1. FATS4 Linking cases to the guideline Jane S Skinner Consultant Community Cardiologist

2. FATS4; 3 main sections People with symptomatic or prior occlusive vascular disease –Coronary artery disease –Cerebro-vascular disease –Peripheral arterial disease People with Type 1, Type 2 diabetes, or IGT (OGTT) High risk people without symptomatic of prior occlusive vascular disease and without diabetes / IGT (OGTT) A5 double sided summary, with supporting notes with additional information

5. Case history JW Mr JW is a 75 year old man who has had angina for 5 years. Stable. Symptoms are mild. Current treatment; –Aspirin 75mg od –Atenolol 50mg od –GTN if required (uses once or twice per month) –Ibuprofen PRN You are considering treatment with a statin –Why? –How?

6. Case history JW Not been treated with a statin before Not taking regular or frequent treatment which may interact Cholesterol 5.6 mmol/l, HDL cholesterol 1.1 mmol/l, triglycerides 5.1 mmol/l (non fasting) Liver function tests normal

7. People with symptomatic or prior occlusive vascular disease Measure lipid profile, AST / ALT If AST/ALT < 2 fold normal, prescribe Drug flow –Simvastatin 40mg at night –Simvastatin 40mg x2 at night –Simvastatin 40mg plus ezetimibe 10mg od, or atorvastatin 80mg od

8. Notes If total cholesterol > 7.5 mmol/l and or triglycerides > 4.5 mmol/l, –Consider possible familial hypercholesterolaemia –Consider discussion with local advisor Consider secondary causes of hyperlipidaemia - alcohol / thyroid / diabetes / nephrotic syndrome

9. Key messages if triglycerides are raised Measure a fasting sample –Triglycerides, HDL cholesterol, total cholesterol Exclude other causes eg diabetes, impaired fasting glycaemia Review and discuss lifestyle factors –Diet –Alcohol –Exercise Reassess (fasting sample) following intervention If remain high, or > 10mmol/l, at baseline, consider referral

11. Case history Mr LK 54 years old. First presentation of IHD 6 weeks ago when he had a non ST elevation MI Admitted and had a PCI. Left ventricular function normal. Now treated with; –Aspirin 75mg od clopidogrel 75 mg od (for 1 year) –Bisoprolol 5mg odRamipril 10mg od –Simvastatin 40mg od

12. Case history Mr LK He is worried about his cholesterol. It was 6.9 mmol/l when he was admitted to hospital You review the notes, other investigations as an inpatient; –HDL cholesterol 1.1 mmol/l, triglycerides 2.2mmo/l. –TFT and LFT normal –Initial glucose 8.8 mmo/l, but fasting glucose before discharge 5.8 mmol/l What do you need to think about?

13. Case history LK His individual management to reduce his cardiovascular risk –Lifestyle changes –Drug treatment –Repeat lipid profile; total cholesterol 5.0 mmol/l, HDL cholesterol 1.1 mmol/l, non HDL cholesterol 3.9 mmol/l, triglycerides (non fasting) 2.0 mmol/l)

14. Intensive vs less intensive statin treatment Acute coronary syndrome trials –PROVE-IT (A80 vs P40) –A-Z (Placebo 4 mths, then S20 vs S40 1 mth, then S80) Stable coronary disease trials –TNT (A80 vs A10) –IDEAL (S20-40 vs A80 -40) JACC 2006;48:438-445

15. Treatment targets Total cholesterol < 5 mmol/l, LDL-C < 3 mmol/l in all Non-HDL cholesterol < 3.8 mmol/l if preferred

16. In very high risk groups only Aim for total cholesterol < 4 mmol/l, LDL-C < 2 mmol/l, non-HDL cholesterol < 2.8 mmol/l –People with recent acute coronary syndrome –People with recent recurrent spontaneous occlusive vascular events MI, unstable angina, PCI, atheromatous stroke (not other causes of stroke), TIA) –People after CABG –People with diabetes and symptomatic occlusive vascular disease If achieved with maximum drug flow

