Cardiovascular Risk Assessment & Statins (Clinical) Flashcards
What is classed as Primary CV risk reduction?
Pt is at risk of CVD
-Aim to prevent CVD in those at a risk of developing it.
Example is Diabetic patients
What is classed as secondary CV risk reduction?
Those who have CVD
-Have had a MI so now we need to reduce the risk of it happening again.
What are the Framingham Equations based on?
CVD risk is estimated on:
-Age
-Gender
-BP
-Smoking status
-Cholesterol (TC:HDL ratio)
Why isn’t the Framingham equation used?
It does not take into account other risk factors, such as;
Ethnicity, Family history, BMI, Socioeconomic status
-Tends to overestimate UK population risk
What is the ASSIGN score?
-Score of risk factors 1-99
High risk = score of 20+
What does NICE recommend to calculator CVD risk?
QRISK
What does QRISK include?
Ethnicity, treated HTN, Social deprivation, BMI, Family history,
Other medication conditions - AF, DM, CKD, RA, Migraines, Steroids, Lupus (SLE), Antipsychotics, Mental illness, ED, Variable systolic bp readings
Who do we use QRISK for and when do we do something about it?
*Pt is 25-84 primary prevention
*Pt has T2DM 25-84
*10 year risk of CVD greater than 10%
–> Do a full formal risk assessment
Who don’t you use QRISK for?
All these patients are already considered high risk
-T1DM
-eGFR <60ml/min &/or albuminuria
-Risk of familiar hypercholesterolaemia / other inherited lipid abnormality
-Above 85, especially if smoke/HTN
What must be discussed before offering statins?
Lifestyle changes and optimise management of other modifiable risk factors (Blood glucose/Bp)
When would a patient who has stopped smoking stop being a CV risk due to that?
5 years still considered a CV risk, anymore than that use clinical judgement
Define what it means by pack years?
A pack year is smoking 20 cigarettes a day for one year:
Number of pack years = packs smoked per day x years as a smoker
OR
Number of cigarettes smoked per day x no of years smoked /20
What percent do statins reduce your relative risk by?
30%
What does relative risk reduction mean?
How much the treatment reduces the risk of bad outcomes relative to the control group who did not have the treatment
What does absolute risk reduction (ARR) mean?
Risk of developing over time from and about the patient.
Percent over 10 years - Percent reduced by.
What does number needed to treat mean?
How many people needed to treat to prevent one adverse event occurring.
Worked out by:
100/ARR
What is NOT routinely offered for primary prevention? CVD
Aspirin 75mg OD - as risk of bleeding outweighs the benefit
What baseline assessments should be done before starting statin therapy?
-Smoking status
-Alcohol consumption
-BP
-BMI
-Lipid profile
-Diabetes status
-Renal function
-LFTs
-TSH
IF you have a patient with T1DM, what should be considered?
Starting Atorvastatin 20mg OD
WHEN:
Pt is 40+
Been diagnosed for more than 10 years or has established nephropathy or other CVD risk factors
If a patient has a 10-year QRISK3 score of >10%, what should they be offered?
Atorvastatin 20mg OD
Pt X has previously had a stroke and has got T2DM, What statin should be offered?
Atorvastatin 80mg OD
*Secondary prevention
Pt J Has previously had a cardiac event occur, and hasn’t got diabetes, what statin should be offered?
Atorvastatin 80mg OD
*Secondary prevention
What should the primary prevention dose of Atorvastatin be for people with CKD?
Atorvastatin 20mg OD
When should the dose of statin be increased?
If target reduction not achieved &
-If renal function 30 or above then increase the dose,
-If eGFR is lower than 30 agree a higher dose with a renal specialised
What statins are classed as being HIGH intensity?
Atorvastatin 20mg-80mg
Simvastatin 80mg
Rosuvastatin 10-40mg
What statins are classed as Medium intensity?
Fluvastatin 80mg
Simvastatin 10mg
Atorvastatin 10mg
Rosuvastatin 5mg
What statins are classed as low intensity?
Fluvastatin 20-40mg
Pravastatin 10mg-40mg
Simvastatin 10mg
What percentage reduction do you aim for when starting statins for hypercholesterinaemia?
> 40% reduction in NON-HDL cholesterol
What tests do you do when the patient has been on statins for 3 months?
-Total cholesterol
-LFTs (if 3x higher than before - discontinue and recheck in 1 month)
What would you do if a patients, 40% reduction is not achieved?
-Discuss adherence
-Optimise adherence to diet and lifestyle measures
-Consider statin dose increase, if dose is less than 80mg an the person is judged to be at a higher risk - use clinical judgement
When would you check a patients Creatine kinase levels?
If they develop symptoms of statin related muscle toxicity - as the enzyme is released upon muscle damage
Once a patient is stable on statins, when and what should be tested?
12 monthly
-Lipid profile and LFTs
- If up-titration required recheck after 3 months
What is the main side effect to keep an eye out for when a patient is on statins?
-Statin associated muscle symptoms ‘myothy’ - very specific
-Symmetrical pain or weakness
-Large proximal muscles
-Worsened on exercise
-Elevated Creatine Kinase CK
-Resolve with discontinuation
What are the general side effects associated with statins?
-GI disturbance
-Hepatotoxicity
-New onset T2DM
-Neurocognitive and neurological impairment
-Intracranial haemorrhage
-Sleep disturbance
What should you do if a patient appears to be intolerant to statins?
-Try a lower dose statin
-Rechallenge at a lower dose of the same high intensity statin
-Change the statin (Hydrophilic (rosuvastatin instead of lipophilic atorvastatin)
-Consider alternate day/twice weekly dosage
If you was considering alternate day/twice weekly dosage of statins, what statin would be preferable?
Pravastatin or Rosuvastatin
If a patient is intolerant to statins what is an alternative drug to use?
Ezetimibe, PCSK9i, Bempedoic acid, Inclisiran
