Affinity Care Lipid Pathway Summary and Assessment
The Affinity Care Lipid Pathway outlines a systematic approach to assessing lipid/cholesterol blood results in individuals over 16 years old. It includes guidelines for managing cholesterol levels, assessing familial hypercholesterolemia, and determining appropriate medication options based on individual risk factors and existing conditions. The pathway emphasizes the importance of minimizing cardiovascular disease risk factors and provides guidance on lifestyle modifications and statin therapy for optimal lipid management. Monitoring and reassessment protocols are also detailed to ensure ongoing management and risk reduction.
- Lipid assessment
- Cholesterol management
- Cardiovascular health
- Familial hypercholesterolemia
- Statin therapy
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Assessing Lipid/Cholesterol blood results Assessing Lipid/Cholesterol blood results Person over 16yrs has cholesterol and lipids assessment (ensure Hba1c is also assessed) Total Cholesterol > 7.5mmol/l or LDL Cholesterol > 4.9 Continue annual reassessment Ensure all CVD risk factors minimized Yes No No Using Dutch Lipid Score assess for Familial Hypercholeserolaemia (FH) and refer as appropriate Yes Does the patient have established diabetes or vascular disease (CAD,PAD,TIA,CVA) Are they taking atorvastatin 40- 80mg (or rosuvastatin 10-20mg)? Total Cholesterol > 4.0mmol/l or LDL Cholesterol > 2.6mmol/l Yes Yes Add ezetimibe 10mg No No CVD No Yes Commence atorvastatin 80mg (or rosuvastatin 20mg if previous intolerant simvastatin or atorvastatin) Patient does not have known FH or CVD Recheck lipid profile at 3 months (or later) Recheck lipid profile at 3 months (or later) Patient is confirmed to have FH Yes Yes Yes FH Lifestyle advice to minimize all CVD risk factors Aim to achieve at least a 50% reduction of LDL-C (or non-fasting non-HDL-C) from baseline in line with secondary prevention protocol Patient unable to take statins Total Cholesterol > 4.0mmol/l or LDL Cholesterol > 2.6mmol/l Total Cholesterol > 4.0mmol/l or LDL Cholesterol > 2.6mmol/l Add Nustendi No Yes Qrisk assessment Total Cholesterol > 4.0mmol/l or LDL Cholesterol > 2.6mmol/l Continue annual reassessment Ensure all CVD risk factors minimized No Refer to the Affinity Lipid Group Yes Qrisk <10% at 10 years Qrisk >10% at 10 years Equivalence Dose Dose Considerations Commence atorvastatin 40mg (or rosuvastatin 20mg if previous intolerant simvastatin or atorvastatin) Atorvastatin 40mg 80mg No renal considerations Reduced interaction profile Rosuvasatin 20mg 40mg Avoid if eGFR <30. Max dose 20mg if eGFR 30-60 Reduced interaction profile Pravastatin 40mg Start 10mg reduced renal function Reduced interaction profile Continue lifestyle advice to minimize all CVD. No need for cholesterol/lipid assessment. LFTs do not need 3 month review unless deranged prior to initiation of statin STATIN DECLINED Lifestyle advice to minimize all CVD risk factors and reassess CVD risk in 3 years Continue lifestyle advice to minimize all CVD there is no need for further cholesterol/lipid assessment Simvastatin 40mg Max dose 10mg if eGFR <10 High interaction profile Affinity Care PCN December 2021
Dutch Lipid Network Score Dutch Lipid Network Score Genotype Scoring Criteria for Patients with a clinical diagnosis of Familial Hypercholesterolemia Please note these criteria only apply for index case, not family members of a known genotype positive patients Points 1st or 2nd Degree relatives Known with premature (<60yrs) CHD Known with premature (<45yrs) CHD Known with LDL-C >4.9mmol/l (or total cholesterol >7.5mmol/l) Known with LDL-C >4.0mmol/l (or total cholesterol >6.7mmol/l) Please specify relation to index case Tendon xanthomata (in 1st/2nd degree relatives) Premature corneal arcus (no score arcus senilis) 1 2 1 Family History