Lipid Management Flashcards
What type of molecule is cholesterol?
Steroid.
Where is cholesterol primarily synthesized?
Liver and intestines.
What role does LDL-C play in atherosclerosis?
LDL-C crosses the endothelial barrier, becomes trapped, and forms plaque in blood vessels.
What are some key functions of cholesterol?
Regulates cell membrane fluidity, used for vitamin D production, steroid hormones, bile acids, and energy storage.
What can happen when a plaque disrupts or breaks?
It can lead to the formation of a blood clot (thrombus), potentially causing unstable angina or myocardial infarction (MI).
How does atherosclerosis affect cardiovascular disease risk?
As LDL-C levels rise, cardiovascular disease risk increases.
What are the cholesterol targets according to NICE guidelines?
Total cholesterol > 9 mmol/L or non-HDL > 7.5 mmol/L requires specialist assessment.
What LDL-C guideline does the European recommendation emphasize?
Lowering LDL-C reduces cardiovascular disease (CVD) risk.
What is familial hypercholesterolemia (FH)?
A genetic condition where high LDL-C levels are inherited.
How is familial hypercholesterolemia (FH) inherited?
Autosomal dominant pattern.
What is the difference between heterozygous and homozygous FH?
Heterozygous FH inherits one mutated gene (more common), while homozygous FH inherits two (more severe).
What is the primary prevention treatment for patients without previous cardiovascular history?
Atorvastatin 20 mg daily if QRISK3 is 10% or more.
When is primary prevention offered?
Offered to all patients with T1DM aged more than 40 years, have had diabetes for more than 10years or established nephropathy or other CVD risk factors
When is primary prevention considered?
Consider T1DM aged 18-40.
What are patients aged 85 or over based on?
Clinical judgement, not QRISK3.
What are patients with CKD offered?
Atorvastatin 20mg.
What is the goal of treatment in primary prevention according to NICE?
Achieve a reduction of more than 40% in non-HDL-C levels.
What is the recommended treatment for secondary prevention of cardiovascular disease?
Atorvastatin 80 mg daily.
What are the LDL-C and non-HDL-C targets in secondary prevention?
LDL-C ≤ 2.0 mmol/L and non-HDL-C ≤ 2.6 mmol/L.
How do statins work?
They inhibit the enzyme HMG-CoA reductase, reducing cholesterol synthesis in the liver.
How do statins reduce LDL-C levels?
They increase LDL receptor expression on hepatocytes, promoting LDL uptake from the blood.
What is considered a high-intensity statin regimen?
A regimen that reduces LDL-C by more than 50%.
What percentage reduction in major vascular events can statins provide?
For each 1 mmol/L reduction in LDL-C, statins reduce major vascular events by 22%.
When can atorvastatin be taken?
Any time of the day.
When do simvastatin, pravastatin, and fluvastatin work better?
In the evening.
Why do you aim for in a full lipid profile?
Aiming for >40% reduction in baseline non HDL-C
When do you do a liver function test?
Ok if transaminases less than 3x upper limit. Repeat within 3 months and again at 12 months.
What does a severe renal function cause dose why’s?
Dose may need reducing.
Why do a Hb1ac test?
To diagnose diabetes.
Why test for TFTs?
To rule out hypothyroidism as a cause of high lipids.
How do CK levels affect?
If persistent muscle pain prior to starting- if raised but <5x upper limit, start statin at low dose. If ≥5x upper limit, re-measure after 7 days. If levels are still five times the upper limit of normal, do not start statin. If pain while on treatment and CK 5x upper limit stop statin.
What are the cautions of statins?
Haemorrhagic stroke, risk factors for rhabdomyolysis eg. muscular disorders, elderly, interacting medicines and history of liver diseases or excessive alcohol intake.
What are the contraindictions to statins?
Acute liver disease, pregnant / breastfeeding or women of child-learning potential not using contraception, certain interacting medicines.
What is the gastrointestinal side effect of satin?
Constipation, flatulence, dyspepsia, nausea, diarrhoea
What is the infectious side effect of satin?
Nasopharyngitis (common)
What is the musculoskeletal side effect of satin?
Myalgia, arthralgia, rhabdomyolysis,necrotising myopathy
What is the metabolism side effect of satin?
Hyperglycaemia/ hypoglycaemia, weight gain/loss
What is the respiratory side effect of satin?
Pharyngolaryngeal pain, epistaxis, interstitial lung disease.
What is the nervous system side effect of satin?
Headache, dizziness, paraesthesia, hypoesthesia, dysgeusia.
What is the skin side effect of satin?
Urticaria, skin rash, pruritus, alopecia.
What is the psychiatric side effect of satin?
Insomnia, nightmares (uncommon).
How much can ezetimibe reduce LDL-C levels?
Around 18.5%.
What is the liver side effect of satin?
Derranged LFTs, liver failure, T2DM.
What is the mechanism of action of ezetimibe?
It inhibits the intestinal absorption of dietary and biliary cholesterol - cholesterol absorption inhibitor. Less cholestrol delivered to liver so liver increases LDL receptor expression, remvoing cholestrol from blood
Which is more effective: statin or ezetimibe?
Statins.
What are the cautions and contraindications of ezetimibe?
Myopathy and rhabdomyolysis (usually in combination with statins).
Moderate to severe liver impairment.
What are the side effects of ezetimibe?
Headache, hot flush, hypertension, abdominal pain, diarrhoea, flatulence, myalgia, fatigue, decreased appetite.
ALT and/or ASTincreased (usuallyincombination withstatins).
When is bempedoic acid recommended by NICE?
For adults with hypercholesterolemia when statins are contraindicated or not tolerated, and ezetimibe alone is insufficient.
What are the cautions and contraindications of bempedoic acid?
Gout, persistent deranged LFTs on Tx, pregnant or breastfeeding.
What are the side effects of bempedoic acid?
Anaemia, gout, pain in extremity, myopathy with statins, deranged LFTs, reduction in eGFR.
Under what conditions is icosapent ethyl approved by NICE?
Triglycerides ≥ 1.7 mmol/L, LDL-C 1.04-2.6 mmol/L, established cardiovascular disease, and on a statin.
What are the cautions and contraindications of Icosapent Ethyl?
Allergy to fish, hepatic impairment, AF, bleed risk
What are the side effects of Icosapent Ethyl?
AF, bleeding, peripheral oedema, gout, musculoskeletal pain, constipation
How do PCSK9 inhibitors, like evolocumab and alirocumab, work?
They prevent PCSK9 from degrading LDL receptors, increasing LDL removal from the blood.
Why are PCSK9 inhibitors considered third/fourth-line treatments?
Due to their high cost, despite significant reductions in LDL-C.
