Hyperlipidaemia QRisk2 and Statins

Hyperlipidaema – management

Primary Prevention

  • 10 year cardiovascular risk > 10%
    • or
  • Most type 1 diabetics
    • or
  • CKD if eGFR < 60ml/min/m2

then → Atorvastatin 20mg OD

Secondary Prevention

  • Known Ischaemic Heart Disease
    • or
  • Cerebrovascular disease
    • or
  • Peripheral arterial disease

then → Atorvastatin 80mg OD

How to assess risk

  • Patients over 40yrs
  • Likely to be at high risk of cardiovascular disease (CVD)
    • defined as 10-year risk 10% or greater

Patients aged ≤84yrs         –         Use QRISK2 CVD risk assessment tool

For patients ≥85yrs           –           They’re automatically high risk due to their age

DO NOT use QRISK2 for:

  • Type 1 diabetics
  • patients with an eGFR<60ml.min and/or albuminuria
  • patients with a history of familial hyperlipidaemia
  • There are more specific guidance for these folks

Be aware; QRISK2 may underestimate CVD risk in the following groups:

  • People treated for HIV
  • People with serious mental health problems
  • Those taking medications that can cause dyslipidaemia
    • antipsychotics
    • corticosteroids
    • immunosurpressants
  • People with autoimmune disorders / systemic inflamatory disorders
    • SLE

Checking Lipid Levels:

  • Total cholesterol
  • and HDL
  • Full lipid profile (including triglycerides) – should be checked before starting statin
  • Doesn’t need to be fasting

If cholesterol is very high – consider familial hyperlipidaemia

If the total cholesterol concentration is > 7.5mmol.l and There is a family history of premature coronary heart disease

Consider familial hypercholesterolaemia – refer

Also refer if:

  • total cholesterol is > 9.0mmol.l with no family history
  • a non-HDL cholesterol (LDL) of >7.5mmol/l – even in the absence of a family history.

Offer statin to anyone with QRISK2 10yr risk ≥10%  (NICE, 2014)

Lifestyle factors are important.

Give pt option of reassessing CKD risk after period of time before starting statin.

Start Atorvastatin 20mg first line.

Special Situations

Type 1 Diabetes

  • Consider statin for all patients with Type 1 DM for primary prevention
  • Atorvastatin 20mg for:
    • older than 40yrs
    • have had DM for more than 10yrs
    • established nephropathy
    • other CVD risk factors

Chronic Kidney Disease

  • Atorvastatin 20mg should be offered to patients with CKD
  • Increase dose if >40% reduction in non-HDL cholesterol is not achieved and eGFR>30ml/min
  • If eGFR is < 30ml/min refer to renal before increasing dose

Secondary Prevention

  • All patients with CVD should be taking a statin in the absence of any contraindication
  • Atorvastatin 80mg should be offered first line

Follow Up of Statin

  • 3 monthly reviews
  • repeat full lipid profile
  • if non-HDL has not fallen by at least 40%
    • concordance should be discussed
    • lifestyle changes should be discussed
    • consider increasing dose of atorvastatin to 80mg