GEM - cardiovascular risk educational module part three - difficult clinical cases

Case 1

A 56 year old man with type 2 diabetes. He smokes 10 cigarettes per day. Treatment for his diabetes is metformin 1g bd. He has been on atenolol 50 mg/d for many years for his blood pressure management. His blood pressure is 130/75 mmHg. His BMI is 31.2 kg/m^2. Recent diabetic review by practice nurse: fasting blood tests revealed HbA1C = 7.7% (61 mmol/mol), cholesterol = 5.2 mmol/l, TG = 4.8 mmol/l; HDL-C = 0.7 mmol/l; Calculated CVD risk > 20%. LFTs normal.

(a) what lipid lowering medication would you consider as first-line therapy:

i. statin

ii. fibrate (GPN reference click here)

iii. anion exchage resin e.g. cholestyramine (GPN reference click here)

iv. nicotinic acid (GPN reference click here)

v. ezetimibe (GPN reference click here)

(b) should this gentleman be treated with aspirin? Y/N (GPN reference click here)

(c) which one or more of these factors may also be contributing significantly to the dyslipidaemia:

i. metformin

ii. smoking

iii. beta-blocker

GPN reference click here

(d) what are the features of the lipid profile which are suggestive of insulin resistance? (GPN reference)

(e) Which change, if any, to diabetic medication is likely to be of most benefit

i. increase dose of metformin

ii. add sulphonylurea e.g. gliclazide

iii. add thioglitazone

iv. add alpha-glucosidase inhibitor

v. add repaglinide

vi. add gliptin

vii. add incretin mimetic

vii. add SGLT2 inhibitor

(f) Name two other interventions that would be of benefit to this patient.

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Case 2

A 40 year old woman has recently become a patient at a general practice in Coventry. During her new patient medical she stated that her father had suffered angina in his 60's and had a 'heart attack' at the age of 70 years. She had no significant past medical history of note and was on no regular medication. She has had no symptoms of cardiovascular disease and her blood pressure was 165/100 mmHg. The practice nurse checked her fasting lipids when she was seen for the new patient medical which revealed total cholesterol = 7.1 mmol/l, TG = 3.9, HDL-C 1.2 mmol/l.

i. Can you carry out a cardiovascular risk calculation given that there is only one blood pressure reading on which to base the calculation? Y/N

ii. What are the groups who are not appropriate for cardiovascular risk estimation according to the Joint British Guidelines?

iii. Is the history of her father's cardiovascular disease significant to undertaking a cardiovascular risk calculation? Y/N

iv. What is the difference between CHD and cardiovascular risk?

v. What other significant changes were outlined in BHS guidelines with respect to estimation of cardiovascular risk?

vi. Should this lady be started on an aspirin?

vii. What initial management is suggested by the BHS guidelines for this lady's blood pressure?

1. start treatment with a beta-blocker and screen for secondary causes and undertake an ECG

2. start treatment with a thiazide and screen for secondary causes and undertake an ECG

3. screen for secondary causes and undertake an ECG and remeasure blood pressure weekly ; if blood pressure remains raised then treat

4. none of the above.

viii. Whilst taking the blood test for the lipid screen the nurse also ticked the box on the blood form for CK which has revealed a markedly raised (predominantly CK-MM). What is the likely cause of this lady's hyperlipidaemia?

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