Nursing in Practice March/April 2019 (issue 107) - Page 34

34 CLINICAL Table 3 Primary and secondary prevention 4 Statins Primary prevention If no diabetes, CKD or occlusive vascular disease: Measure QRISK3 score – if ≥10%, prescribe atorvastatin 20mg Type 1 diabetes: QRISK3 score not required Prescribe atorvastatin 20mg to those who: are over the age of 40 or have had diabetes for more than 10 years or have established nephropathy or have other CVD risk factors Type 2 diabetes: Use QRISK3 to assess CVD risk. Prescribe atorvastatin 20mg if risk is ≥10% In Scotland, patients over the age of 40 with type 2 diabetes are assumed to be at high risk and do not need risk assessment Secondary prevention Prescribe atorvastatin 80mg Ezetimibe Primary prevention Offer ezetimibe 10mg if: statin intolerant Secondary prevention Offer ezetimibe 10mg if: statin intolerant not meeting targets of >40% reduction in LDL-cholesterol or non-HDL-cholesterol What is secondary prevention of CVD 4 ? Patients in this category have a medical history of CVD, such as myocardial infarctions, strokes, cerebrovascular accidents or peripheral vascular disease. Management: CKD 4 Offer atorvastatin 20mg to those with CKD. A QRISK3 calculation is not required. Seek specialist advice if renal function is poor. Management: statin intolerance If adverse effects from statins are reported: Stop statins to check if symptoms are due to the statins. Reduce statin dose. Change statin. Seek specialist advice if patient is intolerant to three or more statins. Management: FH FH is caused by defects in the LDL receptor, apolipoprotein B or PCSK9 gene causing severe elevations in cholesterol levels. It follows an autosomal dominant pattern of inheritance. Every effort must be made to improve detection of FH. Given that this condition may cause heart attacks in young people, it must be recognised and treated early to prevent premature deaths. For a GP practice with 10,000 registered patients, approximately 40 individuals will have FH. A typical patient with FH has a personal history of premature cardiovascular events or a family history of premature cardiovascular events in a first-degree relative. It is imperative to suspect FH if total cholesterol is >7.5mmol/l or if LDL-cholesterol is >4.9mmol/l. A fasting lipid profile is therefore required. A high triglyceride level, however, invariably excludes FH. To clinically diagnose FH, use the Simon Broome criteria. 11 When FH is suspected: Fill in a referral form (if available) to refer the patient to the lipid clinic. 4 March/April 2019 Perform biochemical tests to accompany the referral (fasting lipid profile, fasting glucose, TFT, HbA1c, LFT, creatine kinase muscle enzyme, U&Es, vitamin D level and urine dipstick). The QRISK3 score should not be used in FH patients as these patients tend to have high HDL-C levels rendering low QRISK3. Pregnancy and women of childbearing age 4 Statins are contraindicated in pregnancy. If the patient is of childbearing age, advice on long-term contraception should be given before starting statins. If contraception is to be stopped, statin therapy must first be discontinued for at least three months. Prescribe folic acid at the same time to reduce the risk of neural tube defects. Recall and referral 4 Follow up patients after three months of atorvastatin treatment and perform a lipid profile; assess whether the patient has achieved their non-HDL-C targets of a greater than 50% reduction from baseline for FH and 40% for secondary prevention. On an ongoing basis: Perform LFTs at three months and at 12 months. Review statin treatment annually. Monitor for side-effects of statin therapy. Refer the patient to a specialist lipid clinic if in doubt. Scenarios in which referral may be needed include: Suspected FH. Abnormal pre-treatment liver enzymes. Intolerance to or side-effects from lipid-lowering treatment. A patient taking medications that interact with lipid medication treatments. Mixed hyperlipidaemias (defined as raised total cholesterol and triglycerides). Secondary hyperlipidaemias. NICE does not recommend lipid targets nor follow-up investigations for primary prevention (QRISK3 ≥10%). References 1 Public Health England. Chapter 2: major causes of death and how they have changed. In: Health profile for England. NICE 2017 2 Heart UK. Risk factors for Cardiovascular Disease (CVD). Heart UK 2015 3 QRISK®3-2018 cardiovascular disease risk calculator. 4 NICE. CG181: Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE 2016 5 Dattilo A, Kris-Etherton P. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr 1992;56:320-8 6 Kraus W, Houmard J, Duscha B et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002;347:1483-92 7 Colhoun H, Betteridge D, Durrington P et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-96 8 Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344: 1383-9 9 Shepherd J, Cobbe S, Ford I et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolaemia. West of Scotland Coronary Prevention Study Group. N Engl J Med 1995;333:1301-7 10 Tsujita K, Sugiyama S, Sumida H et al. Impact of dual lipid-lowering strategy with ezetimibe and atorvastatin on coronary plaque regression in patients with percutaneous coronary intervention: the multicentre randomised controlled PRECISE-IVUS trial. J Am Coll Cardiol 2015;66:495-507 11 Heart UK. Diagnostic criteria for Familial Hypercholesterolaemia using Simon Broome register. Heart UK Dr Jolanta Weaver is a senior lecturer in diabetes medicine at Newcastle University and an honorary consultant endocrinologist at Gateshead NHS Foundation Trust Stefan Chiu is a medical student at Newcastle University