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19/10/2023 Hyperlipidaemia 1 Pathophysiology  High level of cholesterol and triglycerides (hypercholesterolaemia and hypertriglyceridaemia)  Total cholesterol should be 5mmol/L or below  You will be given reference ranges in the exam!  Also consider hyperlipidaemia if:  Personal or FH of premature coronary heart disease  Familial hypercholesterolaemia 2 19/10/2023 Clinical features:  Asymptomatic  Detection on general health screen  Investigations for other pathologies e.g. stable angina  Palmar xanthomata  Eruptive xanthomata (hypertriglyceridaemia)  Extensor surface  Tendon xanthomata/tuberous xanthomata  Xanthelasma  May be seen in patients with normal lipid levels 3 4 19/10/2023 Investigations:  Thorough history and examination  Detailed family history of premature cardiac events  Clinical signs e.g. Xanthomata, xanthelasma  Full lipid profile (measure total cholesterol, HDL, triglycerides)  Fasting glucose levels  U&E  Thyroid function tests  DNA testing (familial hypercholesterolaemia) 5 Management:  QRISK to estimate CVD  Multiple editions QRISK 2 or QRISK 3  Age, BP, smoking, BMI, lipid levels, ethnicity etc.  Primary prevention: QRISK > 10%:  Atorvastatin 20mg  PREVENT cardioembolic event  Secondary prevention:  If previous IHD, CVD, peripheral artery disease  Atorvastatin 80mg  Prevent FURTHER cardioembolic event 6 19/10/2023 Caveats to QRISK:  Do not use QRISK 3 in T1D, eGFR < 60, FH of familial hyperlipidaemia.  QRISK 3 underestimates CVD risk in people treated for HIV, people with serious mental health problems, medication causing dyslipidaemia e.g. antipsychotics, corticosteroids, immunosuppressant drugs, autoimmune disorders e.g. systemic lupus erythematosus. 7 Follow-up on statin therapy: Lifestyle changes: 3 month follow up, repeat full lipid profile • Total fat intake < 30% of total energy intake If non-HDL cholesterol • Saturated fats < 7% has not fallen by at least • Cholesterol < 300 mg/day 40%: • Increase in monounsaturated and polyunsaturated fats e.g. olive oil, Enforce lifestyle rapeseed oil changes • Eat well plate Increase dose of • Weight reduction atorvastatin to 80mg • Smoking cessation • Physical activity (150 minutes per week) 8 19/10/2023 Statins and liver impairment:  Check LFTs before starting statin  3 months  12 months  Discontinue if serum transaminases rise 3x above upper limit Small rise may be seen but DO NOT DISCONTINUE 9 Complications of hyperlipidaemia:  Heart attack  Stroke  Coronary heart disease  Carotid artery disease  Sudden cardiac arrest  Peripheral artery disease  Microvascular disease 10 19/10/2023 Hypertension 11 Pathophysiology:  Reduced elasticity of large arteries due to age and atherosclerosis (calcification + degradation of arterial elastin)  Normal blood pressure:  Systolic: 90 – 140 mmHg  Diastolic: 60– 90 mmHg  Hypertension definition:  Clinic reading persistently > 140/90 mmHg  24-hour blood pressure average > 135/85 mmHg 12 19/10/2023 Clinical features:  Asymptomatic Unless very high (e.g. 200/120 mmHg)  Headache  Visual disturbances  Seizures  Life-threatening signs: New onset confusion Chest pain Signs of heart failure AKI 13 Investigations:  Measure BP in both arms  If difference in readings between arms is more than 20 mmHg, repeat. If difference remains -> higher reading  2 readings during the consultation if > 140/90 mmHg, take lower reading  Offer ABPM/HBPM to any patient with BP > 140/90 mmHg 14 19/10/2023 If BP >= 180/120:  Admit for specialist assessment if: ○ hypertension) or haemorrhage or papilloedema (accelerated ○ life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury ○ None of the above, assess for end-organ damage: If organ damage identified: Start antihypertensive ○ fundoscopy: to check for hypertensive retinopathy ○ urine dipstick: to check for renal disease, either as a cause or immediately consequence of hypertension ○ ECG: to check for left ventricular hypertrophy or ischaemic heart If no organ damage disease identified: Repeat clinic BP within 7 days ○ Bloods for HbA1c, renal function and lipids 15 Hypertension stages: 16 19/10/2023 Lifestyle management:  Low salt diet (< 6g/day)  Avoid potassium salt due to risk of hyperkalaemia  Reduce caffeine intake  Smoking cessation  Reduce alcohol consumption  Balanced diet  Physical activity  Lose weight 17 Medical management:  If ABPM/HBPM >= 135/85 (stage 1 hypertension): ● treat if < 80 years of age AND any of the following apply: target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater ● in 2019, NICE made a further recommendation, suggesting that we should 'consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. '. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease 18 19/10/2023 Medical management cont.  ABPM/HBPM >= 150/95 mmHg (stage 2 hypertension):  Offer drug treatment regardless of age 19 Treatment ladder:  Step 1:  < 55 years or background of T2DM: ACEI (e.g. ramipril) or ARB (e.g. losartan) Use ARB where ACEI not tolerated e.g. cough but NOT ANGIOEDEMA  > 55 years or African-Caribbean origin: CCB (e.g. amlodipine) If T2DM, still ACEI/ARB 20 19/10/2023 Treatment ladder cont.  Step 2:  If already taking ACEI/ARB, add CCB or thiazide-like diuretic e.g. indapamide  N.B. nifedipine is contraindicated in heart failure, use another CCB or indapamide  If already taking CCB, add ACEI/ARB or thiazide-like diuretic  In African-Caribbean patients, ARB over ACEI  Step 3:  Add whichever one not taking (e.g. ACEI/ARB, CCB, indapamide) 21 Treatment ladder cont.  Step 4:  Resistant hypertension  If potassium < 4.5 mmol/L add low dose spironolactone  If potassium > 4.5 mmol/L add alpha or beta blocker (e.g. doxazosin or carvedilol) 22 19/10/2023 Anti-hypertensives side effects:  ACE inhibitors:  Cough, hyperkalaemia, angioedema  Indapamide:  Impaired glucose tolerance  CCBs:  Headache, flushing, ankle oedema  Beta-blockers:  Bronchospasm in asthmatics, fatigue, cold peripheries  Alpha blockers:  Postural hypotension 23 BP Targets:  Targets:  Hypertension complications:  < 80 years:  Increased morbidity and  Clinic: 140/90 mmHg mortality  ABPM/HBPM: 135/85 mmHg  Coronary artery disease  > 80 years:  Heart failure  Clinic: 150/90 mmHg  Renal failure  ABPM/HBPM: 145/85 mmHg  Stroke  Peripheral vascular disease SAME IN DIABETES ! 24 19/10/2023 Secondary hypertension: Suspect in: Causes: Investigations:  Young patients with  Intrinsic kidney disease  Raised urea/creatinine in renal few comorbidities  Cushing’s disease  High sodium/low potassium in  Severe HTN that is  Conn’s Conn’s resistant to treatment  Phaeochromocytoma  24 hr urinary  New HTN in patients  Glucocorticoids cortisol/dexamethasone with previously stable suppression test in Cushing’s readings  NSAIDs  Pregnancy  24 hr adrenaline in  Associated with phaeochromocytoma electrolyte  Coarctation of the  Renal USS in APCKD disturbance aorta  CT angiography in narrowing of  COCP renal arteries 25