Lipid management for the primary and secondary prevention of CVD prevention of Flashcards
some essential biological functions of lipids
they are a precursor of vitamin D
Steroid hormone precursor
they are used in bile acid synthesis
is a plasma lipoprotein constituent
they aid with membrane fluidity
they insulate nerve fibres
the main classifications of lipoproteins
HDL
LDL
IDL(intermediate density lipoprotein)
VLDL
chylomicron and chylomicron remnant
HDLs are the smallest, and the order follows on as listed
out of the classifications of liproteins, which have the largest portions of the following molecules;
proteins
cholesterol
triglycerides
HDLs
LDLs
Chylomicrons
what is a healthy cholesterol level
think anout HDL, LDL and total serum cholesterol levels
total serum cholesterol should be below 193mg/dL or 5.0mmol/L
LDL cholesterol should be below 116mg/dL or 3.0mmol
HDL cholesterol levels should be above 1.0mmol/L for a man or 1.2mmol/L for a woman/ above 39mg/dL for a man or 46mg/dL for a woman
total cholesterol levels and HDL levels are very sensitive to fasting, true or false
false, they are not. therefore they can be used as screening method for CV risk
which lipoprotein classes are recommended for testing while fasting
LDLs and triglycerides as they are more affected by fasting
high levels of TG are associated with low levels of ??
triglycerides
LDL function
LDL release cholesterol into the tissues, including the vessel walls.
what does elevated serum LDL cholesterol indicate?
it is a predictor of
cardiovascular disease (CVD) events
HDL function
HDL brings cholesterol back from the tissues(like blood vessels) to the liver
what is low serum HDL levels(<1mmol/L) a strong predictor of
a strong predictor of
coronary heart disease (CHD)
how does the size of LDLs affect the CHD risk it poses
smaller LDLs pose a higher CV risk than larger LDLs. this is because, Small LDL particles are more easily oxidized, making them more likely to trigger inflammation and plaque formation.
Benecheck description
it is the device used commonly in SELFCheck total cholesterol
Benecheck is a brand of medical devices that can test blood glucose, cholesterol, uric acid, and more
watch the youtube video on how it works for lipid/ cholesterol testing. the link to the vid can be found on the slides
some non-pharmacological ways to manage or control high cholesterol levels
Eating a heart-healthy diet
weight management
regular exercise
quitting smoking
plant stanols and sterols
alcohol consumption
etc
describe metabolic syndromes
name 5 markers used in MS diagnosis(at least 3 of these required to make a diagnosis )
triglycerides >150mg/dl
HDL(good fats)<40mg/dl in men and <50mg/dl in women
waist circumference >= 40 in men or >=35 in women
high blood pressure
high fasting glucose >=100mg/dl
Plant sterols and stanols are naturally occurring compounds in plants that can help lower cholesterol levels by reducing the absorption of cholesterol in the gut. They have a similar structure to cholesterol, allowing them to compete for absorption in the digestive system, thus preventing some cholesterol from being absorbed into the bloodstream.
name some classes of drugs or just drugs used in the treatment of high serum lipid levels (hyperlipidaemia)
Statins – HMGCoA Inhibition – upregulated LDL receptors
- Ezetimibe – decrease cholesterol absorption (NPC1L1 block)
- Fibrates – decrease TAG/fatty acids (PPAR inhibition)
- Bile acid sequestrants – bind bile acids decreasing enterohepatic recirculation
- Bempedoic acid – decreases cholesterol synthesis (ACL inhibition)
- Inclisiran - small interfering RNA which limits production of PCSK9, increasing uptake of LDL-cholesterol and thereby lowering
levels in blood
before initiating treatment for hyperlipidaemia, what initial considerations should be made regarding treatment
● Measure non-fasting full lipid profile (total cholesterol, HDL-C, non-HDL-C, triglycerides) and HbA1c as part of an initial baseline assessment.
● Consider secondary causes of hyperlipidaemia and manage as needed.
●Ensure appropriate baseline and follow up tests. Measure BMI.
