lipids

Question 1

what are the CV disease risk factors?

Answer 1

• Risk factors
• Age (mainly >50 years of age)
• Gender
• FHx,
• Ethnicity
• Smoking
• Raised blood pressure
• Cholesterol
• Low income and social deprivation

Question 2

what are lipids?

Answer 2

Lipids are fats used in the body to synthesise cell membranes and provide energy.

Question 3

how are lipids transported around the body?

Answer 3

lipoproteins

Question 4

what are the two major types of lipid found in the blood plasma?

Answer 4

1. Cholesterol: make up cell membranes. Stabilises the cell and forms the barrier between the cell and it’s environment. Also a precursor for the production of steroid hormones and bile acids.
2. Triglycerides: Made up of glycerol and fatty acid molecules. The main store of energy for the body, especially in adipose tissue.
   Insoluble in aqueous environment of the blood so transported in blood by incorporation into lipoproteins.

Question 5

what is a lipoprotein?

Answer 5

Lipoproteins transport cholesterol around the body as it is a fatty substance that does not mix well in blood.

Question 6

what are LDLs?

Answer 6

Low-density lipoproteins (or LDLs)are the major transporters of cholesterol in the bloodstream and, because LDLs seem to encourage the deposit of cholesterol in the arteries, it’s known as “bad cholesterol”.

Question 7

what are HDLs?

Answer 7

High density lipoproteins (or HDLs), on the other hand, are considered to be “good cholesterol” because they carry unneeded cholesterol away from the cells and back to the liver, where it’s broken down for removal from the body.

Question 8

what are triglycerides?

Answer 8

most common dietary saturated fats. They make up approximately 95% of all ingested fats. They too are transported by LDL and HDL molecules in the blood and if in excess can cause a lot of damage to the arteries.

Question 9

normally, if dietary cholesterol is high, what happes?

Answer 9

there is a corresponding reduction of cholesterol synthesis by the liver. So for most individuals, the amount of cholesterol consumed is unlikely to result in an elevated level of cholesterol in the blood.

Question 10

what boosts LDL levels?

Answer 10

Eating lots of animal fat boosts LDL. Other types of fat (mono-unsaturated e.g. in olive oil, and poly-unsaturated as in omega-3 fatty acids) don’t have the same effect, they actually reduce cholesterol.
*Vegetarian diets, exercise and vitamins such as vitamin C and niacin may help to reduce cholesterol.

Question 11

when is statin therapy considered?

Answer 11

when 10 yrCV risk is 10% or greater

Question 12

what is the assessment tool for CV risk?

Answer 12

QRISK2

Question 13

what is the primary prevention medication?

Answer 13

1o Prevention - Atorvastatin 20mg -Statin of
choice

Question 14

when do you not use the CV risk assessment tool?

Answer 14

–Type I diabetes
–Patients with eGFR<60ml/min/1.73m2 &/or
albuminuria
–Patients with already established CVD
–Inherited lipid conditions (e.g. familial
hypercholesterolaemia)

Question 15

who are patients who will be at additional risk not picked up by risk score?

Answer 15

–People treated for HIV
–People with serious mental health problems
–People taking medicines that can cause
dyslipidaemiasuch as antipsychotic medication,
corticosteroid or immunosuppressant drugs
–People with autoimmune disorders such as
systemic lupus erythematosus

Question 16

when will CVD risk be underestimated?

Answer 16

in people who are already taking
antihypertensive or lipid modification therapy,
or have recently stopped smoking

Question 17

what does severe obesity do toCVD risk?

Answer 17

increases

Question 18

what about someone who is 85?

Answer 18

Consider people aged 85 or older to be at
increased risk of CVD because of age alone

Question 19

what advice should be given to people at high risk of or with CVD?

Answer 19

–Reduce their saturated fat intake
–Increase mono-unsaturated fat intake
–Choose wholegrain
–Reduce intake
–Eat 5 portions of fruit and veg per day
–Eat 2 portions of fish per week
–Eat 4 to 5 portions of nuts/seeds/legumes per
week

Question 20

what can you measure with lipids?

