CHAPTER 2: CVS: Hyperlipidaemia

Question 1

Those with over which percentage cardiac risk stand to benefit from treatment with lipid-regulating drugs?

Answer 1

Over 10%

Question 2

Which 3 groups of people are risk calculators not suitable?

Answer 2

1. Patients at high cardiovascular risk
2. Type 1 Diabetes
3. Over 85

Question 3

Which parameters do the QRISK 2 and JBS3 calculator base their risk of cardiovascular disease on? (13)

Answer 3

1. Lipid profile
2. Systolic blood pressure
3. Gender
4. Age
5. Ethnicity
6. Smoking status
7. BMI
8. CKD
9. Diabetes
10. Atrial fibrillation
11. Treated hypertension
12. Rheumatoid arthritis
13. Family history

Question 4

In which patients do risk calculators underestimate risk? (5)

Answer 4

1. Serious mental disorder
2. Autoimmune disorders
3. Antiretroviral treatment
4. Medication causing dyslipidaemia
5. Triglyceride concentration

Question 5

Which medication can cause dyslipidaemia? (3)

Answer 5

1. Antipsychotics
2. Corticosteroids
3. Immunosuppressants

Question 6

Give 5 lifestyle modifications people at risk of cardiovascular disease can make

Answer 6

1. Diet
2. Exercise
3. Smoking cessation
4. Alcohol consumption
5. Weight management

Question 7

What is the first line drug for lipid regulation? Offered if lifestyle modifications are ineffective

Answer 7

Statins

Question 8

Should statins be offered to all patients for secondary prevention of cardiovascular disease?

Answer 8

Yes

Question 9

Why should patients with hypothyroidism receive replacement therapy before starting statins?

Answer 9

Because correcting hypothyroidism may correct lipids

Question 10

Which drug and at which dose does NICE recommend for primary prevention in patients with a 10% 10 year risk?

Answer 10

Atorvastatin 20mg/day

Question 11

Which drug does NICE recommend for secondary prevention?

Answer 11

Atorvastatin

Question 12

As well as for primary and secondary prevention, in which other patients should a statin be considered?

Answer 12

Type 1 diabetes

• especially if over 40
• diabetes for over 10 years
• diabetic nephropathy or any other risk factor

Question 13

What should be checked 3 months after starting treatment with statins? (3)

Answer 13

Total cholesterol
HDL-cholesterol
non-HDL cholestrol

Question 14

What is the % reduction aim for non-HDL cholesterol?

Answer 14

40%

Question 15

What is the target non-HDL cholesterol aim?

Answer 15

below 2.5mmol/L

Question 16

What dose can atorvastatin be increased to, to optimised treatment if non-HDL aims are not being met?

Answer 16

80mg

Question 17

Which 4 drugs are not recommended for primary or secondary prevention?

Answer 17

1. Fibrates
2. Omega-3-fatty acid compounds
3. Bile acid sequestrants
4. Nicotinic acid

Question 18

As well as for reducing risk of cardiovascular events, what are statins also first choice to treat?

Answer 18

Hypercholesterolaemia and hypertriglceridaemia

Question 19

Severe hyperlipidaemia not adequately controlled with a maximal dose of a statin may require the use of an additional lipid-regulating drugs such as?

Answer 19

Ezetimibe

Question 20

As well as ezetimibe, which other drugs can be added to statins to help control hyperlipidaemia? (2)

Answer 20

1. Fenofibrate

2. Nicotinic acid

Question 21

What does the combination of a statin and a fibrate or nicotinic acid increase the risk of?

Answer 21

Rhabdomyolisis

Question 22

What is the % reduction aim for LDL cholesterol when using a high intensity statin such as rosuvastatin?

Answer 22

50%

Question 23

If patients have contra-indications to statin, what must they be given as an alternative?

Answer 23

Ezetimibe

Question 24

What is a side effect of nicotinic acid which limits its value?

Answer 24

Vasodilation

Question 25

What is the mode of action of ezetimibe?

Answer 25

Inhibits the absportion of cholesterol

Question 26

What is the mode of action of fibrates?

Answer 26

Decrease serum triglycerides

Question 27

With use of fibrates, what must be monitored? (2)

Answer 27

1. LFTs every 3 months during the first 12 months (discontinue if 3X upper limit) 2. Creatinine

Question 28

In which patients are fibrates mainly used? (2)

Answer 28

1. Serum-TGs over 10mmol/L | 2. Cannot tolerate statins

Question 29

What is the MOA of statins?

Answer 29

Inhibition of the HMG CoA reductase enzyme involved in cholesterol synthesis

Question 30

What is a notable side effect of all statins?

Answer 30

Muscle effects

Question 31

A statin should not be started if the baseline creatine kinase is what?

Answer 31

5X above the upper limit of normal

Question 32

What should be managed adequately before starting statin treatment due to increased risk of muscle effects?

Answer 32

Hypothyroidism

Question 33

If creatine kinase or muscle pain is reported, other causes must be discounted. What are these other causes? (5)

Answer 33

1. Rigorous physcial activity 2. Hypothyroidism 3. Infection 4. Recent trauma 5. Drug or alcohol addiction

Question 34

If a statin is discontined due to rhabdomylosis, can it be reintroduced when symptoms go and creatine kinase levels are back to normal?

Answer 34

Yes, at a lower dose with close monitoring

Question 35

Is routine monitoring of creatine kinase necessary?

Answer 35

No

Question 36

Are statins safe in pregnancy?

Answer 36

No, congenital anomalies have been reported

Question 37

Should patients take contraception while on statins?

Answer 37

Yes. and 1 month after

Question 38

What is the monitoring for statins?

Answer 38

1. Lipid profile 2. LFTs 3. Creatine kinase if muscle pain - if 5X upper limit when done again 7 days later, do not start statins 4. HbA1c if at risk of diabetes

Question 39

What should patients taking statins be counselled to report?

Answer 39

Muscle pain, weakness

Question 40

Which drug should not be given with statins but can if unavoidable? Reduce statin dose

Answer 40

Ciclosporins

Question 41

Can simvastain be sold OTC?

Answer 41

Yes, at a total daily dose of 10mg, as part of a cardiovascular risk reduction programme, maximum pack size 28