Nursing in Practice March/April 2019 (issue 107) - Page 32

32 CLINICAL 1 CPD HOUR • In review: hyperlipidaemia patients in primary care Screen primary care patients opportunistically for hyperlipidaemia Perform a fasting lipid profi le wherever possible as this is essential for diagnosing familial hyperchol- esterolaemia (FH) Treat hyperlipidaemia on the basis of the patient’s CVD risk using QRISK3 if FH is excluded I n the UK, heart disease remains the leading cause of death in males, and the second most common cause of death in females. 1 Although mortality rates attributed to heart disease and stroke in males and females living in the UK have halved since 2001, many opportunities still remain for clinicians to help manage their patients’ cardiovascular risk. 1 Essentials Current treatment guidelines for hyperlipidaemia are based on the patient’s risk of developing CVD. The management of hyperlipidaemia should not be based solely on the patient’s total cholesterol level, so it is important to recognise the relevant risk factors for CVD (see table 1, page 33). The CVD risk of a patient can be quantifi ed using QRISK3, which is an online risk calculator that determines the patient’s risk of having a heart attack or stroke within the next 10 years (providing FH has been excluded). 3 It is used as a decision-making tool in primary care to establish whether treatment for hyperlipidaemia is indicated; NICE recommends statin therapy if a patient’s QRISK3 score is ≥10%. 4 By altering the variables in the calculator, it can also be used to illustrate to patients the potential CVD risk reduction that can be achieved through lifestyle changes, such as smoking cessation and weight loss. Of the various CVD risk calculators available, QRISK3 is the most adapted to the UK population. It uses a newer algorithm than its predecessor QRISK2, encompassing a wider range of risk factors, such as stage 3 CKD, systemic lupus erythematosus, severe mental health illnesses and the use of steroids and atypical antipsychotics. Risk engines should not be used in patients with FH, chronic kidney disease (CKD) or type 1 diabetes. 4 March/April 2019 Opportunistic screening is also crucial – look for lipid disorders in infrequent attenders where dyslipidaemia might be likely. In this respect, consider patients who are hypertensive, diabetic, in sedentary jobs, unemployed, from a lower socioeconomic background, less physically active, smokers, eating an unbalanced diet, or those who have a family history of premature CVD. It is important to seek these patients proactively as some may present very rarely to primary care. Perform random full lipid profi le tests (total cholesterol, high-density lipoprotein-cholesterol [HDL-C] and triglycerides), when such a patient attends the surgery for other reasons. Screening Although NICE recommends a non-fasting lipid profi le, we still advocate a fasting lipid profi le wherever possible. A fasting profi le allows a calculation of LDL-cholesterol to be made, which can then be used in the diagnosis of FH. When a patient with suspected hypercholesterolaemia comes into the practice, a clinical assessment should be conducted, including the following: History You should enquire about a: Personal history of premature CVD. Family history of premature CVD in a fi rst-degree relative. This may be defi ned as an event such as a stroke or myocardial infarction before the age of 55 years in men and 60 years in women. Signs Examine for stigmata of hypercholesterolaemia: Premature corneal arcus. Tendon xanthomas. Xanthelasma. Key learning points