LIPID PROFILE,DISORDERS AND MANAGEMENT PPT.pptx

WHEN TO TO LIPID FOFILE,ESC AND ACC CRITERIA OF ASCVD,TREATMENT WITH STATINS,MANAGEMENT OF STATIN INTOLERANCE

1. LIPID PROFILE :CLINICAL INTEPRETATION DR SURYAPRAKASH YADAV

2. ATHEROSCLEROTIC PROCESS TRAPPING OF APO B PARTICLES WITHIN ARTERIAL WALL IS THE FUNDAMENTAL STEP IN THE PATHOPHYSIOLOGY OF ATHEROSCLEROSIS ANY APO-B CONTAINING LIPOPROTEINS <70NM IN DIAMETER(LDL,IDL,VLDL,CHYLOMICRONS AND LIPOPROTEIN(a) CAN CROSS THE ENDOTHELIAL BARRIER AND INITIATE THE ATHDEROSCLEROTIC PROCESS.

3. WHY SHOULD IT BE DONE IN OUR COUNTRY ASCVD ARRIVES EARLIER ,MANIFEST IN A MORE SEVERE FORM AND HAS A HIGHER MORTALITY CONSIDERING THIS AND WELL ACCEPTED DICTUM ABOUT LOWERING ATHEROGENIC LIPIDS THAT (LOWER IS BETTER ,EARLIER IS BETTER AND LONGER IS BETTER),APPROPRIATE AGGRESION IS NECESSARY IN MANAGING DYSLIPDEMIA IN OUR COUNTRY

4. WHAT ARE THE LIPID PARAMETRS TO BE ESTIMATED LIPID PANEL CONSIST OF MEASUREMENT OF TC,TG,HDL,LDL FOR NON HDL CHOL=TC-HDL IN SPECIAL SITUATIONS APOB SHOULD BE ESTIMATED IN GENEREL ,LDL-C,NON HDL –C,APO B CONCENTRATIONS ARE VERY HIGHLY CORRELATED, AS A RESULT UNDER MOST CIRCUMSTANCES THEY PROVIDE VERY SIMILAR INFORMATION ABOUT ASCVD RISK

5. STATIN THERAPY REDUCES THE LDL CHOL MORE THAT APO-B,DECREASE IN LDL-C IS GREATER THAN APO-B LOWERING BY 15% HENCE ON TREATMENT APO-B IS MORE REALIABLE INDEX OF RESIDUAL RISK APOLIPROTEIN B PROVIDES AN ACCURATE ESTIMATE OF THE TOTAL CONCENTRATION OF ATHEROGENIC PARTICLES IN ALL CIRCUMSTANCES ,IT IS PREFEREED MEASUREMENT TO FURTHER REFINE THE ESTIMATE THE ASCVD RISK

6. SWEDISH AMORISH TRIAL (APOLIOPROTEIN REALTED MORTALITY RISK ) PROSPECTIVE STUDY DONE IN 1,75,000 INDIVIDUALS APO-I AND APOB MEASURED AND SERIALLY FOLLOWED FOR UPTO 25 YEARS MYOCARDIAL INFARCTION WAS BEST PREDICTED BY APO-B LEVELS FOLLOWED BY NON HDL AND THEN LDL -C

7. FASTING VS NON FASTING LIPID PROFILE DOES NOT REQUIRE FASTING IN MOST CASES HDL-C AND TC ARE MINIMALLY EFFECTIVE BY FASTING IF THE NON FASTING PLASMA TG COMPONENT OF THE LIPID PROFILE RETURNS >400mg/dl, A FASTING LIPID PROFILE TO BE DONE

8. CHANGES IN NON FASTING VS FASTING LEVELS ARE + 26mg/dl FOR TG -8mg/dl FOR TC -8mg/dl FOR LDL-C +8mg/dl FOR Remnant CHOL -8mg/dl FOR NON-HDL-C LP(a),APO-B AND HDL-C SHOWS NO DIFFERENCE

9. WHEN TO MEASURE LIPIDS IT IS RECOMMENDED THAT LIPID PROFILE SHOULD BE OBTAINED AT THE AGE OF 18YEARS ALONG WITH RECORDS OF BMI/LOOD PRESSURE AND BLOOD SUGAR AS PART OF UNIVERSAL SCREENING IT MAY BE DONE EARLIER IF THERE IS FAMILY HISTORY OF PREMATURE CORONARY ARTERY DISEASE OR A FAMILIAL HYPERCHOLESTEROLEMIA IF NOT DONE EARLIER,SHOULD BE DONE AT THE EARLIEST OPP0RTUNITY

10. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK ASSESMENT 2 RISK ASSESMENT SCORE LAI(LIPID ASSOCIATION OF INDIA) RISK CATEGORISATION(PREFERRED) Q RISK SCORE FROM BRITISH HEART SOCIET