When assessment completed, if the patient is eligible, please refer to: 2 Jillian Webster Familial Hypercholesterolaemia Specialist Nurse Huddersfield Royal Infirmary Pathology Lab, Basement, Acre Street , Lindley Huddersfield HD3 3EA 6 4 Physical Examination Patient has premature CHD (<45 yrs) Patient has premature CHD (<50 yrs) Patient has premature CHD (<60 yrs) Patient has premature Stroke/TIA or PVD (<60 yrs) 4 3 2 1 Clinical History LDL-Cholesterol 8.5 LDL-Cholesterol 6.5-8.4 LDL-Cholesterol 5.0-6.4 LDL-Cholesterol 4.0-4.9 Triglyceride 2.5-3.4 Triglyceride 3.5-4.9 Triglyceride 5.0 8 5 3 1 Untreated or Corrected LDL- cholesterol Minus 2 Minus 3 Minus 4 Fasting Triglycerides Please record in referral any secondary issue that may predispose to raised TG s such as diabetes TOTAL SCORE 6 or above eligible for genotyping 5 or less usually not eligible except in exceptional circumstances Eligibility for FH genotyping Affinity Care PCN December 2021
Medication Pathway for Secondary Prevention Medication Pathway for Secondary Prevention Does the patient have established vascular disease (CAD,PAD,TIA,CVA) Ezetimibe:-Lipids and LFTs should be checked after 8 weeks and ezetimibe stopped if the ALT has risen to 3x upper limit of normal Are they taking atorvastatin 40-80mg (or rosuvastatin 10-20mg)? Patient declines all lipid intervention Patient unable to take statins Yes No Commence atorvastatin 80mg (or rosuvastatin 20mg if previous intolerant simvastatin or atorvastatin) Patient unable to take Nustendi Add Nustendi Nustendi:-Lipids and LFTs should be checked after 8 weeks and Nustendi stopped if the ALT has risen to 3x upper limit of normal No LDL Cholesterol <4.0mmol/l(high CVD risk) <3.5mmol/l (very high risk) Total Cholesterol <4.0mmol/l or LDL Cholesterol<2.6mmol/l NICE Patient choice to add inclisiran Patient choice to add ezetimibe 10mg No Yes Inclisiran:-After first injection check LDL-C and Lipids at 6 weeks. Add evolocumab After second injection check LDL-C and Lipids at 6 weeks. Total Cholesterol < 4.0mmol/l or LDL Cholesterol < 2.6mmol/l Total Cholesterol < 4.0mmol/l or LDL Cholesterol <2.6mmol/l Yes Yes Patient unable to use evolocumab Patient unable to take ezetimibe Secondary Care Lipid Clinic If the person has multiple medicine intolerance and /or the LDL- Cholesterol can not be reduce to 2.6mmol/l then consider referral for consideration of PCSK9i No No Add inclisiran Add inclisiran Continue annual reassessment Ensure all CVD risk factors minimized Affinity Care PCN December 2021 *NICE TA733 suggests either adding ezetimibe or inclisiran
Statins Use in Cardiovascular Disease Statins Use in Cardiovascular Disease Healthy Lifestyle advice If patient complains of muscle pain attributed to atovastatin Check CPK and discontinue statin Known Cardiovascular Disease CPK 5x upper limit of normal CPK <5x upper limit of normal Remain off atorvastatin for 6 weeks Recheck in 14 days Known Occlusive Cardiovascular Disease No known Occlusive Cardiovascular Disease No CPK remains 5x upper limit of normal Recommence atorvastatin at 50% of previous dose Yes Qrisk2 Assessment >10% at 10 years Return of previous symptoms Consider referral to investigate elevated CPK Type 2 Diabetes With additional CVD risk factors* Type 2 Diabetes or CKD 3 Hypertension No Yes Stop atorvastatin for 6 weeks, then commence rosuvastatin 5mg Continue atorvastatin at this dose Continue healthy lifestyle and 3 yearly assessment Atorvastatin 80mg Atorvastatin 40mg Atorvastatin 40mg Atorvastatin 80mg Atorvastatin 40mg Return of previous symptoms No Yes Discontinue statin and code intolerance *CVD Risk Factors: Up titrate rosuvastatin to: Albuminuria CKD 3 or worse Erectile dysfunction FH premature CVD Hypertension LDL>2.6mmol/l Psoriasis Smoking Low intensity: Rosuvastatin 10mg High intensity: Rosuvastatin 20mg Affinity Care PCN December 2021
