Leading cause of death for men and women. Coronary heart disease (CHD) most common. Diet Physical inactivity Obesity Alcohol

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1 CHOLESTEROL AND STATINS HEART DISEASE Leading cause of death for men and women Coronary heart disease (CHD) most common Terri Giordano MSN, CRNP, CORLN The Children s Hospital of Philadelphia Division of Otolaryngology CHD Genetic Cholesterol levels Hypertension DM Tobacco use Diet Physical inactivity Obesity Alcohol DEATH RATES 1 in 4 in the United States 785,000 Americans have first heart attack 470,000 Americans will have another attack Highest rate Mississippi Lowest rate Minnesota FUNCTIONAL DISABILITIES Heart Disease Stroke Hypertension FRAMINGHAM HEART STUDY Studied men and women age Observed survival rates Observed survival free of CHD to age % survived to age 85 22% survived free of major morbidities

2 NURSES HEALTH STUDY Established by Dr. Frank Speizer in 1976 with funding from NIH Married RNs age Largest and longest study Expanded in 1989 Prevention of cancer primary focus Questionnaires sent out every 2 years NURSES HEALTH STUDY II Established in 1989 by Dr. Walter Willett with funding from NIH Target population women age Nurses Health Study III NURSES HEALTH STUDY Absence of current smoking Drinking ½ glass of wine per day ½ hour of moderate or vigorous activity per day BMI < 25 Dietary score in top 40% NCEP National Cholesterol Education Program Expert panel on detection, evaluation and treatment of high blood cholesterol in adults ATP I Primary prevention of coronary heart disease in persons with high levels of LDL cholesterol or those with borderline high LDL with multiple risk factors ATP II Affirmed the importance of ATP I and added more intense management of LDL cholesterol in persons with coronary heart disease

3 ATP III Intense treatment of patients with coronary heart disease with focus on primary prevention in patients with multiple risk factors ATP III Multifactorial Reduced intake of saturated fat Therapeutic options Weight reduction Increased physical activity INTERVENTIONS Focus on Patient Focus on Health Care Provider Focus on Health Delivery System CHOLESTEROL Fat-like substance Low density lipoproteins (LDL) High density lipoproteins (HDL) Very low density lipoproteins (VLDL) LDL 60-70% of total serum cholesterol Single apolipoprotein APOB Primary target of cholesterol lowering therapy HDL 20-30% of total cholesterol Apolipoproteins APO I and APO II May protect against atherosclerosis development Lp(a) genetic variation

4 VLDL Triglyceride rich lipoproteins 10-15% of total serum cholesterol Apolipoproteins: APO B, APO C, APO E CHYLOMICRONS Triglyceride rich lipoproteins Formed in intestines from dietary fat May have atherogenic potential Produced by liver and are precursors of LDL TOTAL CHOLESTEROL < > 240 Desirable Borderline High High LDL < > 190 Optimal Near Optimal Borderline High High Very High HDL TRIGLYCERIDE < 40 mg/dl men and < 50 mg/dl women Major risk factor for heart disease < Normal Borderline High High 60 mg/dl and above Considered protective 500 and above Very High against heart disease

5 LIFE STYLE MODIFICATION Diet Omega-3 fatty acids Antioxidants Vitamin D Phytochemicals Cigarette smoking LIFE STYLE MODIFICATION Obesity Alcohol Physical Activity Hypertension Diabetes Mellitus HYPERTENSION Blood pressure > 140 mmhg systolic and > 90 mmhg diastolic Current use of antihypertensive medication DIET High intake of saturated fats and cholesterol with low intake of polyunsaturated fats increases level of serum cholesterol and leads to development of coronary heart disease OMEGA-3 FATTY ACIDS Low rate of cardiovascular disease in populations with high intake of fish such as Alaskan Native Americans, Greenland Eskimos, and Japanese living in fishing villages WHOLE GRAINS Whole wheat bread Brown rice Oats Barley

6 VITAMIN D FIBER Soluble fiber Lower levels of vitamin D have been associated with increased insulin resistance and Type II Diabetes Insoluble fiber ANTIOXIDANTS Vitamin E Beta-carotene Vitamin C PHYTOCHEMICALS Naturally occurring compounds in plant foods Flavonoids, plant sterols, sulfur containing compounds Inhibit LDL oxidation and decrease platelet aggregation in vitro Improve cardiovascular risk factors ALCOHOL 1-2 drinks per day reduces risk of coronary heart disease by 20-40% Increases HDL Improved insulin sensitivity Reduced inflammation Decreases thrombogenic tendency DIABETES MELLITUS (DM) Blood glucose of 126 mg/dl or greater Risk of all forms of cardiovascular disease are increased with Type I or Type II DM Mortality rate of patients with DM and CHD is higher than the non diabetic patient

