PHRD511 Cholesterol 2024 PDF

Dyslipidemia and Heart Disease Richard Dang, PharmD, APh, FCPhA Assistant Professor of Clinical Pharmacy Assistant Director of the Residency Programs Learning Objectives Define dyslipidemia and its impact on cardiovascular health Review screening guidelines for cholesterol levels List t...

Dyslipidemia and Heart Disease Richard Dang, PharmD, APh, FCPhA Assistant Professor of Clinical Pharmacy Assistant Director of the Residency Programs Learning Objectives Define dyslipidemia and its impact on cardiovascular health Review screening guidelines for cholesterol levels List the steps to perform a cholesterol screening List the normal ranges for total cholesterol, triglycerides, LDL, HDL, and non-HDL cholesterol Calculate LDL and non-HDL-C Discuss risk factors and risk assessment tools (ASCVD calculator) Explain treatment options including lifestyle changes and pharmacotherapy DEFINITIONS Dyslipidemia: one or more serum lipid values are outside the normal range Hyperlipidemia: one or more serum lipid values are above the normal range High cholesterol: total cholesterol or LDL is above the normal range Hypertriglyceridemia: triglyceride is above the normal range HDL deficiency: HDL is below normal range Background  High Cholesterol Facts High blood cholesterol is a risk factor of heart 2x the risk of heart disease disease 10% American adults No symptoms have high cholesterol About 2/3 of adults have had their (TC≥ 240 mg/dL)* cholesterol checked in the last 5 years 54.5% of American adults who could benefit from cholesterol Group not being treated medicine are currently taking it *Based on Total Cholesterol CDC https://www.cdc.gov/cholesterol/index.htm Dyslipidemia Dyslipidemia refers to abnormal levels of lipids (cholesterol and triglycerides) in the blood Types of Lipids Measured (in a Lipid Panel): LDL-C (Low-Density Lipoprotein Cholesterol): “Bad cholesterol” HDL-C (High-Density Lipoprotein Cholesterol): “Good cholesterol” Triglycerides (TG): Form of fat found in the blood Total Cholesterol (TC): Combined measure of LDL, HDL, and triglycerides Risk of Cardiovascular Disease (CVD): Elevated cholesterol levels, particularly high LDL-C, are major risk factors for atherosclerosis and heart disease Dyslipidemia Primary Dyslipidemia (genetic) Familial combined hyperlipidemia Familial hypercholesterolemia and polygenic hypercholesterolemia Familial hyperapobetalipoproteinemia Familial hypertriglyceridemia Secondary Dyslipidemia (acquired) Secondary Causes of Hyperlipidemia Diet Drugs Elevated LDL: Diuretics, cyclosporine, glucocorticoids, amiodarone, protease inhibitors Elevated TG: Oral estrogens, glucocorticoids, bile acid sequestrants, retinoic acid, anabolic steroids, raloxifene, tamoxifen, beta blockers, thiazide diuretics, protease inhibitors Diseases Biliary obstruction, nephrotic disease Disorders and altered sense of metabolism Hypothyroidism, obesity, pregnancy Heart Disease Risk factors: High blood pressure, high blood cholesterol, and smoking** Diabetes Overweight and obesity Unhealthy diet Physical inactivity Excessive alcohol use Atherosclerotic Cardiovascular Disease (ASCVD) is a syndrome referring to the following conditions: Coronary heart disease (CHD) - MI, ACS, angina Cerebrovascular disease - stroke,TIA Peripheral artery disease Aortic atherosclerotic disease Heart attack Heart Disease Facts 1 in 20 adults age 20 Heart disease is the and older have Coronary leading cause of death artery disease (CAD) (about 5%) 702,880 Americans died in 2022 (1 in 5 deaths) 382,820 due to CAD Estimated cost of $252 *Coronary artery disease (CAD), also known as coronary heart disease (CHD), ischemic heart 805,000 heart attacks/year billion annually disease, or chronic coronary disease (CCD) (1 heart attack every 40 seconds) 2022 Age-adjusted death rate for the 10 leading causes of death in 2022: United States, 2021 and 2022 The 10 leading causes of death accounted for 72.3% of all U.S. deaths in 2022. CDC Pathophysiology Cholesterol Waxy, fat-like substance Major component of cell membranes and precursor to steroid hormones and bile acid Derived from two sources: Produced by liver (75%) Dietary sources (25%) Carried in the bloodstream by lipoproteins High