CHAPTER 2: CVS: Hyperlipidaemia Flashcards
Those with over which percentage cardiac risk stand to benefit from treatment with lipid-regulating drugs?
Over 10%
Which 3 groups of people are risk calculators not suitable?
- Patients at high cardiovascular risk
- Type 1 Diabetes
- Over 85
Which parameters do the QRISK 2 and JBS3 calculator base their risk of cardiovascular disease on? (13)
- Lipid profile
- Systolic blood pressure
- Gender
- Age
- Ethnicity
- Smoking status
- BMI
- CKD
- Diabetes
- Atrial fibrillation
- Treated hypertension
- Rheumatoid arthritis
- Family history
In which patients do risk calculators underestimate risk? (5)
- Serious mental disorder
- Autoimmune disorders
- Antiretroviral treatment
- Medication causing dyslipidaemia
- Triglyceride concentration
Which medication can cause dyslipidaemia? (3)
- Antipsychotics
- Corticosteroids
- Immunosuppressants
Give 5 lifestyle modifications people at risk of cardiovascular disease can make
- Diet
- Exercise
- Smoking cessation
- Alcohol consumption
- Weight management
What is the first line drug for lipid regulation? Offered if lifestyle modifications are ineffective
Statins
Should statins be offered to all patients for secondary prevention of cardiovascular disease?
Yes
Why should patients with hypothyroidism receive replacement therapy before starting statins?
Because correcting hypothyroidism may correct lipids
Which drug and at which dose does NICE recommend for primary prevention in patients with a 10% 10 year risk?
Atorvastatin 20mg/day
Which drug does NICE recommend for secondary prevention?
Atorvastatin
As well as for primary and secondary prevention, in which other patients should a statin be considered?
Type 1 diabetes
- especially if over 40
- diabetes for over 10 years
- diabetic nephropathy or any other risk factor
What should be checked 3 months after starting treatment with statins? (3)
Total cholesterol
HDL-cholesterol
non-HDL cholestrol
What is the % reduction aim for non-HDL cholesterol?
40%
What is the target non-HDL cholesterol aim?
below 2.5mmol/L
What dose can atorvastatin be increased to, to optimised treatment if non-HDL aims are not being met?
80mg
Which 4 drugs are not recommended for primary or secondary prevention?
- Fibrates
- Omega-3-fatty acid compounds
- Bile acid sequestrants
- Nicotinic acid
As well as for reducing risk of cardiovascular events, what are statins also first choice to treat?
Hypercholesterolaemia and hypertriglceridaemia
Severe hyperlipidaemia not adequately controlled with a maximal dose of a statin may require the use of an additional lipid-regulating drugs such as?
Ezetimibe
As well as ezetimibe, which other drugs can be added to statins to help control hyperlipidaemia? (2)
- Fenofibrate
2. Nicotinic acid
What does the combination of a statin and a fibrate or nicotinic acid increase the risk of?
Rhabdomyolisis
What is the % reduction aim for LDL cholesterol when using a high intensity statin such as rosuvastatin?
50%
If patients have contra-indications to statin, what must they be given as an alternative?
Ezetimibe
What is a side effect of nicotinic acid which limits its value?
Vasodilation
What is the mode of action of ezetimibe?
Inhibits the absportion of cholesterol
What is the mode of action of fibrates?
Decrease serum triglycerides
With use of fibrates, what must be monitored? (2)
- LFTs every 3 months during the first 12 months (discontinue if 3X upper limit)
- Creatinine
In which patients are fibrates mainly used? (2)
- Serum-TGs over 10mmol/L
2. Cannot tolerate statins
What is the MOA of statins?
Inhibition of the HMG CoA reductase enzyme involved in cholesterol synthesis
What is a notable side effect of all statins?
Muscle effects
A statin should not be started if the baseline creatine kinase is what?
5X above the upper limit of normal
What should be managed adequately before starting statin treatment due to increased risk of muscle effects?
Hypothyroidism
If creatine kinase or muscle pain is reported, other causes must be discounted. What are these other causes? (5)
- Rigorous physcial activity
- Hypothyroidism
- Infection
- Recent trauma
- Drug or alcohol addiction
If a statin is discontined due to rhabdomylosis, can it be reintroduced when symptoms go and creatine kinase levels are back to normal?
Yes, at a lower dose with close monitoring
Is routine monitoring of creatine kinase necessary?
No
Are statins safe in pregnancy?
No, congenital anomalies have been reported
Should patients take contraception while on statins?
Yes. and 1 month after
What is the monitoring for statins?
- Lipid profile
- LFTs
- Creatine kinase if muscle pain - if 5X upper limit when done again 7 days later, do not start statins
- HbA1c if at risk of diabetes
What should patients taking statins be counselled to report?
Muscle pain, weakness
Which drug should not be given with statins but can if unavoidable? Reduce statin dose
Ciclosporins
Can simvastain be sold OTC?
Yes, at a total daily dose of 10mg, as part of a cardiovascular risk reduction programme, maximum pack size 28
