cardiovascular disease Flashcards
what is cardiovascular disease?
group of heart conditions that affect heart and blood vessels caused by atherosclerosis and thrombosis eg coronary heart disease, MI, stroke etc
who is at high risk of cardiovascular disease? [4]
men
ethnicity eg south asians
ppl with family history of CVD
ppl aged over 50 and risk increases with age
what are the 9 modifiable risk factors for cardiovascular disease?
hypertension abnormal lipids obesity smoking excess alcohol poor diet diabetes psychosocial eg anxiety and depression low exercise
give examples of some risk calculators?
what do these do?
QRISK 2, QRISK 3, JBS3, ASSIGN
predict likelihood of cardiovascular event and deciding whether statins should be prescribed or nor
what drug is given when there is a 10 year cardiovascular risk?
primary prevention drug normally atorvastatin
what risk factors does the QRISK 2 and JBS3 tools use to assess CVD risk? [12]
gender age ethnicity smoking BMI lipid profile systolic BP chronic kidney disease social status family history of CVD rheumatoid arthritis atrial fibrilliation
there are certain pt at high risk of CVD that using a risk calculator could underestimate their score. it is unsafe to use a risk calculator for these pt. who are these high risk patients? [6]
type 1 diabetes established CVD chronic kidney disease familial hypercholesterolemia risk increases with age [more than 85 years old] 10 year risk of CVD more than 10%
are aspirins recommended for primary prevention of cardiovascular disease?
when are antihypertensives recommended for primary prevention of CVD?
no
only for those who have a BP higher than 140/90
which drugs are recommended for primary prevention of CVD?
lipid lowering drugs
eg atorvastatin
why is atorvastatin preferred over high dose simvastatin for SECONDARY prevention of CVD?
bc high dose of simvastatin increases risk of myopathy [muscle weakness]
what drugs are recommended for SECONDARY prevention of CVD?
LOW dose aspirin, clopidogrel, dipyridamole
are antihypertensives used in SECONDARY prevention of CVD? and when?
yes but when blood pressure higher than 140/90
define hyperlipidaemia
high cholesterol, high triglycerides or both
what are the causes of hyperlipidaemia? [6]
HYPOthyroidism family history lifestyle [smoking, diet] liver/renal impairment drugs [eg corticosteroids, immunosuppressants] diabetes
which patients are at high risk of developing hyperlipidaemia and should be given a statin regardless of serum cholesterol levels? [6]
type 1 diabetics type 2 diabetics only if they have a CVD risk greater than 10% chronic kidney disease familial hypercholesterolemia risk increases with age [over 85 yo] 10 year risk of cvd greater 10%
what is step 1 and step 2 for management of primary prevention of cardiovascular disease?
step 1: lifestyle
step 2: statins
what is step 1 and step 2 for management of SECONDARY prevention of CVD?
step 1: address secondary causes of hyerplipidaemia eg uncontrolled diabetes, hypothyroidism
step 2: statins again should be offered to everyone including elderly
what is a high intensity statin?
a statin that reduces LDL cholesterol by more than 40%
what strengths of atorvastatin are classed as high intensity?
20mg, 40mg, 80mg
what strengths of rosuvastatin are classed as high intensity?
10mg, 20mg, 40mg
what strength of simvastatin is classed as high intensity?
80mg
which statin is recommended for all patients with secondary prevention of CVD?
atorvastatin
what must be monitored and checked 3 months after a patient starts statins?
lipid profile [total cholesterol, HDL and LDL and triglycerides]
what is the amount of total cholesterol in mmol/L that warrants a diagnosis for HYPERlipidaemia?
more than 6mmol/L
can fibrates be used routinely for primary and secondary cvd prevention?
no
can nicotinic acid, bile sequestrants and omega 3 fatty acid be used for primary and secondary CVD prevention?
no
what can be used if statins are not tolerated in hyperlipidaemia?
what can be used if statins ON ITS OWN ARE NOT EFFECTIVE?
