CVD risk management - Pennine GP Training



CVD Primary Prevention < 75yrs (in line with NHS checks)

Primary prevention –

This guideline applies to patients with no history of CVD, PVD, Diabetes, Familial Hypercholesterolaemia and eGFR >60

NICE guidelines suggest that primary prevention strategies should be targeted at known ‘high risk’ patient groups and form part of the schedule of care (e.g. annual medication review) for patients with hypertension or dyslipidaemia.

QOF(2018) requires us to offer statin treatment to those with CVD risk >or = to 10% with hypertension diagnosed in previous 12m( excludes CHD, CVD, PD, diabetes)

Use QRISK2 tool to calculate 10 year CVD risk. In line with NICE guidance start treatment at 10% CVD risk.

The primary prevention assessment should include:

Height, Weight,

BMI, BP,

Premature FH (1st deg male 40%

Some other points to consider:

• Any patient with a Cholesterol > 7.5 should be considered high risk and assessed for Familial hyperlipidemia even in absence of family history.

• Women of child bearing age meeting ≥ 10 % Q-Risk criterion shouldn’t automatically be prescribed statins and discuss risk of teratogenicity and contraception and document in notes. They can have the statin even if they tdonot wish for contraception, but stop taking them if unplanned pregnancy a possibility.

• If planning pregnancy they shouldn’t have statins for at least three months before and not to restart until stopped breast feeding.

• Also consider some people may have low Q-Risk scores but are at a higher risk due to other reasons e.g. BMI >40, Severe mental health problems, recent cessation of smoking, autoimmune illnesses or systemic inflammatory disorders, Treatment for HIV, or on antipsychotic meds, long term corticosteroids, or immunosuppressants.

• If TGs are raised see guidance below.

Follow up

1. Check ALT in 3 and 12 months; not required thereafter. Stop the statin if ALT x3 upper limit of normal. Alt < 3x upper limit of normal can have statins with careful monitoring.

2. Don’t routinely measure CK but can but done beforehand if body aches or symptoms or myopathy. Don’t give statin if CK is > 5xtimes the upper normal limit. If it is < 5x times the upper limit pts can have statins at a lower dose or Pravastatin.

3. If they have myalgia with a normal CK then try switching to a lower dose of Atorvastatin, or Pravastatin 40mg as an alternative. If that fails consider referral for advice.

4.Target is to reduce non HDL cholesterol by > 40% (check at 3 months alongside alt)

Diabetes - Type 1 – Lipid Management in the absence of a history of CVD

NICE 2014 - offer adults with Type 1 diabetes Atorvastatin 20mg and no longer use CVD risk calculation.

They should be age >40, or if adults and been diabetic for >10 years and if have nephropathy or other CV risk factors.

'All' Type 2 diabetics- without existing CVD

Should have an annual 10 year CVD risk assessment using Q-Risk2 and if risk > 10% commence Atorvastatin 20mg long term (rather than 80mg).

Target adult cholesterol = minimum audit/QOF standard < 5.0 and LDL < 2.5

CKD patients (stage G3a A2,A3 and worse)

Don’t use Q-Risk as considered high risk anyway.

Use Atorvastatin 20mg for primary prevention.

If concomitant proven CVD, use Atorvastatin 80mg upto eGFR 30. Lower doses ie 20-40 may be used if on CCBs as well.

High serum triglycerides

In people of any age where TG> 4.5 mmol/l;

• Assess possible secondary causes, including poor glycaemic control, hypothyroidism, renal impairment, liver disease (esp excess alcohol).

• If TG levels remain>20mmol/l, refer urgently to endocrinologists after a repeat within a week.

• If between 10-20 - repeat the triglyceride measurement with a fasting test (after an interval of 5 days, but within 2 weeks),review secondary causes and if the rpt test is >10 ,seek advice.

• If TGs between 4.5 and 9.9 mmol/litre: be aware that the CVD risk may be underestimated by risk assessment tools, optimise the management of other CVD risk factors present and letter to specialist for advice if non-HDL cholesterol concentration is more than 7.5 mmol/litre.

CVD Secondary Prevention

Secondary prevention

Hx of IHD, PVD, TIA, or CVA –Use Atorvastatin 80mg. If on CCBs use Atorvastatin 40mg. Follow up bloods at 3 months and 12 months (Non HDL cholesterol and LFTs)

Adults with diabetes Type 1 (see notes above) Atorvastatin 20mg

For Type 2 DM the minimum QOF target is Cholesterol ................
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