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Daytime Functioning: Sleep apnea can be a cause for daytime sleepiness and may cause difficulties in thinking clearly. In turn, this can lead to an increase in errors throughout the day and result in accidents being made. On average, motor vehicle crashes are two to three times more common in those who suffer from sleep apnea. In addition, those with sleep apnea are twice as likely to suffer from depression as those who do not have sleep apnea.

 

Cardiovascular Risk: Those who have sleep apnea are at an increased risk for various cardiovascular illnesses, such as systemic hypertension, pulmonary hypertension, coronary artery disease, cardiac arrhythmias, heart failure, and stroke.

 

Systemic Risk: Sleep apnea has been found to increase the risk of individuals developing type 2 diabetes among the general population. In a study that followed 8600 individuals with suspected sleep apnea, it was found that there was about a 30% higher risk of developing diabetes among those who had sleep apnea. In addition, sleep apnea has been associated with increased glucose, triglycerides, inflammation, arterial stiffness, atherosclerosis, and nonalcoholic fatty liver disease.

 

Overall, sleep apnea has been found to be a large contributing factor to poor health and adverse outcomes.

ACC Cholesterol Guidelines

Summary of Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults

Encourage heart-healthy lifestyle habits for all individuals
Initiate or continue appropriate intensity of statin therapy
Clinical ASCVD*
Age ≤ 75 years and no safety concerns: high-intensity statin (COE = I; LOE = A)
Age > 75 years or safety concerns: moderate-intensity statin (COE = I; LOE = A)
Primary prevention: primary LDL-C ≥ 190 mg per dL (4.92 mmol per L)
Rule out secondary causes of hyperlipidemia (see Table 6 in full guideline)
Age ≥ 21 years: high-intensity statin (COE = I; LOE = B)
Achieve at least a 50% reduction in LDL-C (COE = IIa; LOE = B)
Consider LDL-C–lowering nonstatin therapy to further reduce LDL-C (COE = IIb; LOE = C)
Primary prevention: persons 40 to 75 years of age with diabetes mellitus and with LDL-C of 70 to 189 mg per dL (1.81 to 4.90 mmol per L)
Moderate-intensity statin (COE = I; LOE = A)
Consider high-intensity statin when ≥ 7.5% 10-year ASCVD risk using the Pooled Cohort Equations† (COE = IIa; LOE = B)
Primary prevention: persons 40 to 75 years of age without diabetes and with LDL-C of 70 to 189 mg per dL
Estimate 10-year ASCVD risk using the risk calculator based on the Pooled Cohort Equations† in those not receiving a statin; estimate risk every 4 to 6 years (COE = I; LOE = B)
To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences (COE = IIa; LOE = C)
Reemphasize heart-healthy lifestyle habits and address other risk factors
• ≥ 7.5% 10-year ASCVD risk: moderate- or high-intensity statin (COE = I; LOE = A)
• 5% to < 7.5% 10-year ASCVD risk: consider moderate-intensity statin (COE = IIa; LOE = B)
• Other factors may be considered‡: LDL-C ≥ 160 mg per dL (4.14 mmol per L), family history of premature cardiovascular disease, high-sensitivity C-reactive protein ≥ 2 mg per L (19.05 nmol per L), coronary artery calcium score ≥ 300 Agatston units, ankle-brachial index < 0.9, or elevated lifetime ASCVD risk (COE = IIb; LOE = C)
Primary prevention when LDL-C < 190 mg per dL and age < 40 or > 75 years, or < 5% 10-year ASCVD risk
Statin therapy may be considered in select individuals‡ (COE = IIb; LOE = C)
Statin therapy is not routinely recommended for individuals with New York Heart Association class II to IV heart failure or who are receiving maintenance hemodialysis
Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments
Assess adherence, response to therapy, and adverse effects within 4 to 12 weeks following statin initiation or change in therapy (COE = I; LOE = A)
Measure fasting lipid levels (COE = I; LOE = A)
Do not routinely monitor alanine transaminase or creatine kinase levels unless symptomatic (COE = IIa; LOE = C)
Screen and treat type 2 diabetes according to current practice guidelines; heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes (COE = I; LOE = B)
Anticipated therapeutic response: approximately ≥ 50% reduction in LDL-C from baseline for high-intensity statin and 30% to < 50% for moderate-intensity statin (COE = IIa; LOE = B)
• Insufficient evidence for LDL-C or non–HDL-C treatment targets from RCTs
• For those with unknown baseline LDL-C, an LDL-C < 100 mg per dL (2.59 mmol per L) was observed in RCTs of high-intensity statin therapy
Less than anticipated therapeutic response:
• Reinforce improved adherence to lifestyle and drug therapy (COE = I; LOE = A)
• Evaluate for secondary causes of hyperlipidemia if indicated (see Table 6 in full guideline) (COE = I; LOE = A)
• Increase statin intensity, or if on maximally tolerated statin intensity, consider addition of nonstatin therapy in select high-risk individuals§ (COE = IIb; LOE = C)
Regularly monitor adherence to lifestyle and drug therapy every 3 to 12 months after adherence has been established; continue assessment of adherence for optimal ASCVD risk reduction and safety (COE = I; LOE = A)
In individuals intolerant of the recommended intensity of statin therapy, use the maximally tolerated intensity of statin (COE = I; LOE = B)
If there are muscle or other symptoms, establish that they are related to the statin (COE = IIa; LOE = B)
For specific recommendations on managing muscle symptoms, see Table 8 in full guideline

