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CONTINUING PROFESSIONAL DEVELOPMENT
Table 4. Clinical variables effecting absolute risk of CVD and statin treatment.25
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
Cholesterol Total 5.5
Cholesterol HDL 1
5 year risk of
9% (low ) >15%
risk after 2
*consider stopping if becomes non-smoker.
cardiovascular event.23 For example,
if a patient's risk of having a myocardial
infarction or stroke over the next
five years is 30%, taking a statin will
reduce this risk to 24%.23 Alternatively,
cardiovascular event, with regular statin
use this risk will be reduced to 8%.23
Evidence supporting the use of statins
in patients with a low risk (five-year risk
<10%) is weaker as their use has been
shown not to reduce all-cause mortality
or serious illness.24
Therefore, when prescribed, statin use
should be recommended for people
based on their individual risk of having
a CVD event and not their cholesterol
alone (unless it is unusually high).25
This risk is expressed as a five-year risk
percentage: if a patient's risk is 10%,
10 out of every 100 people are likely
to have a CVD event in the next five
years.25 A high absolute risk is >15%,
moderate risk is between 10%--15% and
low risk is <10%.25 The absolute risk is
calculated by using all the major factors
that predict risk (Table 3). Conditions
strongly related to increased risk of
CVD events are described in Box 1.
Table 4 shows six similar patients all
with hypercholesterolaemia, however
their five-year absolute risk is different
for cardiovascular disease and
therefore their need for a statin is quite
different too. For example, patient 1
has hypercholesterolaemia, but has
a low five-year risk and is unlikely to
benefit greatly from a statin (but may
experience unwanted side effects);
patient 6 (same as patient 1 but 10 years
older) has a much higher cardiovascular
risk and will probably benefit from a
statin. It can be seen in patient 2 that
smoking is a strong risk factor for
cardiovascular disease and assessing a
patient's smoking status and advising to
cease should be the first intervention.
Actions and recommendations
• Discussed benefits of simvastatin with
patient and noted to GP that patient
was only interested in continuing with
simvastatin if the dose was lowered
(e.g. to 20 mg daily).
• Given improvement in atrial
fibrillation symptoms since
commencing sotalol (but ongoing
symptoms), it was suggested to
increase sotalol dose as tolerated to
80 mg twice daily.
• Consider reducing the dose of
dabigatran to 110 mg twice daily
(creatinine clearance 40 ml/min using
Cockcroft-Gault equation and >75
years of age) to reduce risk of bleeding.
• Consider ceasing the calcium
supplement and encourage patient
to increase calcium intake (from three
dairy products to four dairy
products) given her borderline high
calcium level and limited evidence
in primary fracture prevention in
Outcomes at one month
• Patient had been prescribed a lower
dose of simvastatin 20 mg daily and
advised she was taking this daily.
• Patient was to be reviewed by
cardiologist with a view to increasing
• Dabigatran dose reduced to 110 mg
• Calcium supplement was ceased.
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