● Identify and exclude people with contraindications/drug interactions
what is the first line non pharmacological treatment for both secondary and primary prevention of CVD in hyperlipidaemia
Identify and address all modifiable risk factors - smoking, diet, obesity, alcohol intake, physical activity, blood pressure and HbA1c
first line pharmacological treatment for the primary prevention of CVD in hyperlipidaemia, if lifestyle modification is ineffective or inappropriate
offer atorvastatin once 20mg daily
then review full lipid profile after 3 months
state the conditions that should be met before statin therapy is considered for adults without established CVD in hyperlipidaemia
- if Age ≤84 & QRISK ≥10% over next 10 years
- if Type 2 diabetes & QRISK ≥10% over next 10 years
- Type 1 diabetes, if they have one
or more of the following: - Over 40 years
- Had diabetes for >10 years
- Have established nephropathy
- Have other CVD risk factors
*if CKD and eGFR < 60 mL/min/1.73m2 and/or albuminuria
*Age ≥85 years
high intensity lipid treatment in hyperlipidaemia should achieve reduction of f non-HDL-C greater than what?
40%
Non-HDL cholesterol is a calculated value that represents all the cholesterol in your blood that is not carried by HDL (good) cholesterol. It’s essentially the total cholesterol minus the HDL cholesterol
If patients on a high‑intensity statin have side effects, what do we do
If patients on a high‑intensity statin have side effects, offer a lower dose or an alternative statin
if patients on atorvastatin 20mg still have a higher risk of CVD after 3 months of use, then what do we do for the primary prevention of a cardiovascular event
consider increasing the dose every 2-3 months up to a maximum dose of atorvastatin 80mg daily
If maximum tolerated dose of statin does not achieve non-HDL-C reduction > 40% of baseline
value after 3 months, what do we do
If maximum tolerated dose of statin does not achieve non-HDL-C reduction > 40% of baseline
value after 3 months consider adding Ezetimibe 10mg daily
if statin treatment is contraindicated, or not tolerated, what do we do
-see AAC statin intolerance algorithm
- Ezetimibe 10mg monotherapy may be considered. Assess response after 3 months.
- Ezetimibe 10mg/bempedoic acid 180 mg combination may be considered when ezetimibe alone does not control non-HDL-C/LDL-C well enough
do we offer a fibrate, nicotinic acid, bile acid binder or
omega-3 fatty acids alone or in combination with statin, for the prevention of CVD
nope
do we give statin treatment straightaway in the secondary prevention of CVD in hyperlipidaemia
yup
first line for the secondary prevention of CVD in hyperlipidaemia
atorvastatin 80mg once daily
if CKD offer 20mg
review of lipid profile after 3 months
WHEN ARE WE TO SUSPECT FAMILIAL HYPERLIPIDAEMIA, AND DO WE USE THE QRISK ASSESSMENT TOOL
If TC>7.5mmol/L and/or LDL-C
>4.9mmol/L and/or non-HDL-C
>5.9mmol/L, a personal and/or family
history of confirmed CHD (<60 years)
and with no secondary causes:
suspect familial hypercholesterolaemia
(possible heterozygous FH)
NO WE DONT
TREATMENT TARGET FOR FAMILIAL HYPERLIPIDAEMIA
If clinical diagnosis of FH and/or other risk factors present** follow the recommended treatment management pathway for primary or secondary
prevention as for non-FH**, BUT
Aim to achieve at least a 50% reduction of LDL-C (or non-fasting non-HDL-C) from baseline.
WHAT DO WE USE TO MAKE A CLINICAL DIAGNOSIS OF FH
Use the Simon Broome or Dutch Lipid Clinic Network (DLCN) criteria to make a clinical diagnosis of FH.
WHEN DO WE USUALLY REFER IN FH
they are assessed to be at very high
risk of a coronary event**
- OR therapy is not tolerated
- OR LDL-C remains >5mmol/L
(primary prevention)
- OR LDL-C remains >3.5mmol/L
(secondary prevention)
despite maximal tolerated statin and
ezetimibe therapy.
**defined as any of the following:
* Established coronary heart disease
* Two or more other CVD risk factors
SOME EXAMPLES OF INJECTABLE THERAPIES USED IN THE SECONDARY PREVENTION OF CVD
NOTE THEY ARE NOT ONLY USED IN SECONDARY PREVENTION, THEY CAN ALSO BE USED IN PRIMARY PREVENTION BUT NOT AS OFTEN
Inclisiran
PCSK9i
THEY ARE USED IN VERY SEVERE CASES WHERE OTHER THERAPIES ARE INEFFECTIVE
