Chapter 2: CVD Prevention

Question 1

What is given for primary prevention of CVD?

Answer 1

High intensity statin: atorvastatin 20mg OD

OFFERED WHEN QRISK IS 10% OR MORE OR OVER THE AGE OF 85.

Question 2

What is given in secondary prevention in CVD?

Answer 2

Atorvastatin 80mg OD

Question 3

What are high intensity statins?

Answer 3

Atorvastatin 20mg, 80mg

Simvastatin 80mg

Question 4

What are medium intensity statins?

Answer 4

Atorvastatin 10mg

Simvastatin 20mg, 40mg

Question 5

Low intensity statins?

Answer 5

Simvastatin 10mg

Question 6

What is the mechanism of action for statins?

Answer 6

Inhibits HMG CoA reductase, An enzyme involved with cholesterol synthesis, especially in the liver.

Question 7

What are the cautions of statins?

Answer 7

• Elderly
• High alcohol intake
• Hx of liver disease
• Hypothyroidism
• Patients at an increased risk of muscle toxicity (including family history, renal impairment etc.

Question 8

What condition should be managed 1st before starting statin therapy?

Answer 8

Hypothyroidism

Question 9

For patients with an increased risk of muscle effects, When should statins not be started?

Answer 9

Should not be usually started if the baseline creatitine kinase conc is more than 5X the upper limit of normal.

Question 10

What are the common side effects of statins?

Answer 10

• Asthenia (abnormal physical weakness or lack of energy)
• constipation and diarrhoea
• dizziness
• GI discomfort
• myalgia

Question 11

With regards to the muscle toxicity side effects, when should statins be discontinued? When should they be reintroduced?

Answer 11

• When statin is suspected to be the cause of myopathy
• And creatitine kinase conc is markedly raised
• Or if muscular symptoms is severe

-if symptoms resolve and Cr kinase returns to normal, statin should be introduced at a lower dose and monitored closely.

Question 12

What should be advised if a patient develops lung issues with statins? What are the symptoms?

Answer 12

Seek medical attention!

• SOB
• cough
• weight loss

Question 13

What is the conception and contraception advice with statins?

Answer 13

Adequate contraception should be used during treatment and 1 month afterwards.

Question 14

What is the pregnancy advice with statins?

Answer 14

• Statins should be avoided in pregnancy
• Discontinue 3 months before attempting to conceive
• Congenital abnormalites has been reported and decreased cholesterol synthesis possibly affects foetal development.

Question 15

What is the hepatic impairment advice with statins?

Answer 15

• Use with caution in those with a history of liver disease

- AVOID IN active liver disease or when there is unexplained persistent rise in serum transaminase.

Question 16

What should be monitored BEFORE taking taking statins and their intervals?

Answer 16

• At least 1 full non fasting lipid profile (total cholesterol, HDL, non-HDL, triglyceride concs)
• Thyroid stimulating hormone
• renal function
• (if at risk of diabetes) fasting BG concs or HbA1c before starting THEN EVERY 3 MONTHS
• liver enzymes before starting THEN REPEAT WITHIN 3 MONTHS, and at 12 months of starting
• Cr kinase: measured before in patient with persistent, unexplained muscle pain. If raised but less than 5X upper limit- start at lower dose.

Question 17

What should be done if the serum transaminase conc are raised more than 3 times of the upper limit?

Answer 17

Discontinue statins

Question 18

What is are the patient/carer advice for statins?

Answer 18

Report promptly unexplained, muscle pain, tenderness or weakness.

Question 19

What is the mechanism of action of bile acid sequestrants?

Answer 19

• They bind to bile acid and prevent their reabsorption.
• This promotes the hepatic conversion of cholesterol into bile acid.
• this increases the clearance of LDL cholesterol from the plasma.

Question 20

What should be done when atorvastatin must be taken by a patient on ciclosporin?

Answer 20

The max dose of atorvastain should not exceed 10mg OD.

Question 21

When should the MAX dose of simvastatin 20mg be allowed?? (What drugs?)

Answer 21

-amiodarone, amlodipine, ranolazine

With CYP3A4 inhibitors:
-verapami, diltiazem