1
Q
What is screening according to the SLG? (SLG)
A
- Lipid testing accompanied by an overall CVD risk assessment
2
Q
What are 3 different CVD risk calculators that can be used? (SLG)
A
- University of Edinburgh
- Best Science Medicine
- QRISK2
3
Q
For patients in CKD, what global CVD risk calculator is recommended? (SLG)
A
- QRISK2 – included CKD in its estimation of risk
4
Q
What is another option that can be used to convey cardiovascular risk to patients? (CCS)
A
- Cardiovascular age using the Cardiovascular Life Expectancy Model (CLEM)
- Patient’s age minus the difference between his or her estimated remaining life expectancy (adjusted for coronary and stroke risk) and the average remaining life expectancy of Canadians of the same age and sex
5
Q
What are the only cardiovascular risk calculators that have been validated among a Canadian population? (CCS)
A
- FRS
- CLEM
6
Q
At what age should lipid screening begin in patients without CVD (primary prevention)? (SLG)
A
- Age ≥40 years in men
- Age ≥50 years in women
- Earlier if known CVD risk factors (including but not limited to):
- Hypertension
- Diabetes
- Smoking history
- Family history of premature CVD
7
Q
What conditions are associated with increased risk of CVD and should screening be considered in? (CCS)
A
8
Q
What is the evidence for offering cardiovascular risk screening in women with a history of hypertensive diseases of pregnancy? (CCS)
A
- Independently associated with increased risk of CVD death
- 2.14 for women with preeclampsia
- 9.5 for severe preeclampsia
- Average age of onset of the first vascular event is 38 years (for those who develop an event)
9
Q
How does the CCS guideline differ on when to start lipid screening? (CCS)
A
- Age 40 to 75 for both Men and Women
- Use either the FRS or CLEM
10
Q
By how much does a positive parental history of premature CVD increase an individual’s calculated FRS percent risk? (CCS)
A
- 2-fold
- <55 years in first degree male relatives
- <65 years in first degree female relatives
11
Q
What is the earliest age in which screening could be considered, even in those with risk factors? Why? (SLG)
A
- Age 35
- Risk estimation tools do NOT include patients younger than 35 years
12
Q
Which is preferred, fasting or nonfasting, lipid levels to calculate global CVD risk? Why? (SLG/CCS)
A
- No preference (fasting = nonfasting)
- Equal ability to predict CVD events
- TC and HDL used in risk calculation and minimal variation
- Differences that occur between fasting and nonfasting are less than the within-person variability from repeat lipid testing
13
Q
In which patients do the CCS recommend that statins are indicated without the need for CVD risk assessment? (CCS)
A
- Clinical atherosclerosis
- AAA >3.0 cm or previous aneurysm surgery
- Diabetes mellitus
- CKD
- LDL-C ≥ 5.0 mmol/L OR documented familial hypercholesterolemia
14
Q
How much variation is seen between fasting and non-fasting lipid levels? (CHEP/CCS)
A
- TC <2%
- HDL <2%
- LDL <10%
- DECREASES after eating, hemodilution or exchange of cholesterol on LDL by triglycerides
- TG 20%
- INCREASES after eating normal meals, peaking 4 hours postprandially
15
Q
In which situation do the CCS guideline recommend that fasting lipids be tested? (CCS)
A
- Triglyceride level >4.5 mmol/L (Conditional recommendation, low quality evidence)
- Major studies that determined changes in non-fasting lipids excluded individuals with prior triglyceride levels >4.5 mmol/L
16
Q
How frequent should repeat lipid screening be performed for patients not taking lipid-lowering therapy? Why? (SLG/CCS)
A
- Every ≥5 years (both SLG and CCS)
- Can be earlier if other CVD risk factors develop in the interim
- Substantial short-term variability and minimal long-term change in lipid levels
- Lipid levels constitute only 1 variable in determining global CVD risk assessment
17
Q
When should lipid screening stop in patients without CVD (primary prevention) and why? (SLG/CCS)
A
- Age 75 years (both SLG and CCS)
- Risk equations are not based on patients in this age range
- Except for ASCVD risk estimator
18
Q
Should biomarkers be included as part of the risk assessment for lipid screening? (SLG)
A
- No – limited evidence
19
Q
What does the CCS guideline recommend in regards to using biomarkers as alternate targets to LDL-C? (CCS)
A
- Non-HDL-C (TC – HDL) and apo B SHOULD be considered alternate targets to LDL-C
20
Q
Which is the only biomarker that appears to offer a potentially meaningful improvement in all measures of performance when added to Framingham risk score? (SLG)
A
- Coronary artery calcium level