17. Non HDL cholesterol Total atherogenic lipoproteins, alternative to LDL- C recommended by NCEP when TG are elevated or patient is non-fasting, simpler to calculate than LDL-C: Non-HDL-C = TC – HDL-C Example –TC 5.1 mmol/l, HDL-C 2.0 mmol/l non HDL cholesterol 3.1 mmol/l –TC 4.9 mmol/l, HDL-C 0.9 mmo/l non HDL cholesterol 4.0 mmol/l

18. Non HDL cholesterol Non-HDL-cholesterol is a simple, calculated measure which will be reported alongside LDL- Cholesterol and is an alternative therapeutic target in hypertriglyceridaemic, diabetic and non- fasting samples, or where the fasting status is unknown.

19. Case history; Mr LK What else should you consider if his initial cholesterol had been 8.2 mmol/l?

20. Notes If total cholesterol > 7.5 mmol/l and or triglycerides > 4.5 mmol/l, –Consider possible familial hypercholesterolaemia –Consider discussion with local advisor Consider secondary causes of hyperlipidaemia - alcohol / thyroid / diabetes / nephrotic syndrome

21. Case history Mrs HG 66 year old woman. Presented with angina like chest pain. Investigated and found to have severe aortic stenosis Had aortic valve replacement (mechanical valve) 6 months ago, uncomplicated, good recovery Now treated with warfarin and simvastatin 40mg od Been getting some muscle pains and she wonders if it could be the statin

22. Case history Mrs HG Could she be correct? What actions would you consider taking?

24. Case history Mrs HG Review past history Review other treatment –Check no drugs increase serum simvastatin levels –Grapefruit juice consumption Measure CK; 47 (normal) Consider checking not developed another condition eg hypothyroidism, polymyalgia rheumatica What next?

25. FATS4; 3 main sections People with symptomatic or prior occlusive vascular disease –Coronary artery disease –Cerebro-vascular disease –Peripheral arterial disease People with Type 1, Type 2 diabetes, or IGT (OGTT) High risk people without symptomatic of prior occlusive vascular disease and without diabetes / IGT (OGTT)

26. Practical suggestions if people develop muscle pains on statins Assess severity Check for a raised CK Check they have not developed another condition, either to cause muscle pain or to increase the risk they will do so when treated with a statin Review indications for the statin If treatment indicated and not at risk of serious adverse effects, consider treating with low dose simvastatin (10mg od to start), or try pravastatin (40mg od, or less and uptitrate)

28. Case history Mr JB Your practice has decided it wants to look at how you are doing with primary prevention. You use the tool to search the register to produce a list of people with a possible 10 year cardiovascular disease risk of 40% or more. Mr JB is on the list. He is aged 56 years. He had a blood pressure measured 3 years ago, 160/100, but never returned for it to be repeated. He was smoking 20 per day. What do you do next?

29. Case history; Mr JB You invite him to attend the surgery (bringing his partner if he wishes) and discuss with him the reasons for doing so. He consents to further assessment Assess –Lifestyle (diet, alcohol, physical activity, smoking) Review family history for premature cardiovascular disease Measure –Blood pressure –BMI, consider waist measurement –Lipid profile, glucose, liver function tests, renal function, thyroid function tests

30. Case history; Mr JB Reasonable diet, but has no regular physical activity. Drinks 40-50 units per week. Smokes 5 per day (been cutting down) Father died of MI aged 54, mother still alive aged 86. 2 younger brothers both well. Measurements –Blood pressure 162/88 –BMI 33, waist 42 inches –Total cholesterol 5.2 mmol/l, HDL cholesterol 0.9 mmol/l, (total / HDL ratio 5.8) triglycerides 3.4 mmol/l (fasting) –Fasting glucose 6.4 mmol/l –eGFR 61, LFT, TFT normal

31. Joint British Guidelines 2 Risk Charts JBS Heart 2005 91 Suppl. V