Appendix
Appendix 13
Appendix 13a
Some Common Causes of Secondary Dyslipidemia other than diabetes
| Increased LDL cholesterol level | Increased triglyceride level | Decreased HDL cholesterol level |
|
Hypothyroidism Nephrotic syndrome Obstructive liver disease Drugs |
Alcoholism Hypothyroidism Obesity Renal insufficiency Drugs |
Cigarette smoking Hypertriglyceridemia Menopause Obesity Uremia Drugs |
Appendix 13 b
List of some common drugs and other factors which may increase the risk of statin associated myopathy
| Advanced age (especially more than 80 years) in patients (women more than men) |
| Small body frame and frailty |
| Multisystem disease (e.g., chronic renal insufficiency, especially due to diabetes) |
| Perioperative periods |
| Multiple medications |
| Fibrates (especially gemfibrozil, but other fibrates too) |
| Nicotinic acid (rarely) |
| Macrolides (azithromycin, clarithromycin, erythromycin) |
| Azole antifungals (itraconazole, ketoconazole) |
| Calcium antagonists (mibefradil, diltiazem, verapamil) |
| Protease inhibitors (amprenavir, indinavir, nelfinavir, ritonavir, saquinavir) |
| Cyclosporine, tacrolimus |
| Warfarin |
| PDE-5 inhibitors |
| Nefazodone (antidepressant) |
| Verapamil |
| Amiodarone |
| Large quantities of grapefruit juice (usually more than 1 quart per day) |
| Alcohol abuse (independently predisposes to myopathy) |
NOTE: This does not represent a complete list.
Appendix 13c
Changes in Serum Lipid Values with Different Classes of lipid lowering drugs
| Drug class | Total cholesterol levels | LDL levels | HDL levels | Triglycerides |
|---|---|---|---|---|
| Bile acid binding resins | 20% | 10% to 20% | 3% to 5% | Neutral or |
| Nicotinic acid | 25% | 10% to 25% | 15% to 35% | 20% to 50% |
| Fibric acid analogs | 15% | 5% to 15% | 14% to 20% | 20% to 50% |
| HMG-CoA reductase inhibitors | 15% to 30% | 20% to 60% | 5% to 15% | 10% to 40% |
| Ezetimibe | 15-20% | 2-4% | 3-5% |
Appendix 14
Some points about the suggested drug therapy approach to achievement of blood pressure goal:
All patients must be prescribed lifestyle changes and this should be continued even if drug therapy is started.
If BP <15/10 mm Hg above goal (130/80 mm Hg), then ACE inhibitors (ACEi's) or Angiotensin Receptor Blockers (ARBs) alone may be used to initiate therapy. The doses can be gradually increased, as needed to the highest dose range to achieve the blood pressure goal;
If this does not allow for optimal control, add a small dose of a thiazide diuretic.
If the patient has a blood pressure of >15/10 mm Hg above the goal (<130/80 mm Hg), begin therapy with a combination of an ACEi or ARB and a thiazide diuretic, increasing the dosage of the former, as needed, to the high-dose range to achieve the blood pressure goal.
In both the above cases, if blood pressure is still not controlled, add a calcium channel blocker (CCB); a nondihydropyridine CCB is recommended for those with proteinuria of >300 mg/day. Non-dihydropyridine CCBs, verapamil, diltiazem have been shown to reduce both CV mortality, proteinuria and diabetic nephropathy progression independent of an ACE inhibitor.
Beta blockers may be substituted for calcium channel blockers if the patient has angina, heart failure, or arrhythmia necessitating their use. The newer highly selective beta blockers with proven efficacy to reduce CV events and the lowest side effect profile are preferred.
The use of a beta blocker with a nondihydropyridine CCB should be avoided in the elderly and those with conduction abnormalities. Otherwise, such combinations are safe and particularly effective for lowering blood pressure.
If the blood pressure is still not at the optimal level, add a long acting alpha blocker at bedtime.
Most patients will require multi-drug therapy to achieve and maintain their BP at the optimal levels.
Appendix 15
Appendix 15a
Metabolic and Cardiovascular Risk Factors Associated With Visceral Obesity
Raised blood pressure (systolic and /or diatolic) increased levels of insulin resistance / hyperinsulinemia atherogenic dyslipidemia raised levels of LDL-C and apo-B Endothelial dysfunction increased prothomboitic and procoagulant state raised pro-inflammatory status decrease in levels of antiatherogenic levels of adiponectin premature atherosclerosis (leading to early onset CHD and stroke) Raised levels of serum uric acid sleep apnoea syndrome and related polycystic ovary syndrome microalbuminuria is an integral component of the cardiometabolic syndrome, and patients with this syndrome have a propensity to develop type 2 diabetes.
Appendix 15 b
Partial list of medications which have weight gain as a side effect
These medications should preferably not be used if weight loss is the aim. Moroever, some of these medications lead to lethargy and drowsiness and may make increased physical activity difficult. Some of these medications are given in Table.
| Medications | |
|---|---|
| Antidepressants | Serotonin reuptake inhibitors, tricyclic antidepressants, monamine oxidase inhibitors, eg., amitryptiline, imipramine, doxepin, desipramine, trazodone, lithium, etc., |
| Antiepileptics | Valproate, carabamazepine, gabapentin, lithium |
| Antipsychotics | Atypical neuroleptic agents: clozapine, olanzapine, risperidone etc., |
| Steroids and other hormones | Estrogens, progesterone, hormonal contraceptives, corticosteroids |
| Diabetes medications | Insulin, sulfonylureas, glitazones |
| Antihypertensive Agents | a- and ß-adrenergic receptor blockers |
| Serotonin and histamine inhibitors |
NOTE: This is not a complete list.
Appendix 16
Framingham Point Score Tables
NOTE: This system does not take diabetes into its point consideration as all people with diabetes are considered to be in the high risk category.
People with diabetes and ASCVD are always considered to be in the high risk category.