QuestionSBA
QuestionChoice
NICE recommend lifestyle modification measures in the first instance for patients who have a QRISK score of over 10%. If these are ineffective in lowering cholesterol, a statin should be offered.
10017386
a
Encourage lifestyle modification
QuestionChoice
This is inappropriate as her QRISK score (which is a measure of the risk of a cardiovascular event) is over 10%. She should be encouraged to engage in lifestyle modification measures. If these are ineffective, a statin may be offered.
10017388
c
Reassure the patient she is at low risk of developing a stroke
QuestionChoice
This is inappropriate. Aspirin has no role in the primary prevention of strokes.
10017390
e
Offer daily aspirin for stroke prevention
QuestionChoice
This may well be required if lifestyle modification does not lower her cholesterol, however NICE recommend lifestyle measures in the first instance. Statins may be offered if the QRISK is above 10% and lifestyle modification is inappropriate/ineffective.
10017387
b
Prescribe a statin
QuestionChoice
This would not be appropriate as the patient has had no symptoms of a stroke/TIA.
10017389
d
Arrange for a carotid artery doppler
QuestionComment
https://cks.nice.org.uk/topics/cvd-risk-assessment-management/management/cvd-risk-10percent-or-more/
 --> Discuss the benefit of lifestyle modifications and optimize the management of all other modifiable CVD risk factors, including any relevant comorbidities that may not be optimally treated.
Offer the opportunity to reassess CVD risk again after they have tried to change their lifestyle. 
Recognise that some people may need support to change their lifestyle — to help, refer them to programmes such as exercise referral schemes or smoking cessation services.
-->Offer statin treatment after risk assessment if lifestyle modification is ineffective or inappropriate.
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Hallux Ketone
Concept
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# Definition

Hypercholesterolaemia is the term used to denote raised serum levels of one or more of total cholesterol.

# Causes

Causes can primary or secondary.

Secondary causes include:

- Familial dyslipidaemias
- Familial hypercholesterolaemia
- Apoprotein disorders
- Medical conditions
	- Hypothyroidism
	- Obstructive jaundice
	- Cushings syndrome
	- Nephrotic syndrome
	- Chronic Kidney Disease
- Drugs e.g. thiazide diuretics, glucocorticoids, ciclosporin
- Pregnancy
- Obesity 
- Alcohol abuse


# Physicial signs

Diagnosis is usually biochemical. 

There are two key physical signs which may indicate familial hypercholesterolaemia

 - Premature arcus senilis
 - Tendon xanthomata

# Investigations

- Lipid profile 
- Fasting blood glucose
- Renal function
- Liver function tests
- Thyroid function tests

# Management


## Statins

- Statins are the first line treatment of high cholesterol. 
- They are HMG-CoA reductase inhibitors. 
- This enzyme plays a key role in the production of cholesterol, so inhibiting it reduces the cholesterol in the body.
- In patients with high cholesterol, the QRISK score is used to see if they would benefit from statins as primary prevention against cardiovascular disease. 
- If an adult is under 80 years old and their QRISK is greater than 10% then a statin should be offered. 
- For primary prevention of CVD aim for a greater than 40% reduction in non-HDL cholesterol
- For secondary prevention of CVD, aim for low-density lipoprotein (LDL) cholesterol levels of 2.0 mmol per litre or less, or non-HDL cholesterol levels of 2.6 mmol per litre or less.

## Doses

- Atorvastatin 20mg is the usual starting dose for primary prevention.
- For patients who need a statin as secondary prevention, e.g following a stroke, heart attack, peripheral arterial disease or angina, atorvastatin at 80mg starting dose should be used.

## Side effects of statins


Common side effects of statins include muscle pain, abdominal pain, constipation and headache.

If a patient is struggling with significant myalgia, this may indeed indicate a myositis. Creatinine Kinase can be measured and  if it is 5-10 times the upper limit of normal, the statin should be stopped. 

Statins can also cause abnormal liver function so this should be monitored with a repeat blood test in 4-6 weeks time. If the transaminases (ALT, AST) are 3 times the upper limit the statin should be stopped.

Offer ezetimibe instead of a statin to people for whom statins are contraindicated/cause abnormal blood test results.

# NICE Guidelines

[NICE Guidelines - Cardiovascular disease: risk assessment and reduction, including lipid modification ](https://www.nice.org.uk/guidance/ng238/chapter/Recommendations)
1799
1994
Hypercholesterolaemia
Topic
60
General Practice
16021
For patients with a QRISK score over 10%, lifestyle modifications should be prioritised to reduce stroke risk before considering pharmacological interventions.
A 68-year-old woman visits her GP as she is concerned about her risk of having a stroke, as her brother has just suffered a transient ischaemic attack.

She currently takes no medication, and her QRISK 3 score is calculated as 13%. Blood tests show a mildly raised total cholesterol level, with a normal HbA1c and liver function tests.

What is the most appropriate next step to take?
a