Ezetimibe
a combination of statins and ezetimibe
what can be used if patients cannot take statins or ezetimibe for hyperlipidaemia?
pt must be referred to specialist for either bile acid sequestrants, fibrates, nicotinic acid
when may fenofibrates need to be added to statins to treat hyperlipidaemia?
if the pt has particularly high triglycerides as fibrates are better than statins at reducing trigylycerides
what is the mechanism of action of statins?
inhibit the HMG CoA reductase enzyme [3 hydroxy 3 methylglutaryl coenzyme A] which is an enzyme that is involved in cholesterol synthesis, especially in the liver
what is the main key side effect of statins? what must pt report about this?
muscle toxicity
pt must report signs of muscle pain, tenderness, weakness
what is the conception and contraception advice regarding all statins?
wear contraception during treatment and for 1 month after
are statins safe to use in pregnancy?
no - must discontinue 3 months before trying to concieve
are statins ok for breastfeeding women?
no - avoid
what is the pt and carer advice for statins?
pt must promptly report unexplained muscle pain, tenderness, weakness
what are the monitoring requirements BEFORE starting statins? [6]
- monitor lipid profile
- liver function
- creatinine kinase
- renal function
- thyroid stimulating hormones
- if pt is at high risk of diabetes, monitor HBA1C before statin treatment and then at 4 months
what should be monitored AFTER statin treatment? [2]
after 3 months monitor HBA1C
after 3 months and at 12 months check liver function [LFTs]
can statins be used in liver impairment?
use with caution in liver impairment
do not use in ACTIVE liver disease
can statins be used in renal impairment?
do not use when there is elevated creatine kinase as this is a sign of myopathy
what are the important interactions with statins? [8]
- carbamazepine - increases risk of hepatoxicity
- erythromycin/clarithromycin [macrolides] - increase simvastatin exposure
- fibrates - increase risk of side effects eg rhabdomyolysis
- gemfibrozil: increases risk of rhabdomyolysis
- grapefruit juice: increases exposure to simvastatin
- ketoconazole/miconazole [antifungals]- increase simvastatin exposure
- amlodipine: increase risk of rhabdomyolysis
- amiodarone, colchicine, nicotinic acids, fibrates: rhabdomyolysis
which statins can be given at any time of the day and why?
atorvastatin and rosuvastatin bc they are long acting
which statins can only be given at night time and why?
simvastatin, fluvastatin, pravastatin bc they are short acting
what is the MHRA warning regarding concomitant use of amlodipine and simvastatin?
maximum dose of simvastatin should be 20mg when used with amlodipine due to increased risk of rhabdomyolysis
what is the MHRA warning of concomitant use of simvastatin with either one of amiodarone, ranolazine, diltiazem or verapamil?
maximum dose of simvastatin should be 20mg when given with either of these drugs
what is the MHRA warning of concomitant use of simvastatin and bezafibrate or ciprofibrate?
simvastatin maximum dose should be 10mg when given with these drugs
what is the MHRA warning of concomitant use of clopidogrel and rosuvastatin?
maximum dose of rosuvastatin should be 20mg when given with clopidogrel
what is the MHRA warning of concomitant use of atorvastatin and ciclosporin?
maximum dose of atorvastatin is 10mg
what is the MHRA warning regarding simvastatin 80mg?
increases risk of rhabomyolysis
what is the dose of atorvastatin in:
Primary prevention of cardiovascular events in patients at high risk of a first cardiovascular event
20mg ONCE DAILY
What is the dose of atorvastatin in…
Secondary prevention of cardiovascular events
80mg ONCE DAILY
what is the dose of simvastatin in…
Primary hypercholesterolaemia, or combined (mixed) hyperlipidaemia in patients who have not responded adequately to diet and other appropriate measures
10-20mg oNCE DAILY
what is the dose of simvastatin in …
Homozygous familial hypercholesterolaemia in patients who have not responded adequately to diet and other appropriate measures
80mg ONCE DAILY
WHAT is the dose of simvastatin in…
Prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or diabetes mellitus
20-40mg ONCE DAILY