Answer 20

• Full lipid profile (Total cholesterol, HDL, non-HDL
  and triglyceride levels)
• Non-HDL more closely predicts CVD events
• Raised Triglyceride levels is an independent risk factor for CVD

Question 21

why do we do a lipid measurement?

Answer 21

Exclude possible secondary causes of
dyslipidaemiasuch as excess alcohol,
uncontrolled diabetes, hypothyroidism, liver
disease and nephrotic syndrome

Question 22

when would you consider familial hypercholesterolaemia?

Answer 22

–A total cholesterol concentration more than
7.5mmol/litre
–A family history of premature coronary heart
disease

Question 23

when do you refer after results?

Answer 23

• Total cholesterol
  –>9mmol/L specialist referral
• Non-HDL
  –>7.5mmol/L specialist referral
• Triglycerides
  –>20mmol/L urgent specialist referral
  Unless due to excess EtOH/poor glycaemic control
  –10-20mmol/L repeat with a fasting test within
  2/52
  –R/v secondary causes and refer if remains >10mmol/L

Question 24

what should be done before starting a statin?

Answer 24

• Smoking status
• Alcohol consumption
• Blood pressure
• BMI
• TC, Non-HDL, HDL & TGLs
• HbA1C
• Renal function and eGFR
• ALT/AST
• Thyroid stimulating hormone

Question 25

what should you fo if there is any unexplained muscle pain before starting statin?

Answer 25

measure CK levels
–If Ck>5x ULN, re-test after 7 days, if remains high do
not start statin therapy
–If raised but <5x ULN, start at lower dose and monitor
more closely

Question 26

what should be given in primary prevention for people 85+?

Answer 26

For people 85 years or older consider
atorvastatin 20mg as statins may be of benefit
in reducing the risk of non-fatal myocardial
infarction

Question 27

what would be first line for secondary prevention?

Answer 27

Atorvastatin 80mg once a day

Question 28

when do you offer treatment for the primary prevention of CVD in adults with type one diabetes?

Answer 28

–are older than 40 years or
–have had diabetes for more than 10 years or
–have established nephropathy or
–have other CVD risk factors
atorvastatin 20mg

Question 29

what should you give to someone with CKD?

Answer 29

atorvastatin 20mg for the primary or
secondary prevention of CVD to people with
CKD.

Question 30

when should you increase the dose of a statin in patients with CKD?

Answer 30

Increase the dose if a greater than 40% reduction in
non-HDL cholesterol is not achieved and eGFRis
30ml/min/1.73m2 or more.

Question 31

what is the follow up therapy in patients started on statin therapy?

Answer 31

Measure total cholesterol, HDL cholesterol
and non-HDL cholesterol in all people who
have been started on high-intensity statin
treatment at 3 months –aim for >40%
reduction. If this is not achieved:
–Discuss adherence
–Diet and lifestyle
–Consider increasing the dose

Question 32

what is C/I with a statin?

Answer 32

Itraconazole
Ketoconazole
Posaconazole
Erythromycin
Clarithromycin
Telithromycin
HIV protease inhibitors (eg, nelfinavir)
Nefazodone
Ciclosporin
Danazol
Gemfibrozil

Question 33

what medication should you not exceed 10mg simvastatin with?

Answer 33

Other fibrates (except fenofibrate)

Question 34

what medications should you not exceed 20mg simvastatin with?

Answer 34

Amiodarone
Amlodipine
Verapamil
Diltiazem

Question 35

why are statins C/I in pregnancy?

Answer 35

Advise women of childbearing potential of the
teratogenic risk of statins and to stop taking
them if pregnancy is possible
* Advise women planning pregnancy to stop
taking statins 3 months before they attempt to
conceive and to not restart them until
breastfeeding is finished