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Management of Lipids in Practice

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The management of dyslipidaemia has become a particularly important component of the treatment of cardiovascular disease such as coronary artery disease and stroke. These conditions are generally managed in primary care under the supervision of both GP and practice nurse and are a large component of the GMS contract. This resource composed of 10 assessment questions, tests your knowledge of commonly encountered problems relating to the management and diagnosis of lipid disorders typical of clinical practice. Complete the questions and gain 1hr of continuous professional development to add to your personal development portfolio.

After successful completion of this resource, the user should have

A better understanding of the role of dyslipidaemia in the generation of cardiovascular and cerebrovascular disease.

An improved understanding of the approaches to the management of lipid disorders with specific therapies.

An improved knowledge of the contribution of various lipid fractions to cardiovascular disease and its treatment.

The management of dyslipidaemia has become a particularly important component of the treatment of cardiovascular disease such as coronary artery disease and stroke. These conditions are generally managed in primary care under the supervision of both GP and practice nurse and are a large component of the GMS contract. This resource composed of 10 assessment questions, tests your knowledge of commonly encountered problems relating to the management and diagnosis of lipid disorders typical of clinical practice. Complete the questions and download your CPD certificate to add to your  portfolio. You should record the time spent on this resource. 

After successful completion of this resource, the user should be able to:

Understand the role of dyslipidaemia in the generation of cardiovascular and cerebrovascular disease.

Understand the approaches to the management of lipid disorders with specific therapies.

Understand the contribution of various lipid fractions to cardiovascular disease and its treatment.

A 45 year old man is admitted to hospital with an inferior myocardial infarction. He is discharged from hospital on a variety of medications including simvastatin 40mg daily. Which target LDL- cholesterol concentration should one aim to achieve in this man?

The target for total cholesterol in patients treated with a statin for secondary prevention of cardiovascular disease is less than 4 mmol/l and less than 2 mmol/l for LDL-Cholesterol according to 

. NICE advocate the use of simvastatin 40mg as a first line agent.

Question 1

A 51 year old woman attends clinic as she is concerned about her 'cholesterol'. She attended a well woman clinic in a shop car park and was told that her cholesterol was high and that she should seek a medical opinion. She is well and has no family history of note. She takes no medication and is a non-smoker. Since the encounter in the car park she has been on a 'low cholesterol' diet. Her weight is 78kg with a BMI of 28 kg/m

 and her blood pressure is 128/72 mmHg. Her fasting lipid profile reveals:

Which of the following is the most appropriate approach to managing her lipids?

This woman has a low cardiovascular risk as she is well, has no family history of heart disease and has no overt risk factors such as smoking and diabetes. Referring to cardiovascular risk tables, her chances of developing a CV event over the next 5 years is less than 3% and she should not receive any treatment for this lipid profile. According to the risk calculator below, based on Framingham equations, the risk is 5.7% over 10 years.

Question 2

A 49 year old man is diagnosed with type 2 diabetes. He is being treated with metformin 500 mg tds. He has a family history of diabetes with his elder brother and mother suffering from the condition. His blood pressure is 146/88 mmHg for which he also receives ramipril 10mg daily. He is a non-smoker and drinks little alcohol. His lipid profile reveals:

Which of the following would be the most appropriate approach to treating this man

This man has been diagnosed with diabetes and is hypertensive. His cardiovascular risk based upon the diabetes, hypertension and lipid profiles would suggest a cardiovascular event rate of approximately 15% over 5 years (25.7% according to Framingham risk equation as detailed below) and studies such as ASCOT, reveal that treating with statins effectively reduces this high risk. According to the NICE guidelines, Statin therapy is recommended for theprimary prevention of CVD for adults who have a 20% or greater 10-year riskof developing CVD. The patient should be commenced on a statin such as simvastatin 40mg daily, which is licensed for the reduction of cardiovascular mortality and morbidity in people with diabetes mellitus (with either normal or increased cholesterol levels).

http://www.nice.org.uk/nicemedia/pdf/TA094guidance.pdf

Question 3

A 55 year old man attends clinic as six weeks ago he was admitted to hospital with an inferior myocardial infarction which was treated with thrombolysis. He made an uneventful recovery and was discharged home on atorvastatin 20mg daily, aspirin 75mg daily, ramipril 10mg daily and bisoprolol 2.5 mg daily. His weight is 85kg, BMI 25.6 kg/m2 and his blood pressure 128/74 mmHg. His lipid profiles reveal:

Which of the following is most appropriate regarding his further management?

