What are unmodifiable risk factors of cardiovascular diseases?
- Men
- 50+
- Fx
- South asian, Afro-caribbean
What is a cardioprotective diet?
- INC: fibre, fruit + veg, oily fish
- RED: sat fats, salt <6g, alcohol <14 units
What is used for cardiovascular risk assessment?
Offer to 40+ and those w/ estimated 10 year risk >10%
High risk:
- QRISK: >10%
- ASSIGN: >20%
Which group of people don’t require a cardiovascular risk assessment?
Don’t require calculating bc already at high risk:
Established CV
85+
Diabetes:
- 40+
- Type 1 >10 years
- Type 2 >20 years
- Target organ damage (nephropathy, retinopathy)
- Significantly elevated CVD risk factors
CKD (GFR <60), albuminuria
Familial hypercholesterolemia
What is the primary prevention for a cardiovascular event?
High intensity statin = Atorvastatin 20mg
What is the secondary prevention for a cardiovascular event?
Secondary prevention: Atorvastatin 80mg
- Atherosclerosis: 75mg aspirin daily
- Stroke/TIA + sinus rhythm: Clopidogrel OR dipyridamole AND aspirin
Which drugs are a risk factor for hyperlipidaemia?
- Antipsychotics
- Immunosuppressants
- Corticosteroids
- Antiretrovirals (HIV)
What are the target levels for lipids?
- Total cholesterol - 5 or less
- Non-HDL (bad cholesterol) - 4 or less
- LDL cholesterol (bad cholesterol) - 3 or less
- Triglycerides (bad cholesterol) - 2.3 or less
- HDL cholesterol (good cholesterol) - 1 or above
What is the treatment for hyperlipidaemia?
First line for high LDL cholesterol + moderately high triglycerides: Statin
- Severe: ADD lipid lowering drug (ezetimibe)
- If triglycerides still high: ADD fenofibrate
Familial hypercholesterolemia: High intensity statin
- Alt: ezetimibe
Give examples of drugs that lower lipids
Statins: DEC LDL
Ezetimibe - statin alt
Fibrate: DEC TG
Bile acid sequestrant:
- Colesevelam
- Colestyramine
How do bile sequestrants work?
- Interferes w absorption of fat soluble vitamins (ADEK)
- Take 1 h BFORE (4h for coleveselam) OR 4h AFTER
What is the MOA of statins?
-Competitively block HMG-CoA reductase involved in cholesterol synthesis by the liver
-Most effective lowering LDL cholesterol
What is the indication of statins?
Hyperlipidaemia
CVD prevention
Which statins do you take at night?
Simvastatin + fluvastatin (Cholesterol synthesis at highest)
What are the types of high intensity statins?
Atorvastatin
- Primary: 20mg
- Secondary: 80mg
Rosuvastatin 10mg
Simvastatin: 80mg
- MHRA: risk of myopathy
What are the side effects of statins?
Myalgia
Myasthenia gravis - muscle weakness
- MHRA: inform doctor if hx. Report weak arms/legs that worsen after activity, double vision, dropping eyelids, SOB. Seek immediate medical attention if severe breathing/swallowing problems
Myopathy, myositis, rhabdomyolisis
- Monitor: creatine kinase (5x upper limit- do not give statin)
Interstitial lung disease
- Counselling: Report dyspnoea, cough + weight loss
Diabetes - INC blood glucose + DEC glycaemic control
Hepatotoxicity
- Monitor: LFT - liver transaminase
- STOP 3x upper normal limit
When would you be cautious to use statins?
Uncontrolled diabetes - INC cholesterol levels
- Monitor: HbA1c, fasting blood glucose
Hypothyroidism - INC cholesterol levels
- Monitor: TSH
Nephrotic syndrome (kidney damage)
- Monitor: RFT
Liver disease
- Monitor: LFT liver transaminases
Are statins used in pregnancy?
Teratogenic
- Child bearing age: effective contraception during treatment + 1 month after stopping
- Should be discontinued 3 months before trying to conceive
What are the interactions of statins?
Macrolides → INC statin level = myopathy
- Counsel: stop statin until abx course completed
Enzyme inhibitors → INC statin level = myopathy
Fibrate → INC rhabdomyolisis (AVOID gemfibrozil)
Hepatotoxic drugs (flucoxacillin, tetracyclines, azole antifungals, methotrexate, sulfasalazine, carbamazapine) → INC hepatotoxicity
What are the dose adjustments of simvastatin?
- 10mg: bezafibrate, ciprofibrate
- 20mg: amiodarone, amlodipine, dilt + verapamil
What are the dose adjustments of atorvastatin?
10mg: ciclosporin
What are the dose adjustments of rosuvastatin?
- 5mg: bezafibrate, ciprofibrate, fenofibrate
- 5mg, 20mg: clopidogrel
