Cardiovascular risk assessment + Statins Flashcards
What is the difference between primary and secondary CV risk reduction?
- Primary: Aim of preventing CVD in those at risk of developing it e.g. patients with diabetes
- Secondary- Risk reduction in those who already have established CVD e.g. already have had a MI. Aim is to decrease the risk of further cardiovascular events and deterioration of cardiovascular function.
What are the Framlingham equations- what factors did they consider when estimating CVD risk and what were their limitations?
Involved the Framlingham heart study in which men and women aged 30-62 were followed up every 2 years to aim to identify CVD risk factors
Looks at;
Age
Gender
BP
Smoking status
Cholesterol ( TC:HDL ratio)
Produced charts that are divided into gender and age
Limitations
- Don’t take into account many factor that we now know to be CVD risks e.g. ethnicity, family history, BMI, Socio-economic status
- Only representative of 1960-1980s in a north-American cohort- not representative of us in the UK
Therefore, is no longer recommended
Now the Framlingham equations are no longer recommended for estimating CVD risk, what tool does NICE reccommend?
The QRISK3 score
What factors are taken into account by the QRISK3 score?
- Age
- Gender
- Blood pressure
- Smoking status
- Cholesterol
- Ethnicity
- Deprivation
- BMI
- family history of CHD in first degree relative
- Diabetes
- chronic kidney disease- stage 3+
- Rheumatoid arthritis
- Atrial fibrillation
- Migraines
- Systemic lupus erythematosus
- Corticosteroid use
- Severe mental illness diagnosis
- HIV or AIDS diagnosis
- Erectile dysfunction diagnosis
- Second generation “atypical” antipsychotic use
In what circumstances are QRISK scores not appropriate?
- In patients with type 1 diabetes mellitus
- In patients with an eGFR of <60 ml/minute +/- Albuminuria
- Patients who are >85 years old
- Patients with a risk of familial hypercholestraemia or an inherited lipid abnormality
If a patient stopped smoking in the last 5 years, how should you consider their smoking status when looking at CV risk?
Still consider the patient as a smoker when assessing their CV risk
- If the patient stopped smoking more than 5 years ago, it should be considered un regards to their lifetime exposure- use clinical judgement
How do you calculate pack years?
Pack years is a clinical measurement that estimates a patients exposure to tobacco?
Number of pack years = Packs smoked per day x years as a smoker
OR
Number of pack years= Number of cigarettes per day x number of years smoked / 20
(Assumes a pack is 20 cigarettes)
What are the guidelines for offering cardiovascular disease risk prevention?
Calculate a patients QRISK3 score:
If the patients QRISK3 score is above 10%:
Before offering statin treatment,
- Discuss the benefits of lifestyle interventions and modifications. Offer the patient a re-review after they have made some changes. Be aware that some patients may need support to change their lifestyle e.g. refer to smoking cessation or diet classes.
- Optimise the management of other modifiable risk factors in the patient e.g. Blood pressure, Blood glucose
- Exclude any possible secondary causes of dyslipidemia e.g. hypothyroidism, alcoholism, hypothyroidism, liver disease and any possibilities of familial hypercholestraemia
If lifestyle intervention is ineffective or inapropriate for the patient:
- Discuss the benefits and risks of taking a statin, taking into account additional factors such as comorbidities, potential benefits from lifestyle interventions, the person’s preferences, polypharmacy, frailty and life expectancy.
- If patient decides take a statin: Offer a statin- most commonly Atorvastatin 20mg
in those groups where the QRISK3 score is not appropriate, different approaches must be taken:
- Aged 85 years + :consider offering atorvastatin 20 mg, which may be of benefit in reducing the risk of non-fatal myocardial infarction. But, take into account factors that may make treatment inappropriate such as comorbidities, polypharmacy, general frailty, and life expectancy.
- chronic kidney disease
- With type 1 diabetes mellitus - Offer atorvastatin 20 mg to adults aged over 40 years, or who have had diabetes for more than 10 years, or who have established nephropathy, or have other CVD risk factors.
With hypercholesterolaemia
What is ‘Absolute risk’ and what is ‘Relative risk’?
Absolute risk: The patients risk of developing disease taking into account the patients original risk.
Relative risk: Compares the risk in two groups- these that have been treated and those that have not been treated. This doesn’t take into account the patients original risk and so often makes data look better.
If a statement says ‘Statins can decrease CVD risk by 30%” what type of risk is this referring too and what does it actually mean for the patient (if their QRISK is 20%)?