This man who has had a myocardial infarction is being treated with a statin, as well as aspirin, an ACE inhibitor and beta blocker. Omega-3 fatty acids reduce the production of triglycerides, and thromboxane (which reduces the likelyhood of clot formation). It can be used in combination with this gentleman's medication to further reduce the risk of cardiovascular events by approximately 20%, as revealed by the GISSI-3 study. Thus the patient should also be prescribed Omega-3 fatty acids - Omacor.

Question 4

A 55 year old man with a history of stable angina associated with familial hypercholesterolaemia is being treated with simvastatin 40 mg daily. His lipid profile reveals:

Which of the following is the most appropriate approach to managing his lipid profile?

In this case, as this patient has coronary artery disease, a target cholesterol would be less than 4 mmol/l. NICE guidance would, therefore, advocate initially an increased dose of the simvastatin to 80mg daily. If this is unsuccessful then the patient could receive add on therapy such as ezetimibe 10mg daily. Ezetimibe can be taken at the same time as a person's usual statin when cholesterol levels are not low enough despite increasing the dose of the statin, or if a person is unable to try higher doses of the statin because it is likely to cause side effects.

Question 5

A 76 year old man attends clinic as he has been diagnosed to have had a stroke. His lipid profile reveals:

Which of the following is most appropriate concerning his treatment?

Patients who have had a stroke should be treated with a statin unless there are contra-indications. NICE guidelines states that treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. Studies such as CARE and 4S reveal that statins are associated with a significant reduction in cerebrovascular risk as well as the well-recognised reductions in cardiovascular disease.

http://www.nice.org.uk/nicemedia/pdf/CG67NICEguideline.pdf

Question 6

An 82 year old man attends clinic as he has been diagnosed with hypertension for which he has been commenced on amlodipine 10mg daily. He has otherwise been fit and well and also takes bisoprolol 2.5 mg daily plus warfarin for atrial fibrillation. He is a non-smoker and drinks occasional alcohol. He is otherwise fit and active. His blood pressure is 134/82 mmHg. His lipid profile reveals:

He enquires whether this should be treated. What is the most appropriate approach to managing this patient?

Studies reveal that elderly patients benefit from reduced cardio and cerebro - vascular risk following treatment with statins just as much as younger patients. Hence this man with hypertension should be treated with a statin. Although risk calculators do not go beyond 75 years, his risk would be considered high at over 30% at 10 years and hence statin therapy would be considered to modify this risk particularly as he is otherwise fit.

Question 7

A 45 year old man attends clinic as he is concerned about his risk of developing heart disease. His father had a heart attack at the age of 50 from which he died. He is a non-smoker and drinks little alcohol. He is entirely asymptomatic. His blood pressure is 134/78 mmHg. His lipid profile reveals:

Which of the following would be the most appropriate approach to his treatment?

This man with a family history of premature cardiovascular disease is likely to have heterozygous familial hypercholesterolaemia (FH) with such a raised cholesterol. In view of the strong family history of CVD he has a high risk of a cardiovascular event over the next 10 years of at least 20%. Statins are the first choice of treatment for FH, therefore he should be prescribed a statin with a target cholesterol below 4 mmol/l.

http://www.nice.org.uk/nicemedia/live/12048/41697/41697.pdf

Question 8

A 40 year old man attends clinic. He has been diagnosed with familial hypercholesterolaemia and has started Atorvastatin 40mg daily. Which of the following signs on physical examination might you expect to find in such a patient with familial hypercholesterolaemia?

Heterozygous familial hypercholesterolaemia is associated with increased risk of developing coronary artery disease and has a number of physical signs including tendon xanthomas (nodules on the extensor tendons like the Achilles and triceps tendons), xanthelasma (yellowish nodules around the skin of the corners of the eyes), and corneal arcus (yellowish deposit around the edge of the iris). These features are due to cholesterol deposition and reflect what is also going on in the arteries.

Question 9

A 40 year old man with a diagnosis of heterozygous familial hypercholesterolaemia is being treated with atorvastatin 80mg daily. His results on this treatment reveal:

Which of the following is the most appropriate approach regarding the management of his lipid profile?

This patient has a diagnosis of familial hypercholesterolaemia with a significantly increased risk of cardiovascular disease. Consequently his cholesterol target should be less than 4 mmol/l and to achieve this often high dose statins are required with additional treatment such as bile acid sequestrants (cholestyramine), ezetimibe or nicotinamide.

Management of Lipids in Practice

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