- Requires further validation, safety assessment, and cost-effectiveness analyses
21
Q
For which patients do the CCS guidelines suggest coronary artery calcium (CAC) levels may be used for screening? (CCS)
A
- Asymptomatic, middle-aged adults (FRS 10-20%) where treatment decision are uncertain
- Low-risk middle-aged individuals with a family history of premature CHD
22
Q
How can the CAC score be used to estimate risk of a CVD event? (CCS)
A
- CAC = 0 –> NPV 95-99% of any CVD event within 2 to 5 years
- CAC > 100 –> high risk (>2% annual risk) of a CVD event within 2 to 5 years
- CAC > 300 –> very high risk of a CVD event within 10 years (28%)
23
Q
For which patients do the CCS guidelines suggest Lipoprotein (a) or Lp(a) levels may be used for screening? (CCS)
A
- Intermediate FRS or with a family history of premature CAD
24
Q
What 10-y CVD risk score should patients be recommended to start a statin for primary prevention of CVD? (SLG)
A
- <10% = retest lipid levels in 5y
- 10-19% = suggest discuss initiation of statins (preferably moderate-intensity)
- ≥20% = strongly encourage discuss initiation of statins (preferably high-intensity)
25
**In patients at intermediate risk (10-19%), which circumstances would make statin therapy indicated? (CCS)**
* LDL-C ≥ 3.5 mmol/L OR
* Apo B ≥ 1.2 g/L OR
* Non-HDL-C ≥ 4.3 mmol/L OR
* Men ≥ 50 or Women ≥ 60 years and 1 additional risk factors including:
* Low HDL-C
* Impaired fasting glucose
* Increased waist circumference
* Cigarette smoking
* Hypertension
26
**What is the evidence for recommending statin therapy for intermediate risk (10-19%) patients with an LDL-C ≥ 3.5 mmol/L? (CCS)**
* Majority of studies in intermediate risk patients included subjects with baseline LDL-C near or above 3.5 mmol/L
* Except for JUPITER where all had LDL-C \< 3.5 mmol/L with an elevated CRP
* HOPE-3 trial included male ≥ 55 or female ≥ 65 years and one additional risk factor
* Demonstrated reduction in CVD events with rosuvastatin 10 mg daily REGARDLESS of LDL-C levels (mean LDL-C 3.3 mmol/L)
27
**In which circumstance would you consider offering statins to patients \>75 years for primary prevention? (SLG)**
* Life expectancy and overall health status are good
* Should be left to the discretion of the clinician and patient
28
**What cholesterol target is recommended for reducing CVD? (SLG)**
* None
29
**What modifiable causes of hyperlipidemia should patients be tested for? (CFPC)**
* Alcohol abuse
* Thyroid disease
30
**What are 3 lifestyle interventions with proven evidence that should be discussed with patients for global CVD risk reduction? (SLG)**
* Smoking cessation
* Mediterranean diet
* Exercise
31
**Are omega-3 polyunsaturated fatty acid supplements recommended to reduce CVD events? (CCS)**
* No
* No benefit based on meta-analyses of randomized trials involving 75,000 participants
32
**How much exercise is recommended for CVD prevention? (SLG)**
* \>150 min in \>4 sessions of moderate (brisk walking) to vigorous exercise weekly
33
**What intervention has been shown to offer the best risk reduction for CVD? (SLG)**
* Smoking cessation
34
**How does the Mediterranean diet, exercise, statin intensity and ASA compare in terms of RRR for CVD? (SLG)**
Therapy
Relative Risk Reduction (%)
Mediterranean diet
30
Exercise
30
Low intensity statin
25
Moderate intensity statin
30
High intensity statin
35
ASA
12
35
**What baseline testing is recommended prior to starting a patient on a statin? (SLG)**
* Generally unnecessary however evidence against testing baseline ALT or CK is poor and up to the discretion of the clinician
36
**Should CK and ALT be routinely monitored in patients treated with a statin? (SLG)**
* No
* Reserve for patients who are SYMPTOMATIC or at higher risk of adverse events
37
**Which statin should not be considered first-line therapy in patients ≥65 years and why? (SLG)**
* Pravastatin - ?risk of cancer
38
**By how much do low-potency and high-potency statins reduce baseline estimated CVD risk? (SLG)**
* Low-potency = 25% RRR
* High-potency = 35% RRR
* Based on secondary prevention trial (no trials comparing statin doses for primary prevention)
39
**By how much do statins reduce all-cause mortality? (SLG)**
* 10% RRR
40
**What are examples of low, moderate and high intensity statins? (SLG)**
41
**In which patients could lower-intensity statins be offered? (SLG)**
* Elderly (frail)
* CKD
42
**What LDL targets should be used when dosing statins? (SLG)**
* No evidence to recommend adjusting doses to achieve specific LDL targets
* Only fixed doses are tested in trials