- This statement (30% reduction) is the relative risk reduction and so doesn’t take into account the patients individual risk
- If a patient has a QRISK score of 20%, this will be decreased to 14%. 30% of 20 = 14%. This is the relative risk and should NOT be communicated to the patient
- the absolute risk = 20-14= 6%. This is what should be told to the patient.
- The number needed to treat here ( no of patients that need to take a statin before 1 stroke/MI is prevented) = 100/ absolute risk reduction = 100/6= 17
What does the term ‘Number needed to treat (NNT)’ mean?
This is the number of people that need to be treated with a statin before one stroke or myocardial infarction is prevented.
Calculated by: 100/Absolute risk reduction
How could you explain the benefits of statin treatment to a patient with a 10% 10-year risk of CVD?
If 100 people had the same risk as you, in the next 10 years - 10 of those people would suffer a myocardial infarction or a stroke. If these 100 people, then take a statin, 4 out of these 10 will be prevented but 6 will still have a myocardial infarction or stroke regardless of the statin therapy. We can’t identify whether the patient will be in this group that the statin helps avoid the stroke/MI or the statin will have no benefit to you.
Is aspirin recommended for primary prevention of cardiovascular disease?
Aspirin is no longer routinely recommended for the primary prevention of CVD risk.
This is because the bleeding risk outweighs its use for prevention.
What lifestyle interventions should be encouraged for the primary prevention of CVD risk?
- Healthy balanced diet
- Cardioprotective diet - e.g. low saturated fats
- Increase physical activity- minimum of 150 minutes of moderate exercise per week
- Weight management- Target BMI is 18.5-24.9
- Decreased alcohol consumption
- Smoking cessation
What is the QRISK-lifetime tool and when is it used?
Where the QRISK3, score calculates a patients 10 year risk of developing CVD, the QRISK-lifetime score looks at a patients overall lifetime risk (up to 99 years).
- Its use should be considered to inform discussions on CVD risk and to motivate lifestyle changes, particularly for people with a 10-year QRISK3 score less than 10%, and people under 40 who have CVD risk factors.
- it compares the current risk with the risk if the known risk factors were controlled e.g. smoking cessation, BMI, cholesterol, Blood pressure
How are patients who don’t seek regular medical attention identified to having a high QRISK score?
In England all people aged 40–74 years are offered an NHS Health Check every 5 years, which includes an assessment of CVD risk
What baseline assessments should be done before statin treatment is initiated?
Smoking status
Alcohol consumption
Blood pressure
BMI
Lipid profile- total cholesterol, non-HDL and HDL, Triglycerides
Diabetes status
RenaL function
Liver function tests (LFTs)- especially transaminase level ( Alanine or Aspartae aminotransferases (ALT or AST))
TSH levels- hypothyroidism can increase cholesterol and the muscle-related side effects of statins.
Why do TSH levels need to be checked before starting a statin?
- Underactive thyroid (hypothyroidism) can lead to an increased cholesterol level, and treating hypothyroidism may cause your cholesterol level to decrease, without the need for statins.
Hypothyroidism will be confirmed by HIGH TSH levels and LOW
Free T4 and T3 levels - raised TSH level is gold standard for
diagnosis
e.g. above above 4.5 mU/L
What is the primary prevention for patients with a 10 year QRISK score above 10% ( in terms of drugs)?
Atorvastatin 20mg OD
What is the difference in prescribing statins for CV risk in type 1 diabetes and type 2 diabetes?
Prescribing statins for CV prevention in patients with T2DM, is the same as non-diabetic patients- if QRISK is above 10% or patient is above 85 years old
In type 1 diabetes:
Offer Atorvastatin 20mg daily for all T1DM when:
- >40 years old
- Had DM for >10 years
- Established nephropathy
- CVD risk factors
What is the secondary prevention for CVD (i.e. had a previous cardiovascular event)?
Atorvastatin 80mg
+ Lifestyle recommendations
In what cases may the secondary prevention Atorvastatin 80mg dose be reduced?
- If there is drug interactions
- If the patient has high risk adverse drug reactions
- Patient preference
What is the primary and secondary prevention of CVD in patients with chronic kidney disease?
Atorvastatin 20mg
- if the target cholesterol reduction is not achieved with this and eGFR is over 30, a higher dose may be considered.
- If eGFR is less than 30, agree a higher dose with a renal specialist.
What eGFR is required in order for a patient with chronic kidney disease to have an Atorvastatin dose increase above 20mg?