 

High-, Moderate-, and Low-Intensity Statin Therapy (Used in the RCTs Reviewed by the Expert Panel)*

HIGH INTENSITY MODERATE INTENSITY LOW INTENSITY
Daily dosage lowers LDL-C by approximately ≥ 50% on average Daily dosage lowers LDL-C by approximately 30% to 50% on average Daily dosage lowers LDL-C by < 30% average
Atorvastatin (Lipitor), 40†to 80 mg Atorvastatin, 10 (20) mg Simvastatin, 10 mg
Rosuvastatin (Crestor), 20(40) mg Rosuvastatin, (5) 10 mg Pravastatin, 10 to 20 mg
Simvastatin (Zocor), 20 to 40 mg‡ Lovastatin, 20 mg
Pravastatin (Pravachol), 40(80) mg Fluvastatin, 20 to 40 mg
Lovastatin (Mevacor), 40 mg Pitavastatin, 1 mg
Fluvastatin XL (Lescol XL), 80 mg
Fluvastatin, 40 mg twice daily
Pitavastatin (Livalo), 2 to 4 mg

 

Flow Chart for treatment

Major Recommendations for Statin Therapy for ASCVD Prevention

DMD Nephrology Case 1 – Acute Renal Failure

 

You are requested to see an 80-year-old man on the surgical service because of an elevated BUN and creatinine. He had just undergone a splenectomy for thrombocytopenia secondary to splenomegaly from underlying chronic lymphocytic leukemia.  Immediately before surgery his BUN was 22 mg/dl, creatinine was 1.3 mg/dl, urinalysis was normal.  When checked two days post operatively, his BUN had increased to 40mg/dl, and creatinine was 3/0 mg/dl.  Urine output for each of the last two days was approximately 250 ml/day.

 

Discussion points:

  • Given the above information, how would you characterize this patient’s kidney problem? (Go through the differential of prerenal, renal and post renal causes of azotemia)
  • What further information do you need to get historically, through the hospital record, and on physical exam on assessing this patient’s problems?

