Cardiovascular Treatment Flashcards
What are some modifiable risk factors of CVD
Smoking
Diet
Exercise
Weight
Alcohol
Non modifiable risks of CVD
Age
Ethnicity
Genetics
Males
Who gets statins regardless of their QRISK score
High risk patients
Whats the QRISK tool
A tool used to assess 10 year CVD risk. If they get 10% or more theyre at risk hence need primary prevention (20mg atorvastatin)
Primary prevention of CVD includes
20mg atorvastatin and lifestyle changes
Anti hypertensives if bp >140/80
What ages are at higher risk of CVD
50+yrs
85+yrs are at higher risk
What comorbidities of CVD are modifiable
Depression/anxiety
Abnormal lipids
Hypertension
T2DM
Social isolation
Whats the definition of cardiovascular disease
Group of disorders of the heart caused by atherosclerosis and thrombosis
Cardiovascular diseases include
MI
stroke
Angina
QRISK2 estimates….
10 year CVD risk
Qrisk 3 estimates
10 year CVD risk
JBS3 estimates
The lifetime risk of CVD events and 10 year
ASSIGN estimates
10 year risk of CVD
Which CVD risk tool is used in scotland
ASSIGN
The rest are used in england and wales
Who are the high risk patients of CVD who require statins regardless of the risk assessments
T1DM
established CVD
CKD
familial hypercholesterolaemia
80 yrs or over especially if they smoke or have hypertension
10% or more 10 yr CVD risk
Which drugs are used in primary prevention of CVD
Lipid regulating drugs
Antihypertensives (only high risk patients with BP >140/90mmHg)
Are antiplatelets used in primary prevention of CVD
No
Whens antihypertensives given in CVD primary prevention
If theyre high risk with a BP of >140/90mmHg
What drugs are used in CVD secondary prevention
Lipid regulating drugs such as high dose (atorvastatin 80mg)
Antihypertensives (bp >140/90mmHg)
Antiplatelets
A patient requires primary prevention as they achieved 14% on the QRISK tool. They also have anxiety and depression. What primary prevention would you give?
Lifestyle measures
If ineffective give a low dose statin
A patient requires primary prevention as they achieved 11% on the QRISK tool. They also have a history of familial hypercholestraemia. And they present with a blood pressure of 164/93mmHg. What primary prevention would you give?
Atorvastatin 20mg or ezetimibe
Antihypertensive because theyre high risk and have BP >140/90mmHg
In primary prevention what would be the first line?
Lifestyle if theyre not high risk
If ineffective give a low dose statin
In primary prevention we aim to reduce non HDL cholesterol by……
> 40%
What is hyperlipidaemia?
High cholesterol, triglycerides or both
What are the main causes of hyperlipidaemia?
Hypothyroidism
Drugs — antipsychotics especially 1st gen, immunosuppressants, antiretrovirals and corticosteroids)
Liver/ kidney disease
Family history
Diabetes
Lifestyle- smoking, obesity
Which drugs can cause hyperlipidaemia
Antipsychotics especially 1st gen
Antiretrovirals
Corticosteroids
Immunosuppressants
How do thyroid levels affect cholesterol
Low thyroid levels (hypothyroidism) causes high cholesterol levels
Patients at high risk of developing hyperlipidaemia include….
T1DM, T2DM if their CVD risk is 10% or more
CKD
family history
Age
CVD risk 10% or more
Which patients do you give statins regardless of serum cholesterol levels
Patients at high risk
- T1DM, T2DM if their CVD risk >10%
- CKD
- family history
- over 80
- CVD risk 10% or more
If you cant use statins in primary prevention of CVD, what is the second line?
First line is a low dose statin
2nd line is ezetimibe
What is a high intensity statin?
A statin which reduces LDL/ bad cholesterol by more than 40%
What are examples of high intensity statins?
