Kevin Fernando, GP, North Berwick
Hannah Beba, Consultant Pharmacist, West Yorkshire
• Every 1 mmol/L reduction in LDL-cholesterol results in an annual cardiovascular risk reduction of up to 28%, regardless of the intervention used.
• Growing evidence has driven down LDL-C targets over time; the 2019 ESC guideline recommends <1.4 mmol/L and a >50% decrease from baseline for those at very high cardiovascular risk.
- Combination lipid-lowering therapy should now be the norm to achieve these tighter LDL-C targets.
• If statin intolerance, consult the NHS England pathway.
- Risk factors include female gender, age >75 years, frailty, history of muscle disorders, impaired renal or hepatic function, personal or family history of intolerance to lipid-lowering therapies, hypothyroidism, excessive alcohol intake, high-intensity exercise, dehydration, vitamin D deficiency, statin drug interactions.
• Adding ezetimibe to statins achieves >20% additional reduction in LDL-C (doubling effective statin dose reduces LDL-C by around 6%).
• Bempedoic acid (Nilemdo®): NICE TA694 recommends use with ezetimibe where statins are not tolerated or contraindicated; licensed for use with statins and other lipid-lowering drugs.
- Increases in AST, ALT, uric acid, urea and creatinine and decreased haemoglobin seen in trials – monitor U&Es, LFTs
- Gout more common if elevated urate or previous gout at baseline.
• Icosapent ethyl (Vaskepa®): NICE TA805 recommends use for secondary prevention to decrease cardiovascular events if TGs are ≥1.7 mmol/L, statins are being used, and LDL levels are >1.04 and ≤2.60 mmol/L.
- Primary prevention: only if familial hyperlipidaemia and LDL-C >4.0 mmol/L.
- Secondary prevention:
– In high risk (single CVD event), if LDL-C >4.0 mmol/L.
– In very high risk (multiple CVD events or events in different vascular beds), if LDL-C >3.5 mmol/L.
– In familial hyperlipidaemia, if LDL-C >3.5 mmol/L.
• Inclisiran (Leqvio®): NICE TA733 recommends use for primary (heterozygous familial and non-familial) or mixed dyslipidaemia when LDL is ≥2.6 mmol/L persistently despite maximum tolerated lipid-lowering therapy.
Diagnosis and management of hypertension in 2022
Richard McManus, GP and Professor of Primary Care Research, Oxford
Helen O’Neil, Lead Clinical Pharmacist, Sunderland
• One third of people on hypertension registers remain uncontrolled: 6–8 million people living with undiagnosed or uncontrolled high BP in England (NHS Digital, 2020).
• Reducing systolic blood BP by 10 mmHg reduces stroke risk by 41% and CHD events by 22% (Law et al, 2009). Diabetes increases absolute stroke and CHD risk, so amplifies risks of hypertension and benefits of treatment.
• Delays in follow-up and treatment intensification beyond 6 weeks increases cardiovascular events (Xu et al, 2015).
• Diagnose hypertension as for those without T2DM. Treatment:
- Lifestyle advice (diet and exercise, alcohol, smoking cessation, salt and caffeine intake) reduces BP and CVD risk: offer at diagnosis and periodically.
- ACE inhibitor (ARB if African–Caribbean or ACEi not tolerated).
- Add CCB or thiazide-like diuretic.
- ACEi/ARB, CCB and thiazide-like diuretic.
- Resistant hypertension (uncontrolled on 3 treatments): add spironolactone; check potassium prior to commencing; regular potassium monitoring – higher risk of hyperkalaemia as on ACEi.
– If potassium ≥4.5 mmol/L, consider alpha-blocker or cardioselective beta-blocker instead of spironolactone.
- If BP remains elevated despite optimal dose of 4 drugs, refer for specialist advice.
• Same-day specialist review if severe hypertension (clinic BP ≥180/120 mmHg) with:
- Retinal haemorrhage or papilloedema.
- Accelerated or malignant hypertension.
- Life-threatening symptoms.
- New-onset confusion.
- Chest pain, signs of heart failure.
- Acute kidney injury.
- Suspected phaeochromocytoma.
• NICE targets (clinic BP):
- Diabetes and no CKD: <140/90 mmHg (<150/90 mmHg if >80 years).
- CKD and ACR <70 mg/mmol: <140/90 mmHg.
- CKD and ACR ≥70 mg/mmol: <130/80 mmHg.
• Home monitoring is a good option for ongoing management (McManus et al, 2018).