W 12 Hyperlipidaemia Flashcards
What are the risk factors for CV disease?
High BP High cholesterol: high LDL, low HDL Diabetes Lack of exercise Family history Age Stress Ethnicity History of CVD Smoking Overweight/ Obesity Junk food Gender - males are more affected Substance abuse Low SES Mental health issues
What are lifestyle interventions or Non pharmacological treatmetn to improve CV disease ?
Smoking cessation Not drinking Healthy diet Manage Stress Manage high BP Lower fat intake + low salt e.g. Mediterranian Regular exercise Manage diabetes Reduce weight Better sleeping habits Lower cholesterol containing food or junk food Lower alcohol intake
Assume you know very little about Mr Wehi. What are the variety of ways you could optimise your communication with Mr Wehi? Think about techniques you have learnt in the skills workshops.
Introduce yourself, provide a comfortable environment - offer to chat in a counselling room/quieter environment
Motivational interviewing techniques (BEARDS)
Explain high BP is a silent killer thus better to stay with current medications, and if the doctor suggests increased dose then it is likely due to the dose he is on not being effective in lowering his BP so it will actually help him.
Expressing empathy by acknowledging his pill burden.
Explain to him motivationally that the risk vs benefit ratio suggests he is to take the one extra medication for his own benefit. If he refuses to take medication it could lead to further complications/CV events down the line which might result in a greater pill burden later for him.
Use visual aids
Use analogies
Explain using simple terms - avoid jargon.
Use the 3 step model - teach back
Encourage patient to talk comfortably
Making a connection with the patient
Ask open questions
Incorporate family into the conversation
Using the risk estimation you got from the calculator, what does the Cardiovascular Disease Risk Assessment and Management for Primary care 2018 document say about the decision to start treatment with atorvastatin?
How does this apply to Mr Wehi’s situation?
Atorvastatin is the first-line choice of statin in NZ
Discuss the benefits and harms of starting lipid-lowering meds (include adverse side effects that may occur) between 5-15% risk
Do not have to start immediately (only do this once CV risk is > 15%)
Emphasise the risk management of CV through the use of atorvastatin
Emphasise that for the best results - medications alone are not sufficient. He needs to change his lifestyle to aid in minimising his BP and lipids. Such as regular moderate exercise and lowering fat/salt content of food (healthier eating)
Suggest at least 5 specific strategies you can use to help Mr Wehi understand his level of cardiovascular risk and the possible benefits of starting a statin?
Using visual aids to explain
Define what you mean by a Cardiovascular event
Use analogies to communicate the risk (e.g. 14 out of 100 people instead of 14%)
Ask him what he knows about the CV disease and ‘fill in the blanks’ for information he doesn’t know about - teach-back method
Using Frequency not probability (use statements instead of probabilities) i.e. 14 out of every hundred people in the same position as you will experience a cardiac event (in the next 5years)
Can give him some information that he can take with him
Distinguishing between modifiable and non-modifiable risk factors
What other changes could you suggest to improve Mr Wehi’s risk score? Play with the risk calculator to see the influence of adjusting various risk factors. The accumulated benefits of multiple changes to risk factors will be greater than any single change alone.
Physical activity (Change sedentary lifestyle)- down to 10.8%
Low fat diet/Mediterranian diet - down to 10.1%
Encourage him to continue with his smoking cessation (praise him)
Continuing to take his BP meds - reduces risk by 4.3%
Reducing alcohol intake (3 standard drinks in 24 hours and 12 maximum in a week)
Eat more less-processed food, reducing takeaway.
Mr Wehi has heard on talkback radio that medications for high cholesterol can cause muscle problems and he is worried about this. What would you say to Mr Wehi about this topic?
Statins are generally well-tolerated and these side effects are rare but can occur e.g. myopathy and rhabdomyolysis
Five cases of myopathy occur for every 10,000 people treated for five years
If these side effects do occur, we can reverse the effects by taking the following actions
Reducing the dose
Changing the statin medication
Changing to a different type of lipid lowering medicine e.g. bile acid binding agents
CK test every week to monitor side effects if showing myopathy symptoms, otherwise yearly.
Acknowledge his concerns
Atorvastatin has fewer side effects than other statins
Provide information about what to look out for in terms of muscle problems e.g. muscle weakness, muscle pain
What is the recommendation for drug therapy at each level of risk?
< 5% - lifestyle changes = smoking cessation
5-15% - lifestyle changes = smoking cessation; discuss risks/benefits of medication
> 15% - advise to take medication as well as lifestyle changes
Established CVD - put patients immediately on BP medication, antiplatelet therapy, and advise lifestyle modifications.
If Patient has already had a heart attack thus automatically goes into high risk - no need to calculate the risks.
What is your recommendation for Amita regarding the use of lipid-lowering medicines and why?
Yes we recommend her to take medication. (eg. Atorvastatin). = it is very effective lipid-lowering and well tolerated.
Funded in NZ.
Long half-life ( therefore, you can take any time Morning or night time )
Which lipid-modifying drug would you choose?
Atorvastatin - first line treatment option
Better tolerated than simvastatin and is 1st line statin treatment option in New Zealand
High efficacy in lowering lipid levels and funded in NZ
Atorvastatin vs. simvastatin
Night time is when LDL cholesterol levels are highest
Atorvastatin has a longer half-life therefore, it can be dosed anytime of the day - improves compliance
Simvastatin can only be taken at night - shorter half life and most cholesterol production occurs at night
Rosuvastatin is unfunded
All others are funded
What would the target blood cholesterol level of lipid-modifying treatment be?
Lower than 4mmol/L for Total cholesterol.
For individuals with a five-year CVD risk of 15 percent or more, lipid-lowering drug treatment, in addition to dietary changes, is strongly recommended, with an LDL-C treatment target below 1.8 mmol/L
Any reduction in LDL will reduce risk
When should this treatment be reviewed?
Blood test every 12 months until management target has been achieved
Annual monitoring once target has been achieved
Monitoring side effect, be caution about muscle pain (myopathy), rhabdomyolysis
Might have to check the creatine kinase if there are symptoms of muscle pain, tenderness and weakness. (every week with a CK rise 3-10x normal with symptoms)