7 OBESITY 97 million adults in the United States Obesity BMI > 30 Overweight BMI Increase risk of CHD, stroke and mortality Associated with dyslipidemia, Type II DM, and hypertension PHYSICAL ACTIVITY Associated with lower LDL and triglyceride levels, increases HDL, improves insulin sensitivity, and lower blood pressure 150 minutes of moderate aerobic activity weekly 75 minutes of vigorous aerobic activity weekly PHYSICAL ACTIVITY Decrease risk of CVD Decrease risk of Type II DM Decrease risk of some cancers Strengthens bones and muscles Improve mental health and mood Increase chance of living longer Improve ability of daily activities MODERATE INTENSITY Walking briskly Water aerobics Bike riding less than 10 miles/hour Doubles tennis Ballroom dancing General gardening VIGOROUS ACTIVITY Race walking, jogging or running Swimming laps Singles tennis Bicycling over 10 miles/hour Jumping rope Heavy gardening Hiking uphill LIPITOR Atorvastatin HMG -CoA reductase inhibitor(statin) as an adjunct therapy to diet Reduce the risk of MI and stroke Reduce elevated total cholesterol, LDL, triglyceride levels Increase HDL

8 LIPITOR mg once daily Recommended starting dose 10 or 20 mg daily LIPITOR Not recommended for children less than 10 years of age years 10 mg daily LIPITOR Side effects Myopathy Arthralgia Rhabdomyolysis Rash Headache Elevated serum transaminase LIPITOR Contraindications Liver disease Elevated serum transaminase Pregnancy Nursing mothers LIPITOR Drug interactions Inhibitor of cytochrome P450 3A4 LIPITOR Precautions Monitor liver function studies May increase serum levels of digoxin and oral contraceptives

9 MEVACOR Lovastatin Cholesterol lowering agent isolated from a strain of Aspergillus terreus MEVACOR mg once daily May increase to maximum of 80 mg daily Reduce the risk of MI and unstable angina Reduce total cholesterol MEVACOR Not recommended in children less than 10 years of age years mg once daily May increase to 40 mg daily MEVACOR Side effects Myalgia Pruritus Dizziness Rash Elevated serum transaminases Rhabdomyolysis MEVACOR Contraindications MEVACOR Drug interactions Active liver disease Elevated serum transaminases Pregnancy Nursing mothers Inhibitor of cytochrome P45034A Monitor oral anticoagulants Use in caution with Spironolactone, Cimetidine and Verapamil

10 MEVACOR Precautions Monitor liver function studies Discontinue if myopathy occurs ZOCOR Simvastatin HMG -CoA reductase inhibitor (statin) as an adjunctive therapy to diet Reduce elevated total cholesterol, LDL and triglyceride levels Increase HDL ZOCOR 5 80 mg once daily Starting dose mg once daily ZOCOR Not recommended for children < 10 years of age years starting dose 10 mg once daily, may increase to maximum dose 40 mg daily ZOCOR Side effects Myopathy Arthralgia Rhabdomyolysis Headache Rash Elevated serum transaminase ZOCOR Contraindications Active liver disease Elevated serum transaminase Pregnancy Nursing mothers

11 ZOCOR Drug interactions Inhibitor of cytochrome P450 3A4 ZOCOR Precautions Monitor liver function studies May increase serum levels of digoxin and oral contraceptives Discontinue if myopathy or elevated creatine kinase level occurs CRESTOR Rosuvastatin HMG -CoA reductase inhibitor as an adjunctive therapy to diet Reduce elevated total cholesterol, LDL and triglyceride levels Increase HDL CRESTOR 5 40 mg once daily Starting dose 20 mg once daily CRESTOR Not recommended for children < 10 years of age years starting dose 5 mg once daily with maximum dose 20 mg once daily CRESTOR Side effects Myalgia Headache Abdominal pain Nausea

12 CRESTOR Contraindications Active liver disease Elevated serum transaminase Pregnancy Nursing mothers CRESTOR Drug interactions Increased risk of myopathy if given with niacin, cyclosporin and fibrates Increased INR with Coumadin Administer antacids 2 hours after CRESTOR Precautions Monitor liver function studies Discontinue if myopathy or elevated creatine kinase levels occur PRAVACHOL Pravastatin HMG -CoA reductase inhibitor as an adjunctive therapy to diet Reduce elevated total cholesterol, LDL and triglyceride levels Increase HDL PRAVACHOL mg once daily PRAVACHOL Not recommended for children < 8 years of age Starting dose 40 mg once daily 8-13 years 20 mg once daily years 40 mg once daily

13 PRAVACHOL Side effects Headache Nausea Myalgia Myopathy Dizziness PRAVACHOL Contraindications Active liver disease Elevated serum transaminase Pregnancy Nursing mothers PRAVACHOL Drug Interactions Increased risk of myopathy if given with niacin, cyclosporin, erythromycin and fibrates Increased effect with cholestyramine and colestipel PRAVACHOL Precautions Monitor liver function studies Discontinue if myopathy or elevated creatine kinase levels occur