Nursing in Practice March/April 2019 (issue 107) - Page 33

33 Clinical examination Include the following: Blood pressure – ensure the patient is relaxed and silent before and during the measurement. Measurement of waist/hip ratio while lying flat – waist circumference is measured at the midpoint between the lowest rib and the top of the iliac crest and hip circumference is measured at the widest portion of the gluteal region. Body mass index calculation. Investigations Carry out a full lipid profile blood test – remember that fasting lipids are essential for finding FH. Exclude possible secondary causes of hyperlipidaemia (see table 2 below). Management: lifestyle changes Diet The importance of adhering to a heart-healthy diet should be stressed to all patients. The total fat intake should be ≤30% of total energy intake, with saturated fats making up <7% of total energy intake. 4 Where possible, replace saturated fats with mono- unsaturated fats (eg olive oil for cooking, or cold rapeseed oil for dressings) and polyunsaturated fats (eg walnuts and sunflower seeds). Choose wholegrain or higher fibre varieties of starchy food such as granary bread, rye/wheat flakes, wholewheat pasta and brown rice. 4 Eat five portions of vegetables a day with some fruit. Reduce sugar intake, including varieties of fruit such as prunes, raisins and dates. Eat at least two portions of fish a week, including one portion of oily fish such as mackerel, trout, sardine or salmon. 4 Exercise The role of exercise cannot be overstated. NICE recommends that patients with CVD as well as those at high risk should do at least 150 minutes a week of moderate aerobic exercise, such as cycling or brisk walking, and strength exercises targeting all major muscle groups at least twice a week. Table 1 CVD risk factors 2 Modifiable risk factors Cigarette smoking Physical inactivity High blood pressure Impaired fasting glucose Elevated LDL-cholesterol Raised triglycerides Non-modifiable risk factors Increasing age Ethnic background (particularly South Asians) Family history of heart disease (particularly first-degree family members with an early onset of a cardiac event) Low socioeconomic background Weight loss and its effect on lipid profile Weight loss may improve a patient’s lipid profile. A meta- analysis of 70 studies investigated the effect of weight reduction through dietary modification on changes in total cholesterol, LDL-cholesterol and triglycerides. The results showed a 0.5mmol/l, 0.2mmol/l and 0.15mmol/l decrease in these components respectively for every 10kg of weight loss. 5 One study investigated the effect of exercise on lipid profile and found that an improvement in lipoprotein profile through increased physical activity is possible even in the absence of clinically significant weight loss. 6 Management: medications Statins Statins are the only medications to demonstrate CVD protection, and therefore are the mainstay treatment for hypercholesterolaemia. 7-9 They act by lowering LDL- cholesterol production, which in turn reduces the risk of a cardiovascular event. Atorvastatin is recommended by NICE as first line for CVD prevention. 4 Simvastatin is no longer recommended as it is not as potent as other statins and is associated with more drug interactions. Patients may develop side-effects from statin use. Statin intolerance is defined as ‘the presence of clinically significant adverse effects that represent an unacceptable risk to the patient or that may reduce compliance with therapy’. 4 All statins are associated with an increased risk of myopathy (disease of muscle fibres) and rhabdomyolysis (death of muscle fibres causing an acute increase in serum creatine kinase) and these present with new-onset muscle pain. Myopathy, however, is not always associated with raised creatine kinase. Statin intolerance is also associated with low vitamin D and hypothyroidism. Ezetimibe Ezetimibe may also be used as an option to treat hypercholesterolaemia and works by decreasing cholesterol absorption in the small intestine. It is indicated in patients being treated for primary hypercholesterolaemia, particularly for those who are statin intolerant. Patients not meeting LDL-cholesterol reduction targets of 40% with statins alone may also benefit from ezetimibe as add-on therapy; the PRECISE-IVUS study found that LDL-cholesterol reduction was greater using a combination of atorvastatin and ezetimibe compared with atorvastatin monotherapy. 10 Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors Alirocumab and evolocumab are monoclonal antibodies that work by favouring LDL receptor recycling. They increase the uptake of LDL-cholesterol into cells, which clears more cholesterol from the circulation. These medications are expensive, and so are only to be prescribed by lipid specialists according to NICE guidelines. Medications no longer routinely recommended for preventing CVD Fibrates, nicotinic acid and bile acid sequestrants are not to be offered to people being treated for primary or secondary prevention as clinical trials have failed to show a CVD benefit. 4 What is primary prevention of CVD 4 ? Patients in this category have never had a cardiovascular event. Table 2 Secondary causes of hyperlipidaemia 4 Secondary causes of hyperlipidaemia Investigation Alcohol excess Alcohol history (maximum 14 units/week for both men and women) Diabetes mellitus Fasting glucose or HbA1c Cholestasis LFT Hypothyroidism TFT Renal failure/nephrotic syndrome U&E; urinalysis March/April 2019