- if the target cholesterol reduction is not achieved with this and eGFR is over 30, a higher dose may be considered.
- If eGFR is less than 30, agree a higher dose with a renal specialist.
How are statins classified?
Statins are classified based on their ability to reduce cholesterol levels:
- Low: 20-30%
- Medium: 31-40%
- High- 40%+
What intensity of statin is recommended by NICE for cvd prevention?
A high intensity statin, especially Atorvastatin
What are the high intensity statins that are recommended for CVD prevention and which is not?
- Atorvastatin is the first choice
- Rosuvastatin can also be used as a high intensity statin
- Simvastatin 80mg is also a high intensity statin, but is not recommended by NICE as it has an increased risk of muscle toxicity.
Why is Simvastatin 80mg not recommended by NICE to be used as a High intensity statin in CVD Prevention?
is not recommended by NICE as it has an increased risk of muscle toxicity (myopathy)
NICE GDG concluded that since equivalent or greater benefits can be obtained from atorvastatin, with a lower risk of myopathy, there is no reason for considering initiating simvastatin 80 mg for the primary prevention of CVD
What is myopathy?
Myopathy is a general term referring to any disease that affects the muscles that control voluntary movement in the body. Patients experience muscle weakness due to a dysfunction of the muscle fibers
What is the target for cholesterol reduction following initiation of a statin?
Aim is for a >40% reduction in non-HDL cholesterol (bad)
HDL cholesterol (good): >1mmol/L
What monitoring is needed after initiation of statin therapy and when should this occur?
At 3 months:
- Total cholesterol, HDL, Non-HDL
- liver function tests (LFTs)
if the LFTs (AST or ALT) are >3 x that of the upper limit of normal, discontinue the statin and re-check in 1 month.
If the LFTs are elevated but not as high as 3x, continue the statin and recheck LFTs in 1 month.
Follow up;
If after 3 months, the target of 40% decrease in non-HDL cholesterol has not been achieved:
Discuss adherence and timing of dose
Optimise adherence to diet and lifestyle measures
Consider an increase in dose if taking less than Atorvastatin 80mg. if dose is increased, re-monitor 3 months after
Once stable, monitor the lipid profile, LFTs at 12 months and then annually thereafter.
What does it mean if AST or ALT levels are raised and what is the procedure if they are?
AST and ALT are measured in LFTs and raised levels can be a sign of liver damage.
- If levels of AST or ALT is raised >3 x the normal limit, the statin should be discontinued and then levels re-checked in 1 month
- If levels are elevated but not 3 x the normal, continue and re-check in 1 month
What enzyme levels may be raised in statin-induced myopathy?
Creatine Kinase- this enzyme is released in the presence of muscle damage
- it is not measured routinely, only if patient reports symptoms of statin-related muscle toxicity.
The European society of cardiology guidelines state that:
Guidelines for the Management of Dyslipidaemias recommend re‐ evaluation of indication for statin treatment if CK becomes elevated ≥ 4 x upper limit of normal (ULN). If > 10 x ULN, treatment should be stopped.
Normal levels : Male 40-320; Female 25-200 u/L
What are the side effects of statins?
- Statin related muscle toxicity (SRM):
Symmetrical pain +/or weakness
worsened on exercise
large proximal muscles- muscles at the centre of body eg. shoulders, hips
elevated creatine kinase (toxic monitoring parameter)
Resolved with discontinuation of statins
also: - GI disturbances e.g. diarrhoea
- Hepatotoxicity
- New onset of T2DM
- Sleep disturbance
- Intracranial haemorrhage
- Neurocognitive and neurological impairment e.g.; dementia
the evidence for these last 2 points is conflicting
If a patient is intolerant to a statin what can be done?
A lower dose is better than no dose at all!
- Dechallenge- stop drug initially and the re-challenge- use a lower dose of the same staton
- Change the statin- e.g. try rosuvastatin or pravastatin instead of atorvastatin. e.g. as r + p are hydrophilic, whereas atorvastatin is lipophilic- so are less likely to cross into other tissues and cause adverse effects
- Consider alternate days or twice weekly dosing
- As a last resort, consider alternative drugs e.g. Ezetimibe, Inclisiran, Bempedonic acid
What other drugs can be as an alternative to statins where they are not tolerated (last resort)?
- Ezetimibe
- Bempedoic acid
- Inclisiran
- PCSK9 inhibitors
What would you do with statins should a patient be prescribed an antibiotic e.g. Clarithromycin?
Hold statin till course complete
