Hyperlipidaemia: Management

Question 1

What 10-year risk percentage means patients are at high risk of CVD?

Answer 1

10%

Question 2

When should QRISK2 not be used?

Answer 2

• T1DM
• Patients with eGFR <60ml/min and/or albuminuria.
• Familial hyperlipidaemia
• Patients age 85yrs and older (Due to their high risk of CVD due to their age)

Question 3

In what populations does QRISK2 underestimate CVD risk?

Answer 3

• People treated with HIV
• Serious mental health problems.
• People taking medicines that cause dyslipidaemia (e.g. antipsychotics, corticosteroids or immunosuppressants)
• Autoimmune disorders (e.g. SLE)

Question 4

At what cholesterol level would you consider the possibility of familial hypercholesterolaemia and investigate further?

Answer 4

>7.5mmol/l and there is a family history of premature coronary heart disease

Question 5

At what cholesterol/LDL would you refer?

Answer 5

NICE recomends referring patients with a total cholesterol of > 9.0mmol/l or an LDL of >7.5mmol/l even in the absence of a first degree relative having premature coronary heart disease.

Question 6

At what QRISK2 percentage score do we offer statins?

Answer 6

10%

Question 7

What statin is offered first line in primary prevention of CVD?

Answer 7

Atorvastatin 20mg ON.

Question 8

NICE wants us to consider statin treatment in ALL T1DM as primary prevention. If a patient is T1DM, under what circumstances should atorvastatin be offered?

Answer 8

They are T1DM and:

• > 40 years
• Have had diabetes for more than 10 years.
• Established nephropathy
• CVD risk factors.

Question 9

If a patient has CKD, how do you manage their hyperlipidaemia?

Answer 9

1. ALL patients with CKD should be offered 20mg Atorvastatin.
2. Increase the dose if a greater than 40% reduction in LDL cholesterol is not achieved and the eGFR is still >30ml/min.
3. If eGFR is <30ml/min then a renal specialist should be consulted before increasing the dose.

Question 10

What statin should be offered to patients first line with CVD, as a part of secondary prevention?

Answer 10

Atorvastatin 80mg ON.

Question 11

How do we follow up with patients who are on statins?

Answer 11

1. Follow up at 3 months.
2. Repeat a full lipid profile.
3. If LDL has not fallen by 40% then discuss lifestyle changes with the patient.
4. NICE recommends at this point we consider increasing the dose of atorvastatin up to 80mg.

Question 12

These are the blood tests at 3 months. What action should you do? (Increase, atorvastatin, reduce it, discuss lifestyle changes or keep it the same.)

Answer 12

• NICE look for a 40% reduction in non-HDL cholesterol after 3 months.
• A 10% reduction in a non-HDL cholesterol of 4.0 would be 0.4 so a 40% reduction would take it down to (4.0 - 1.6 = 2.4 mmol/l). This patients non-HDL cholesterol of 2.1 mmol/l is therefore acceptable.

Question 13

How does Ezetimibe work?

Answer 13

It inhibits cholesterol receptors on enterocytes thus decreasing cholesterol absorption in the small intestine.

Question 14

What are NICE’s guidance on the use of ezetimibe?

Answer 14

• Monotherapy - if statin is not tolerated or contraindicated.
• Can be used in conjunction with a statin for patients to lower their serum total or LDL cholesterol.