Atorvastatin
Rosuvastatin
Simvastatin
For primary prevention of CVD what statins would you use and why
High intensity (Rosuvastatin, atorvastatin, simvastatin) or ezetimibe
Because they reduce LDLs by more than 40%
Why are statins beneficial in 85yrs ans over in CVD disease risk
They reduce risk of non fatal MI
Can we use fibrates in primary and secondary prevention of CVD
No
What lowering lipid drugs cant we use in primary and secondary prevention of CVD
Give examples
Fibrates
Clofibrate
Fenofibrate
Gemfribrozil
What lowering lipid drugs aren’t recommended in primary and secondary prevention of CVD
Nicotinic acid, bile acid sequestrants and omega 3 fatty acid compounds
Healthy Range for HDL
> 1
Range for triglycerides
< 1.8
LDL range in high risk patients
2 or less
LDL range in a healthy adult
3 or lower
TC range in high risk adults
4 or less
TC range in healthy adults
5 or less
Hyperlipidaemia diagnosis lipid range
6 or more
Hypercholesterolaemia drug of choice
Why
Statins to reduce LDL by 50% or more
Hypercholesterolaemia first line, 2nd line and 3rd line
- Statins
- Ezetimibe
- Refer to specialist for nicotinic acid, bile acid or a fibrate
If triglyceride levels are high (>1.8mmol) what can be added to a statin and why
Fenofibrate
Because theyre effective at lowering triglycerides than statins
Whats used to lower triglycerides and LDL cholesterol
Nicotinic acid
Statins interact with fibrates because
They increase the risk of rhabdomyolysis
Whats rhabdomyolysis
Muscle wastage
Statin monitoring
Liver function and creatinine kinase
How frequently would you monitor liver function in statin use
liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment, unless indicated at other times by signs or symptoms suggestive of hepatotoxicity
How frequently would you monitor creatinine kinase in statin use
Before treatment and in patients who have had persistent, generalised, unexplained muscle pain
When would you discontinue statins when monitoring liver function
If they have more than 3x the upper limit of the reference range
Measure hbA1c in those at high risk of diabetes who are using statins, how frequently
Before and after 3 months
Statin is contraindicated with ____ because of increased risk of rhabdomyolysis
Gemfibrozil
Which fibrate is contraindicated with statins
Gemfibrozil
Statins MOA
Inhibit HMG CoA reductase
An enzyme involved in cholesterol synthesis in the liver
Can statins be given in pregnancy
No
Can statins be given in breastfeeding
Avoid
How prior would you stop statins before pregnancy
Stop statins 3 months before trying to conceive
Statins patient and carer advice, look out for_____
Rhabdomyolysis—> unexplained muscle pain, tenderness or weakness
Can statins be used in hepatic impairment
Use with caution
But avoid in active liver disease or when there are unexplained persistent elevations in serum transminases (3x the upper limit)
Can statins be used in renal impairment
Discontinue if elevated creatinine kinase because of sign of myopathy
A patient is on simvastatin, he went in for his monitoring at 3 months and his creatinine kinase was elevated. What would you do and why?
Discontinue statins because its a sign of myopathy
Whats myopathy
Muscle weakness
Do the SE of statins increase with dose increase
Yes
Whats a common side effect of statins
Muscle toxicity
Which statins can you give anytime of the day and why
Atorvastatin and Rosuvastatin due to their long half life
Which statins do you need to give at night
Simvastatin
Pravastatin
Fluvastatin
Atorvastatin 80mg OD dose for
Secondary prevention if CVD
Simvastatin 80mg MHRA warning
Causes rhabdomyolysis
Whats the max strength of simvastatin with amlodipine
Why
20mg simvastatin
Because amlodipine increases statin exposure
Whats the max strength of atorvastatin with ciclosporin
10mg atorvastatin
Whats the max strength of Rosuvastatin with clopidogrel
20mg Rosuvastatin
Maximum strength of simvastatin with a fibrate
Simvastatin 10mg
Max strength of simvastatin with amlodipine
Simvastatin 20mg
Max strength of simvastatin with Amiodarone
20mg
Max strength of simvastatin with diltiazem
20mg
Max strength of simvastatin with verapamil
20mg
A patient presents to you with muscle pain and cramps in their legs, their on statins, what do you do?
Check creatinine kinase levels
If 5x above upper limit repeat in 7 days
Withhold statin until less than 5x the upper limit of the normal range then start at a lower dose
A patient on a statin needs their LFTs monitored how frequently
Before
3Months
12 months
Whats monitored before starting statins
LFTs
U&Es
Creatinine kinase
HbA1c or fasting blood glucose
Hypothyroidism
Renal function
Whats monitored after starting statins
LFTs at 3 months and 12 months
HbA1c in those at high risk of diabetes at 3 months
Important statin interactions
Nicotinic acid, fibrates, Amiodarone, colchicine
Carbamazepine
Clarithromycin/ erythromycin
Grapefruit juice
Ketoconazole/ miconazole
Amlodipine
Statins and amlodipine interaction
Increases exposure of statin and increased risk of rhabdomyolysis
Statin interaction with ketoconazole/ miconazole
Increased exposure to statins
Grapefruit interaction with statins
Increases exposure to statin
Clarithromycin/ erythromycin snd statin interaction
Increases exposure to statin
Carbamazepine and statin interaction
Increased risk if Hepatotoxicity
Amiodarone interaction with statin
Increased risk of rhabdomyolysis
Colchicine interaction with statin
Increased risk of rhabdomyolysis
Nicotinic acid and statin interaction
Increased risk of rhabdomyolysis
Fibrates and statin interaction
Increased risk of rhabdomyolysis
statins CI with Gemfibrozil
Max strength of simvastatin with Ronalazine
20mg
Simvastatin at high intensity strength is
80mg
Simvastatin strength at medium intensity is
40, 20mg
Simvastatin strength at low intensity
10mg
Simvastatin 20mg is what intensity
Medium
Atorvastatin high intensity strengths
20,40,80mg
Atorvastatin medium intensity strengths
10mg
Fluvastatin medium intensity strength
80mg
Fluvastatin low intensity strength
20,40mg
Pravastatin low intensity strengths
10,20,40mg
Rosuvastatin high intensity strengths
10,20,40mg
Rosuvastatin medium intensity strength
5mg