levels of cholesterol can lead to https://watchlearnlive.heart.org plaque formation Atherogenesis Formation of fatty plaques in the arteries As plaque builds up in the arteries of a person with heart disease, the inside of the arteries begins to narrow, which lessens or blocks the flow of blood. Plaque can also rupture (break open). When it does, a blood clot can form on the plaque, blocking the flow of blood. Atherosclerosis A disease of the arteries Deposition of plaques of fatty material on the inner walls of the arteries Narrowing of the arterial lumen Foam cell → Fatty streak → Lesions → Plaque https://watchlearnlive.heart.org Consequences of High Cholesterol Asymptomatic But eventually… Angina pectoris (chest pain or discomfort) Myocardial infarction (heart attack) Transient ischemic attacks (mini-strokes) http://www.healthcentral.com/common/images/1/17004_3699_5.jpg Stroke Pulmonary embolism Lipoproteins Lipoproteins Total cholesterol (TC) Triglycerides (TG) Low-Density Lipoprotein Cholesterol (LDL-C) High-Density Lipoprotein Cholesterol (HDL-C) Non-HDL Cholesterol (Non-HDL-C) Chylomicron Others (VLDL, IDL, Lp(a))  Total Cholesterol Proxy for overall cholesterol and atherogenesis risk https://watchlearnlive.heart.org  LDL & HDL Cholesterol Friedewald Equation LDL = TC – HDL + TG/5 LDL: HDL: Major carrier of cholesterol in the blood Higher levels are protective Primary target of therapy Primary CHD risk factor https://watchlearnlive.heart.org  Triglyceride Associated with increased CHD risk; elevated levels can increase CVD risk Mainly from dietary fats (75%) Absorbed in the small intestine Used as immediately energy Excess stored in adipose tissue Secondary causes of hypertriglyceridemia DM, alcohol, obesity, non- fasting Severe hypertriglyceridemia associated with increased risk of pancreatitis May become a primary Used by body as energy target of therapy if elevated ≥ 500 mg/dL (and especially or stored in adipose if ≥ 1000 mg/dL) https://watchlearnlive.heart.org Non-HDL Cholesterol Non-HDL-C = TC – HDL-C Includes only the atherogenic cholesterol May be a primary or secondary target of therapy May be more predictive than LDL-C Most useful when nonfasting lipid profile is obtained Risk Assessment and Screening Purpose of Screening Early detection of dyslipidemia can prevent or delay cardiovascular disease CVD Prevention: Identifying and managing cholesterol levels is key to reducing risk Screening Recommendations Cholesterol testing every 4-6 years for people age 20 years or older, who are at low risk for cardiovascular disease Consider more frequently for 40-75 years More frequently for those with risk factors for high cholesterol: Family history of heart disease, high blood cholesterol, premature ASCVD Familial hypercholesterolemia Diabetes Older age (Men ≥ 45 years, Women ≥ 55 years) Male Overweight or obesity Previous history of high cholesterol Screening Methods Estimate Assess lifetime risk risk factors Assess lipid panel Lipid Panel Use as proxy to estimate ASCVD risk Lipid Panel: TC, LDL*, HDL, TG *Fridewald equation: LDL = TC – (HDL + TG/5) *Not valid, if TG ≥ 400 **Direct measurement of LDL is available as a separate lab Fasting lipid profile Analyze LDL-C and TG Non-fasting lipid profile Analyze Non-HDL-C and HDL-C Other labs may include direct LDL-C, non-HDL-C, apoB, or Lp(a)  ASSESSING LIPID PANEL VALUES ELEVATED ELEVATED 100 – 159 mg/dL 150 – 199 mg/dL DESIRABLE HIGH DESIRABLE < 150 mg/dL 200-499 mg/dL HIGH < 100 mg/dL ≥ 160 mg/dL VERY HIGH VERY HIGH ≥ 190 mg/dL ≥ 500 mg/dL LDL TG DESIRABLE ≥ 40 mg/dL (men); ≥ 50 mg/dL (women) LOW < 40 mg/dL (men); < 50 mg/dL (women) Total Cholesterol < 200 mg/dL HDLDesirable 200-239 mg/dL Borderline High ≥ 240 mg/dL High ASCVD Risk Assessment: Pooled Cohort Equation Gender Smoking Age Risk Factors Assessed: Age, Tx HTN gender, race, total Race cholesterol, LDL-C, HDL- C, TC, systolic blood pressure, smoking status, hypertension, Diabetes diabetes. HDL/LDL/TC SBP / DBP TC http://tools.acc.org/ASCVD-Risk-Estimator-Plus/ ASCVD Risk Score Assesses the risk for CHD/MI and stroke (i.e. ASCVD) Most accurate for African American and non-Hispanic white individuals aged 40-79 years Limited use in certain populations 10 year ASCVD Risk Score