LOGIC March 2018 Vol 17 Vol 1 - Page 24

While not used first-line for primary and secondary prevention of CVD, non-statin therapy such as ezetimibe (inhibits absorption of cholesterol) can be used as a monotherapy for people who cannot tolerate statins or when statins are contraindicated. Ezetimibe may also be added to a statin for secondary prevention of CVD when maximally tolerated statin therapy and lifestyle changes have not lowered lipid levels sufficiently for a person with a high CVD risk (Pirillo 2015; Scott 2017; Stroes 2015). Fibrates are no longer favoured for lipid lowering. Bezafibrate is sometimes used with a statin in this situation but the risk of myopathy is increased with a statin-fibrate combination. Gemfibrozil and a statin can cause rhabdomyolysis and is contraindicated (Scott 2017). New drugs not yet available in New Zealand include proprotein convertase subtilisin/kexin 9 inhibitors (PCSK9 inhibitors) e.g. evolocumab and alirocumab. These monoclonal antibodies have been shown to reduce LDL levels markedly. They increase LDL receptors on hepatic cells and thus reduce circulating low density lipoprotein cholesterol (LDL-C) (Chaudhary 2017; Pirillo 2015; Stroes 2015). Cost could be a limiting factor to their use March 2018 L.O.G.I.C and more data is needed to determine whether CVD mortality and morbidity is reduced long term (Chaudhary 2017). g. Supplements There is insufficient evidence to support the use of supplements such as Coenzyme Q10 and Vitamin D to manage SAMS. Some short-term trials have shown red yeast rice to lower LDL but more evidence is required regarding long-term outcomes and safety data. There are some concerns about variability in bioavailability of different red yeast rice products and also contaminants that could be toxic (Stroes 2015). Nurse Role in Supporting Patients with Statin Therapy Evidence Nurses are in a prime position to provide support and counselling to patients being treated with statins for primary and secondary prevention of CVD risk. Nurse-led interventions for CVD risk and management strategies can take place in a variety of settings including cardiology or CVD clinics, inpatient and outpatient counselling and patient counselling within general practice (either face-to-face or via telephone). Evidence has shown nurse-led interventions including CVD risk counselling can improve statin adherence and lipid lowering to reduce CVD risk. (Harbman 2014; Irewell 2015; Nieuwkerk 2012). Nieuwkerk et al (2012) found that patients in the extended care (EC) group of their study benefited psychologically by having an increased understanding of their CVD, their modifiable and un- modifiable risk factors and by developing control over the process of their disease. The controllability a patient perceives they have over their illness has been found to be significantly associated with “problem-focused coping strategies such as adherence to self-management techniques” as discussed by Nieuwkerk et al (2012) who referenced the work of Hagger and Orbell. Nieuwkerk et al’s (2012) findings were consistent with this. The increased perception of control over the process of their CVD translated into significantly lower anxiety and symptom and concern scores for the EC group, as well as significantly higher statin adherence (95-100% versus 90- 95%, p <0.01). In turn, increased statin adherence led to significantly lower LDL-C levels in the primary prevention patients of the EC group 22