statins and beta blockers

anti-cholersterol agents

1. statins

2. cholesterol absorption inhibitors

3. PCSK9 inhibitors

4. bile acid sequestrants

5. fibrates

6. omega 3 fatty acid derivatives

7. vitamin B3 supplements

most common prescribed meds for high cholesterol

statins

statins mechanism of action

inhibit HMG-CoA reductase in the liver

statins effect on CV system

reduce LDL production to reduce risk of CV disease

statins PT implications

skeletal muscle breakdown (resting muscle pain, cramping, fatigue, rhabdomyolysis)

increased blood glucose

increased bleeding time

statins impact on exercise

resistance training is important to maintain skeletal muscle integrity, differential diagnosis with claudication and over exertion/muscle strain

statins on the market

lipitor and crestor

cholesterol absorption inhibitors mechanism of action

reduce cholesterol absorption in the small intestine

cholesterol absorption inhibitors effect on CV system

reduce LDL levels to decrease risk of CV disease

cholesterol absorption inhibitors PT implications

liver toxicity (monitor liver labs)

skeletal muscle breakdown (resting muscle pain, cramping, fatigue, rhabdomyolysis) when combined with statin

when is cholesterol absorption inhibitors used

when statin therapy is not enough

PCSK9 inhibitors are

injectable

very expensive

used when pt is intolerant of statins

PCSK9 inhibitors mechanism of action

increase liver removal of LDL from blood stream

PCSK9 inhibitors effect on CV system

lower LDL levels to reduce risk of CV disease

PCSK9 inhibitors PT implications

skeletal muscle breakdown risk is lower but still need to monitor for it

bile acid sequestrants mechanism of action

bind bile acids in the intestine, forcing liver to convert cholesterol to bile acids

bile acid sequestrants effect on CV system

reducing LDL levels

bile acid sequestrants PT implications

GI side effects

nutritional deficiencies

Fibrates are used for

hypertriglyceridemia to decrease risk of pancreatitis

fibrates mechanism of action

agonists for the peroxisome proliferator-activated receptor-alpha, which binds to DNA, activating genes that enhance lipid metabolism

fibrates effect on the CV system

lowers triglycerides and raises HDL levels

fibrates PT implications

skeletal muscle breakdown (resting muscle pain, cramping, fatigue, rhabdomyolysis)

recommend lower intensity exercie

omega 3 fatty acid derivatives are used for

severe hypertriglyceridemia

-fish oil supplements

-not broadly recommended for daily health because large-scale, high quality studies have failed to show consistent cardiovascular benefits

omega 3 fatty acid derivatives mechanism of action

reduces triglyceride synthesis in the liver

omega 3 fatty acid derivatives effect on the CV system

decrease VLDL-triglycerides

omega 3 fatty acid derivatives PT implications

increased bleeding risk

vitamin B3 supplements

old, not used as much

vitamin B3 supplements mechanism of action

inhibiting hepatocyte DGAT2, which reduces hepatic triglyceride synthesis, VLDL, and LDL secretion

vitamin B3 supplements effect on CV system

lowers LDL cholesterol and triglycerides, raises HDL levels

vitamin B3 supplements PT implications

flushing

liver toxicity

orthostatic hypotension

myopathy when used in combo with statins

beta blockers action

block beta receptors, compete with NE and epi

beta blockers effect on the heart

decreased O2 demand of the heart

decreased HR

decreased CO

decreased contractility

decreased BP

side effects of beta blockers

CNS penetration (sedation, fatigue, insomnia, depression)

smooth muscle spasm (cold extremities, bronchospasm, claudication, sexual dysfunction)

exaggerated heart therapy (bradycardia, hypotension, heart block)

hypoglycemia/impaired glucose tolerance

-weight retention or gain can be very frustrating to pts

beta blocker PT implications

need to know HR response when on medication, changing doses might require new exercise prescription, use RPE scale to monitor intensity

betablocker meds end in

ols

HR response with beta blockers

-reduce HR and contractility

pts may not reach predicted target HR during activity

when pt on beta blockers PTs should rely more heavily on

RPE (moderate intensity 11-13)

symptoms

talk test

functional tolerance

when to modify intensity, terminate exercise, or refer back to medical team with pt on beta blockers

abnormal symptoms during exercise:

-excessive fatigue

-dizziness

-chest pain

-dyspnea

-inadequate hemodynamic response (BP drops during exercise)

with pts on beta blockers need to educate pt on

abnormal symptoms with exercise

reason they can’t rely on HR response

BP response with beta blockers

contribute to hypotension, dizziness, fatigue or orthostatic hypotension

-monitor vitals with ascent against gravity in acute

-monitor vitals with aerobic exercise in OP

how can beta blockers mask symptoms of hypoglycemia

-especially in diabetes pts

-blunt sympathetic NS responses, making hypoglycemia more difficult to recognize

in a pt on beta blocker what symptoms may a pt have if hypoglycemic

NO tachycardia

-confusion

-fatigue

-weakness

-delayed responses

-impaired coordination

what is the gold standard for calculating target HR with beta blockers

use a measured peak HR from a graded exercise test performed while pt is taking meds

-if not use HRR

-DO NOT USE 220-age