* Patients at equivalent levels of risk get the same benefit regardless of pretreatment LDL levels
43
**What LDL targets are recommended by the CCS guidelines when dosing statins? (CCS)**
* LDL-C \<2.0 mmol/L or \>50% reduction of LDL-C
* Alternatives are apoB \<0.8 g/L or non-HDL-C \<2.6 mmol/L
* \>50% reduction of LDL-C for patients with LDL-C \>5.0 mmol/L
* LDL-C \<1.8 mmol/L or \>50% reduction of LDL-C with a recent acute coronary syndrome (IMPROVE-IT trial)
* There is NO conclusive evidence for using targets for lipid-lowering therapy, as no randomized controlled trial have tested specific lipid targets
* To date, no clear lower limit of LDL-C below which there is no additional benefit, specifically with statin therapy, has been identified
44
**What should be done for patients that do not tolerate a specific statin regimen? (SLG)**
* Offer a lower-intensity regimen
* Either the same or a different statin
* Or can try a short drug holiday followed by a rechallenge
45
**What % of patients with an adverse reaction to a statin will be able to tolerate an alternate statin regimen? (SLG)**
* 70%
46
**In what circumstance would a retrial of a statin not be appropriate after previous intolerance? (SLG)**
* Severe reaction (e.g. rhabdomyolysis)
47
**What can be trialed in patients that do not tolerate a daily statin at any dose? (SLG)**
* Alternate daily dosing
48
**Which statin is the most prone to drug interactions?**
* Simvastatin
49
**Which non-statin lipid-lowering medications can be used as first-line monotherapy or in combination with statins for primary prevention? (SLG)**
* None
50
**What are the adverse effects associated with statin use compared to placebo? (SLG)**
51
**What is the evidence regarding the safety of statins in patients with elevated liver test results (presumably due to NAFLD)? (SLG)**
* Patients randomized to statins were more likely to have a decrease in abnormal liver test findings
* Placebo group was more likely to see an increase
52
**What is the risk associated with statin use and new-onset diabetes? (SLG)**
* 1 in 250 for low-potency statins
* 1 in 125 for high-potency statins
53
**What is the evidence for fibrates in CVD prevention? (SLG)**
* Reduction in nonfatal myocardial infarction if given alone
* Less overall CVD reduction than statins
* No mortality benefit
* Added to statins there is NO benefit
54
**Should risk estimation with lipid levels be used in patients currently taking lipid therapy? Why? (SLG)**
* No – calculators are NOT designed to adjust for changes with lipid therapy
* Some medicines modify lipid levels with little or no effect on CVD risk
* Most reliable would be to use lipid levels from before treatment and then reduce by 25% to 35% based on statin dose and potency
55
**In patients already taking and tolerating a statin for secondary prevention, should their statin be stopped or reduced when they age beyond 75? (SLG)**
* No
56
**In secondary-prevention patients, what type of statin is recommended? (SLG)**
* High-intensity statin
57
**Which non-statin lipid-lowering medications can be used as first-line monotherapy or in combination with statins for secondary prevention? (SLG)**
* Ezetimibe can be considered as ADD-ON to statins
* Owing to higher relative benefit of statins, statin therapy should be maximized first (to high intensity)
* IMPROVE-IT study randomized patients on simvastatin 40 mg to ezetimibe 10 mg or placebo for secondary prevention
* 6% RR in CVD events
* NNT = 70
* ~1/2 of benefit seen from increasing to a high intensity statin
58
**What do the CCS guidelines recommend regarding the use of ezetimibe for secondary prevention? (CCS)**
* Recommended ezetimibe as 2nd-line therapy to lower LDL-C in patients with clinical cardiovascular disease if targets are not reached on maximally tolerated statin therapy
59
**What do the CCS guidelines recommend regarding the use of PCSK9 inhibitors for CVD prevention? (CCS)**
* Recommended for:
* Heterozygous familial hypercholesterolemia whose LDL-C remains above target despite maximally tolerated statin therapy
* Evolocumab can be added to background therapy in patient with homozygous familial hypercholesterolemia and continued if LDL-C lowering is documented
* Atherosclerotic cardiovascular disease in those not at LDL-C goal despite maximally tolerated statin +/- ezetimibe therapy
60
**What is the recommendation for the use of ASA as primary prevention? (SLG)**
* \<20% = discourage
* ≥20% = consider if bleeding risk is low
* USPSTF recommend for adults aged 50 to 59 years with CVD risk ≥10%
Primary Care
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