 

The patient denies symptoms of congestive heart failure.  He has not been extremely thirsty over the last several days.  He has had difficulty urinating over the past several years with a weak urinary stream and nocturia 3-4 times per night. His doctor told him that he had BPH but no therapy was given. The patient denies leg pain or flank pain.  The hospital chart is reviewed which showed the patient had significant bleeding in the operative period with several episodes of hypotension with systolic blood pressure in the 80 range.  These episodes lasted for short periods of time less than 5 minutes and returned to normal blood pressure after that period.  His urine output was 700 ml/day immediately after surgery and dropped to 200-300 ml/day over the past two days.  For the three days after surgery his total fluid balance is positive 3 liters.  His only medication postoperatively was analgesia with Dilaudid.  He did receive one dose of Cephalothin preoperatively and none since that time.

 

Discussion point:

  • How does this historical information affect your differential? (Include possibilities of post-obstructive renal failure secondary to prostatism, and acute tubular injury secondary to hypotensive episodes.)

 

The patient’s physical exam showed his T-37 C, RR-14, BP-130/90, P-82 with no orthostatic changes.  His mucous membranes were moist.  Neck pains were 1cm above the sternal angle.  The patient’s lung exam was clear to auscultation and percussion without rales.  Cardiac exam has a normal S1, S2 without S3 or murmurs appreciated.  The patient’s abdomen was soft with slight tenderness over the surgical scar.  No ecchymosis were noted.  The patient had no CVA tenderness or ecchymosis present in the back.  A foley catheter was placed in the patient at that time which showed approximately 50 cc of urine in the patient’s bladder.

 

Discussion points:

  • How does his physical examination help you in determining the cause of this patient’s acute renal failure? (No signs or symptoms of prerenal azotemia, or post renal obstruction.  The patient could conceivably have ureteral obstructions or trauma to his ureters during surgery though both seem unlikely?
  • What laboratory tests would you order at this time?

 

A fresh specimen of the patient’s urine is examined under the microscope and showed numerous epithelial cells and brown degenerating cellular casts.  No crystals or WBC’s were noted, and only rare RBC’s were present.  The urine sodium was 40 meq/l.  Urine specific gravity was 1.01.  Repeat BUN and creatinine on the 4th day after surgery are BUN-52 mg/dl, creatinine-3.5mg/dl. Uric acid was 9.2 mg/dl.  A renal ultrasound is done, kidneys are normal in size, and no signs of obstruction are present.

 

Discussion points:

  • What is your diagnosis at this time? (ATN seems most likely secondary to the patient’s episode of  hypotension during surgery. Both physical examination and renal ultrasound confirm no signs of bladder obstruction or ureteral obstruction)
  • How would you treat the patient at this time?

 

On day 6 after surgery, the patient’s BUN is 68 mg/dl, creatinine is 4.1 mg/d.  His urinary volumes are between 300-500 ml/day.  Serum electrolytes are NA – 142 mg/dl, K-4.2 mg/dl, Cl-98 mg/dl, HCO3-23 mg/dl.  The patient is started on fluid and salt restriction but he remains oliguric. By day 8 the patient’s BUN is 85 mg/dl, creatinine is 6.3 mg/dl.

 

Discussion points:

  • Is there anything else you would do to manage the patient at this point? (When do you start dialysis on a patient? What are the signs of uremia?)
  • What is the expected course of patients with acute tubular necrosis?

On day 9, postoperatively the patient’s urine output begins to rise to one liter per day, and by day 11 it is up to 3 ½ liters per day.  The patient’s BUN is up to 92 mg/dl, creatinine is 6.9 mg/dl on day 11.

 

Discussion points:

  • Given the patient is now in the polyuric phase of ATN, how would you change his fluid and electrolyte management?

On day 12 the patient’s urine output begins to decrease to 1/5 liters per day.  His BUN and creatinine begin to fall.  Fluid and salt restrictions are discontinued.  The patient is discharged from the hospital on day 14 and followed up as an outpatient. His BUN and creatinine returned to normal three weeks after surgery.

 

West Hills, Calabasas, Woodland Hils.