11. HOW TO ACHIEVE THE LIPID GOALS THERAPEUTIC LIFE STYLE INTERVENTION IS AN ESSENTIAL AND INTEGRAL PART OF THIS EXERCISE,SHOULD BE GIVEN TO THOSE IN LOW RISK GROUP BEFORE CONSIDERING DRUG THERAPY. THERE ARE NUMBER OF DRUGS AVAILABLE IN THE ARMENTARIUM TO REDUCE ATHEROGENIC LIPIDS STATINS IS THE FIRST LINE ,FOLLOWED EZETIMIBE,BEMPEDOIC ACID,PCSK9 INHIBIOTORS(MONOCLONAL ANTIBODIES –EVOLOCUMAB AND ALIROCUMAB),SMALL INTERFERING RIBONUCLEIC ACID(SiRNA)MOLECULES,AND ANGPLT3 MONOCLONAL ANTIBODIES(EVINACUMAB)

12. SECONDARY CAUSES OF DYSLIPEDIMEA

13. COMPARISON OF ESC AND LAI ON MAGEMENT OF DYSLIPDEMIA IN ADULTS LDL LEVEL ESC LAI LOW RISK <=115 <100 MODERATE RISK <100 <100 HIGH RISK <70 <70 VERY HIGH RISK <55 <50 EXTREME RISK < 40 <30

14. APPROACH TO DYSLIPDEMIA

15. STATINS

16. PREVALENCE

17. MANAGEMENT TO STATIN INTOLERANCE SWITCHING TO ALTRENATE STATINS ALTERNATE DAY DOSING NON STATIN DRUG THERAPY LIKE EZETIMIBE/BEMPEDOIC ACID/PCSK9 INHIBITORS

18. BEMPEDOIC ACID

19. INDICATIONS If LDL-C goals are not achieved despite maximally tolerated statin therapy and ezetimibe, bempedoic acid may be added as one of the non-statin drugs in patients with established ASCVD and HeFH In patients with true statin intolerance or contraindications, ezetimibe 10 mg once a day in combination with bempedoic acid 180 mg once a day is recommended. Bempedoic acid may be initiated in patients presenting with ACS who are not at LDL-C goal despite statins and ezetimibe as per the LAI risk stratification algorithm for LDL-C management in ACS

20. ADVANTAGES AND DISADVANTAGES LESSER DEGREE OF MUSCULAR SYMTOMS DECREASE RISK OF NEW ONSET OR WORSENING DM INCREASES RISK OF GOUT COSTLY

21. EZETIMIBE(ABSORPTION INHIBITOR)

22. PCSK 9 INHIBITORS

23. MICROSOMAL TRIGLYCERIDE TRANSFER PROTIEN (MTP) INHIBITOR MOLECULE-LOMITAPIDE MTP IS PREDOMINANTLY EXPRESSED IN HEPATOCYTES AND ENTEROCYTES,WHOSE ACTION IS REQUIRED FOR SYNTHESIS OF APOB,THAT TOO PREDOMINANTLY VLDL INHIBITION OF MTP RESULTS IN THE DECREASED SNYTHESIS AND SECRETION OF VLDL IN THE LIVER BY INHIBITING LIPIDATION OF APOB ORALLY ACTIVE MOLECULE APPROVED FOR HFH

24. ANTISENSE OLIGONUCLEOTIDE (MOLECULE) MIPOMERSAN AND VOLANESORSEN MIPOMERSAN IS A POLYNUCLEOTIDE OF 20 BASES WHICH BINDS TO SEGMENT OF HUMAN APOB-100MRNA AS IT COMPLIMENTARY TO MRNA,BLOCKING THE TRANSLATION PROCESS OF THE GENE PRODUCT THEREBY REDUCING SYNTHESIS OF APOB AND CONSEQUENTLY VLDL,IDL PROTIEN 200MG SC ONCE A WEEK IS THE DOSE

25. VOLANESERON IS THE ASO TARGETING APO-C-III MRNA THAT IS CRITICAL IN THE REGULATION OF TG RICH LIPOPROTEINS CLEARANCE VOLANESERON REDUCES PLASMA TG BY 70%

26. INCLISIRAN SMALL INTERFERING RNA MOLECULE THAT INHIBITS TRANSLATION OF PROTIEN PCSK9 THIS COMPLEX BINDS TO PCSK9 MRNA ,LEADING TO ITS DEGRADTION,MORE LDL RECEPTOR UPREGULATION AND CLEARANCE OF LDL-C DOSE-284MG ON DAY 1,AT 90 DAYS F/B 6MONTH THEREAFTER AS SUBCUTANEOUS INJECTION