Cardiovascular Disease

• Medical Co-Morbidities increasing the risk of atherosclerosis

  • Diabetes, Hypertension, Chronic kidney disease (CKD), Inflammatory conditions such as rheumatoid arthritis, Atypical antipsychotic medications
• End Results of Atherosclerosis

  • Angina
  • Myocardial infarction
  • Transient ischaemic attacks
  • Strokes
  • Peripheral arterial dis
• Atherosclerosis causes


  • Chronic inflammation and activation of the immune system in the artery wall, deposition of lipids in the artery wall, development of fibrous atheromatous plaques
• Risk Factors for Cardiovascular Disease

  • Non-modifiable: Older age, Family history, Male
  • Modifiable: Raised cholesterol, Smoking, Alcohol consumption, Poor diet, Lack of exercise, Obesity, Poor sleep, Stress
• TOM TIP: 'Consider risk factors when taking a history from someone with suspected atherosclerotic disease. Ask about exercise, diet, past medical history, family history, occupation, smoking, alcohol intake, and medications'
• Atherosclerosis

  A combination of atheromas (fatty deposits in the artery walls) and sclerosis (hardening or stiffening of the blood vessel walls) affecting medium and large arteries
• Effects of Atherosclerosis

  Stiffening of artery walls leading to hypertension and strain on the heart, stenosis leading to reduced blood flow, plaque rupture creating a thrombus that can block a distal vessel and cause ischaemia
• Rare and significant side effects of statins include myopathy, rhabdomyolysis, type 2 diabetes, and haemorrhagic strokes
• Diet and Exercise

  1. Aerobic activity for a total of at least 150 minutes at moderate intensity or 75 minutes at vigorous intensity per week

  2. Strength training activities at least 2 days a week
• Prevention of Cardiovascular Disease

  • Primary prevention for patients that have never had a diagnosis of cardiovascular disease
  • Secondary prevention after a diagnosis of angina, myocardial infarction, TIA, stroke or peripheral arterial disease
• Other Cholesterol Lowering Drugs

  • Ezetimibe works by inhibiting the absorption of cholesterol in the intestine
  • PCSK9 inhibitors (e.g., evolocumab and alirocumab) are monoclonal antibodies that lower cholesterol
• Diet and Exercise

  1. Total fat is less than 30% of total calories (primarily monounsaturated and polyunsaturated fats)

  2. Saturated fat is less than 7% of total calories

  3. Reduced sugar intake

  4. Wholegrain options

  5. At least 5 a day of fruit and vegetables

  6. At least 2 a week of fish (one being oily)

  7. At least 4 a week of legumes, seeds, and nuts
• Key interaction to remember with statins is with macrolide antibiotics like clarithromycin or erythromycin
• End Results of Atherosclerosis

  • Angina
  • Myocardial infarction
  • Transient ischaemic attacks
  • Strokes
  • Peripheral arterial disease
  • Chronic mesenteric ischaemia
• Statins

  • Reduce cholesterol production in the liver by inhibiting HMG CoA reductase
  • Check lipids 3 months after starting statins and increase the dose to aim for a greater than 40% reduction in non-HDL cholesterol
  • Check adherence before increasing the dose
  • Check LFTs within 3 months of starting a statin and again at 12 months
• Benefits of statins usually outweigh the risks, and newer statins (such as atorvastatin) are well tolerated
• Primary Prevention of Cardiovascular Disease

  1. Medication based on the QRISK3 score

  2. Offer statin, initially atorvastatin 20mg at night for QRISK3 score above 10%

  3. Atorvastatin 20mg offered for primary prevention to patients with chronic kidney disease or type 1 diabetes for more than 10 years or over 40 years
• Factors to consider for performing well in exams and when presenting to seniors

  • Age, diet, past medical history, family history, occupation, smoking, alcohol intake, medications
• Optimise Modifiable Risk Factors

  1. Address diet, exercise, and obesity

  2. Stop smoking

  3. Reduce alcohol consumption

  4. Optimise treatment of co-morbidities (such as diabetes)
• Antiplatelet medications

  • Aspirin, Clopidogrel, Ticagrelor
• Management of familial hypercholesterolaemia

  • Specialist referral for genetic testing and testing of family members
  • Statins
• PCSK9 inhibitors


  • Monoclonal antibodies that lower cholesterol
  • Given as a subcutaneous injection every 2-4 weeks
• Homozygous means both copies of the gene are abnormal, causing extremely high cholesterol (over 13 mmol/L) and almost guaranteed early cardiovascular disease
• Statins are involved in the management of familial hypercholesterolaemia
• Features of Familial Hypercholesterolaemia

  • Autosomal dominant genetic condition causing very high cholesterol levels
  • Heterozygous means only one copy of the gene is abnormal
  • Homozygous means both copies of the gene are abnormal
  • Simon Broome criteria or Dutch Lipid Clinic Network Criteria are used for making a clinical diagnosis
• The Simon Broome criteria or the Dutch Lipid Clinic Network Criteria are used for making a clinical diagnosis of familial hypercholesterolaemia
• Heterozygous means only one copy of the gene is abnormal and occurs in about 1 in 250 people
• After a myocardial infarction

  Patients are offered dual antiplatelet treatment initially with Aspirin 75mg daily (continued indefinitely) and Clopidogrel or Ticagrelor (generally for 12 months before stopping)
• Secondary prevention mnemonic "4 As"

  • Antiplatelet medications, Atorvastatin 80mg, Atenolol or an alternative beta blocker, ACE inhibitor
• Secondary Prevention of Cardiovascular Disease

  1. Depends on the specific condition

  2. Can be remembered with the "4 As" mnemonic: Antiplatelet medications, Atorvastatin 80mg, Atenolol or an alternative beta blocker, ACE inhibitor
• Clopidogrel is the antiplatelet of choice in peripheral arterial disease and following an ischaemic stroke
• Familial hypercholesterolaemia is an autosomal dominant genetic condition causing very high cholesterol levels