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
