trial: Statins plus PCSK9 inhibitors achieved a significantly lower median LDL than statins alone.
- GLAGOV Trial: Statins plus PCSK9 inhibitors achieved coronary plaque regression.
Bempedoic Acid (Nexletol)
- Bempedoic acid is a newly approved adenosine triphosphate-citrate lyase (ACL) inhibitor.
- Indication: Heterozygous familial hyperlipidemia or established ASCVD risk with a goal of achieving LDL-C targets despite maximized tolerated statin therapy.
- MOA: ACL enzyme upstream of HMG CoA reductase in cholesterol synthesis.
- Inhibition of ACL reduces cholesterol biosynthesis in the liver and decreases LDL.
- Anticipated LDL-C reduction is 18%.
- Drug combination: Bempedoic acid + Ezetimibe (Nexlizet) = LDL reduction of 38% when used maximally with statin.
- Monitor uric acid levels and be aware of the risk of gout flare and tendon rupture.
Homozygous Familial Hypercholesterolemia
- Rare condition characterized by dysfunctional LDL receptors on the liver.
- Leads to severely elevated LDL levels, >600mg/dl.
- Treatment includes specialized training and consultation, with medication options including:
- Juxtapid
- Kynamro
- Management often includes PCSK9 inhibitors, maximum statin therapy, and ezetimibe.
- Adding bile acid resins can be challenging due to absorption issues.
- Limited data on statin and niacin benefits.
Fibrates
- Fibrates (gemfibrozil, fenofibrate): Mainly lower triglycerides, mildly increase HDL.
- MOA: Unclear stimulation of lipoprotein lipase, enhancing the breakdown of very-low-density lipoprotein (VLDL) to LDL cholesterol.
- Studies show that fibrates added to statins may trend toward fewer cardiovascular events in patients with triglycerides >500 mg/dl and low HDL despite dietary modifications.
- Efficacy is limited, contraindicated in patients with cholecystitis, cholelithiasis, hepatic or renal disease.
- Higher risk of myopathy reported when used with statins.
- No studies in pregnant women.
Other Non-Statin Medications for Lipid Management
-
- Niacin: Lowers triglycerides and lipoprotein (a). Poorly tolerated.
-
- Bile Acid Resins: Indicated for triglycerides >300mg/dl fasting, heavy routine adherence burden.
-
- Fish Oil: Need at least 4gm/day to lower triglycerides. Over-the-counter preparations have only 400-500 mg per capsule versus 1,000mg per capsule Rx strength. No proven benefit on cardiovascular outcomes.
Interactive ASCVD Risk Calculator
- Download MDCalc.
- Save the ASCVD Risk Algorithm to favorites.
- Use the calculator for different scenarios, including:
- History of ASCVD (yes or no)
- LDL cholesterol level
- Age
- Diabetes status
- Gender
- Total cholesterol
- HDL cholesterol
- Blood pressure
- Smoking status
Lipid Management Points
- Lifestyle changes are essential for cardiovascular prevention and should never be neglected.
- "Primordial prevention" is key!
- Plaque burden risk is influenced by both the magnitude of LDL elevation and the duration of exposure.
- The new ASCVD risk categories include:
- Low risk (<5%)
- Borderline risk (5-10%)
- Intermediate risk (>10%)
- High risk (≥20%)
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Description
This quiz covers the essentials of blood pressure measurement and home monitoring techniques. It includes the importance of cuff size, the impact of lifestyle factors on readings, and the differences between automated and manual methods. Understand the implications of out-of-office readings for better health management.
