Lipids Flashcards
Qrisk3 variables
1) Age 25-84
2) Gender
3) Ethnicity
4) Postcode - social deprivation
5) Smoking status
6) DM/AF/migraines/RhA/SLE/CKD 3-5/severe mental illness (schizophrenia/bipolar/moderate or severe depression)
7) On antihypertensives/atypical antipsychotics/regular steroids/treatment for erectile dysfunction
8) Angina/MI in 1st degree relative < 60y
9) Cholesterol/HDL ratio
10) Systolic BP
12) BMI
Primary target for reducing CV risk with lipid modifying treatment
Non-HDL cholesterol
Who should be offered lipid modification for primary prevention of CVD?
1) 25-84y if QRisk3 >=10% , but can be considered for a score of < 10% if patient chooses/concern risk is underestimated
2) T1DM: consider for all. Offer to those > 40y, had DM for > 10y, nephropathy, other CVD RFs
3) CKD
4) Familial hypercholesterolaemia
5) > 85y without risk assessment, especially if they smoke or have HTN taking into account risk vs benefit
Things to do before starting lipid modification therapy
1) Check for familial hypercholesterolaemia
2) Exclude secondary causes - excess alcohol, uncontrolled DM, hypothyroidism, liver disease, nephrotic syndrome
3) Offer to reassess CVD risk again after lifestyle changes
Blood tests prior to starting lipid modification for primary prevention
1) Lipid profile
2) LFT - can still have statin if < 3x ULN
3) U&E - ensure correct dose.
4) HbA1c - to diagnose DM.
5) TSH - if symptomatic
6) CK - if symptomatic
Interpreting the lipid profile
1) Total cholesterol > 7.5 + FH premature CHD - ?FHC
2) Total cholesterol > 9 or non-HDL > 7.5 - arrange for assessment for FHC
3) Triglyceride > 20 that is not due to excess alcohol or poor glycemic control - urgent specialist review.
4) Triglyceride 10-20 - repeat with a fasting test after 5 days. but within 2 weeks, if remains > 10 for specialist review
5) Triglyceride 4.5-9.9 - CVD risk may be underestimated by risk assessment tools, optimise management of CVD RFs and seek advice if also non-HDL > 7.5
1st line lipid modification therapy for primary prevention of CVD
Atorvastatin 20mg OD with lifestyle changes
If not tolerated switch to different statin eg. simvastatin 80mg or rosuvastatin 10mg
CI in pregnancy
Statin monitoring
3 months after starting treatment measure:
1) Lipid profile: target > 40% reduction in non-HDL-C
- if target not med check compliance, diet, increase dose, consider if eligible for extra lipid modifying drug or specialist advice
2) LFT
3) CK if symptomatic, but if < 5x ULN symptoms not due to statin and can continue unless symptoms severe
4) HbA1c if at high risk of T2DM
Statin for secondary prevention of CVD
Atorvastatin 80mg OD
If already on simvastatin encourage switching to atorvastatin as this has lower risk of myopathy, even if this means lower dose of atorvastatin
When would you consider offering icosapent ethyl to patients already on a statin for secondary prevention?
At high risk of CV events
AND Fasting triglycerides >= 1.7
AND LDL-C 1.04 - 2.60
When would you offer inclisiran?
Primary hypercholesterolaemia (FH) or mixed dyslipidaemia
AND history of CV events (ACS/unstable angina needing hospital admission/coronary or other arterial revascularisation procedures/CHD/ischaemic stroke, PAD)
AND LDL-C >= 2.6 despite maximum tolerated statin +/- or other lipid lower therapies
What treatments may secondary care offer patients with primary non-familial hypercholesterolaemia or mixed dyslipidaemia and what is the criteria?
Proprotein convertast subtillsin/kexin type 9 (PCSK9) inhibitor: alirocumab or evolocumab +/- statin or other lipid lowering drug
Criteria:
1) High risk of CVD + LDL-C > 4
2) Very high risk of CVD + LDL-C > 3.5
Statins:
Mechanism of action & CI of atorvastatin
Inhibits HMG-CoA reductase (involved in cholesterol synthesis) –> reduces LDL-C
CI: active liver disease/ALT > 3x ULN, pregnancy/breastfeeding/not on contraception - stop 3 months before TTC
Interactions:
1) Low dose/safety net:
- amiodarone
- ciclosporin
- amlodipine, diltiazem, verapamil
- ezetimibe, fibrates
- HIV protease inhibitors eg. ritonavir
- fluconazole
- ticagrelor
2) Temporarily stop statin:
- Erythromycin, clarithromycin
- ketonazole, itraconazole
3) Avoid grapefruit juice & St John’s Wort
SE:
- nasopharyngitis
- hyperglycaemia, hypogycaemia, weight gain, headache
Causes of secondary hypercholesterolaemia
Without hypertriglycerideaemia:
1) Hypothyroidism/Cushing;s syndrome
2) Anorexia nervosa
3) Nephrotic syndrome
4) Cholestatic liver disease (PBC)
5) Androgens/ciclosporin
With hypertriglycerideaemia:
1) DM/obesity
2) Pregnancy
3) End-stage CKD
4) Monoclonal gammopathy
5) Excess alcohol
6) HIV
7) Thiazide diuretics, steroids, retinici acid, BB, anti-retrovirals
Simon Broome criteria
FH:
1) Lipids:
< 16y: Total cholesterol > 6.7 or LDL > 4
> 16y: Total cholesterol > 7.5 or LDL > 4.9
2) DEFINITE if also:
- tendon xanthomata in patient/1st or 2nd degree relative
- OR genetic mutation (LDL receptor/apo B-100/PCSK9)
3) POSSIBLE if also:
- FH MI < 60y in 1st degree relative/< 50y in 2nd degree relative
- FH of total cholesterol > 7.5 in adult 1st/2nd degree relative
- FH of total cholesterol > 6.7 in < 16y child or sibling
Make clinical diagnosis of FH if possible or definite and refer for confirmation