Assess:

  •    How do you know what your risk of having a heart attack will be? Should you be on therapy to lower your risks? What are the best ways to check your cardiovascular risks?
  •    To calculate your Heart Attack Risk, click here and have your recent Cholesterol and blood pressure numbers ready.

This calculator will give you your risk percentage of having a heart attack over the next 10 years

  •     How do you know what your cancer risk is? What are factors that increase my risk? What can I change in my life to lower that risk?

To evaluate your risk of cancer please click here.

Education

  •         Educating yourself on risk factors for having a heart attack is a crucial first step.
  •         Unsure what HDL Cholesterol or Total Cholesterol are?

o   Total Cholesterol:

  •  This is simply a total of all your cholesterol you have in your blood which includes the bad cholesterol  (VLDL and LDL) as well as the good cholesterol (HDL).
  •  What kind of numbers do you want?
  •         Anything over 240 mg/dL is considered high and puts you at twice as much of a risk of developing a heart attack
  •         At the Cardiovascular Institute we like to have our patients aim to keep their total cholesterol levels below 200 mg/dL

o   HDL Cholesterol:

  •  This is considered the good cholesterol. It is good because it carries cholesterol in your blood and brings it to the liver to remove it from your body. In doing so, HDL helps fight the “bad” cholesterol from building up in your arteries, thereby preventing strokes, heart attacks and high blood pressure.
  •  What kind of numbers do you want?
  •         Anything below 40 mg/dL puts you at risk for a heart attack
  •         At the cardiovascular Institute we like to aim to have our patient’s have levels above 60 mg/dL for optimal heart protection.

What can I do to increase my HDL cholesterol?

One of the best ways proven to increase your HDL or “good” cholesterol is exercise! Regular walking, jogging, or activity each day has been shown to increase HDL cholesterol.

  •         Unsure about blood pressure?

o   How exactly does high blood pressure affect my chances of having a heart attack?

  •  A heart attack is the result of a blocked blood supply to the heart muscle tissue. This can happen when the arteries to the heart become thicker and harder from a buildup of plaque. High blood pressure causes scarred arteries that fill up with plaque and become more prone to blood clots. Sometimes plaque or a blood clot can completely close an artery, blocking the blood flow to tissue on the other side.

High blood pressure, over time, also puts a strain on the heart and makes it work harder to pump blood out to the body. With this extra effort to pump, the heart grows in size and may compromise its ability to pump blood as well.

 

  •  What kind of numbers do you want?
  •         
Total cholesterol
Desirable Below                       Below 200
Borderline high                        200-239
High                                           240 or above
LDL (bad) cholesterol
Optimal                                 Below 70
Near/above optimal 100-129
Borderline high 130-159
High 160-189
Very High 190 or above
HDL (good) cholesterol
High 60 or above
Low Below 40
Triglycerides
Normal Below 150
Borderline high 150-199
High 200-499
Very high 500 or above

 

Up to 35% of cases of cancer have a dietary component, with some cancers being tied directly to diet. Research shows patients who follow a plant based diet that is low in fat and high in antioxidants and nutrients is associated with a lower risk of developing cancers such as colon, breast, pancreatic, and prostate cancer.

Implement:

Two of the biggest things you can do to lower your risk of both cancer and heart disease is to eat a healthy diet and exercise daily.

 

Exercise

  • Daily exercise is highly encouraged. We recommend 30 minutes to 1 hour of aerobic exercise. This can include jogging, walking, swimming, or biking. The benefits of daily exercise will not only make you feel better, more confident and happier but it will ultimately prevent disease and unnecessary trips to the doctor.

Diet

  • The old saying of “we are what we eat” has truth to it. We get out of our bodies what we put into them and how we care for them. New research points to a plant based diet reducing the risk of heart disease and many cancers. We also highly encourage a diet low in salt and carbohydrates. For numerous tips on what to eat , tasty recipes, and exercise please take a look at our book online, From Our Heart To Yours,

 


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