What is cholesterol?

Where does it come from?

Why do we need cholesterol?

Why is it bad?

Need to know something about Lipoproteins - the molecules transport cholesterol

Cholesterol on it's own not good enough

  1. Low density lipoproteins (LDL-C) is BAD cholesterol
  2. High density lipoproteins (HDL-C) is GOOD cholesterol
  3. Triglycerides

Plaque formation

Data

British Hyperlipidaemia Society classifies level (Total Cholesterol)

Abnormal value - What should we do?

Confused?

So am I

Primary prevention of CHD

Government decided only those with risk of CHD events greater than 30% over 10 years warrant treatment

So what should we be doing?

Secondary Prevention EASY --> all know what to do?

Primary Prevention NOT so EASY - High cholesterol levels alone poor predictor CHD

Generally Abnormal Values are:

National Service Framework (NSF) for Coronary Heart Disease (CHD)

Cost of achieving CHD NSF lipid-lowering goals 31,000 to 52,000 per GP

Currently

Secondary Prevention of CHD

This group most to gain from therapy

Currently

Key message

2001

Where are we now?

Doing rather well

  • 77% of our patients with CHD have had a cholesterol measurement

WE MUST IDENTIFY THE REMAINING 13% without a cholesterol measurement

  • 52% with a cholesterol measurement were below 5 mmol/1 --> GOOD
  • 48% with a cholesterol measurement were above 5 mmol/I --> BAD

WE MUST IDENTIFY THIS GROUP AND LOWER THIS LEVEL ACCORDING TO NSF

FACTS AND FIGURES - GROAN

  • 639 of our patients have CHD

Therefore 142 of our NSF criteria patients still no cholesterol measurement

  • total practice population 10665
  • number taking statins 383
  • that is 3.6% of our practice takes statins

Benefits of Statins

How do they work

Biosynthesis precursors --- HMG-CoA reductase enzyme --> cholesterol

Statins act here

30% coronary events in secondary prevention

So, which drug?

Choice of statin to be used open for debate

Evidence-based medicine suggests simvastatin or pravastatin first choice per major clinical trials

Atorvastatin may be first choice for mixed hyperlipidaemia since reduced triglycerides


Examples

Mrs Shirley S Age 67 years

Clinical data: Hypertension Probable angina Atenolol Fasting

  • Cholesterol 7.2mmol/l 3.2 - 6.5 
  • Triglyceride 3.66mmol/l 0.79 - 1.97 
  • HDL-CHOL. 1.0 mmol/l 1.2 - 1.7 
  • CHOL/HDL RATIO 7.2

 

Mrs Felicity H Age 52 years

Clinical Data: Hypercholesterolaemia Brother died MI Heart Failure

  • Cholesterol 8.2mmol/l 3.2 - 6.5 
  • Triglyceride 0.88 mmol/l 0.79 - 1.97 
  • HDL-CHOL 1.6 mmol/l 1.2 - 1.7 
  • CHOL/HDL RATIO 5.1 
  • LDH-CHOL 6.2 mmol/l 0.0 - 4.2

 

Mr John M Age 62 years

Clinical Data: C.A.B.G.

  • Cholesterol 7.4mmol/l 3.2 - 6.5 
  • Triglyceride 1.41 mmol/l 0.79 - 1.97 
  • HDL-CHOL 1.3 mmol/l 1.2 - 1.7 
  • CHOL/HDL RATIO 5.7 mmol/l

A cholesterol protocol

Secondary prevention --> Total cholesterol below 5 mmol/l (proven CHD) (ignore other lipoproteins)

Primary Prevention (risk >30%)--> Total cholesterol to 5 mmol/l or reduce by 30% (which greater)