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Smaller factor than smoking, HT DM

reduce cholesterol via .... (but evidence for statins is better)
reduce sat fat intake / choose mono-unsat fats
increase intake F&V / pulses / oats
inc exersize and loose weight
also can use ...
colestipol (anion exchange resin)
fibrates (high TG rather than Chol) ... TG - think alcohol, exersize, diet and TFT.
Nicotinic acid (but lots SE - vomiting and flushing)
Ezetimibe (use with statin)

Any skin signs of hyperlipid - xanthelasma etc - needs lipid profile

''Statins ''
dec deaths via dec 
  LDL Chol
  Pleitropic effects - anti-inflammatory, antithrombogenesis, improved vasomotor properties
competitive inhibitor of HMG CoA reductase - final step in cholesterol synthesis
reduce entry of LDL Chol into circulation
upregulate expression of surface LDL chol receptors

//For who//  (ie. not on chol levels only)
established atherosclerotic disease
if risk of CVS event is >20% over 10 years
ACS, CVA, TIA - take while in hospital
if DM .... 40+ years or under if one other factor (retinopathy, nephropathy, HT, FH, Chol>6, HbA1C>9%)

//Aim for//  (whichever gives lower value of total or %reduction
Cholesterol - 4.0mmol/l total or 25% reduction
LDL 2.0mmol/l total or 30% reduction

''In secondary prevention''
reduces incidense of major coronary event / stroke by 20% in those with established CVS disease
include women, renal transplant, diabetes, elderly, ACS, normal chol/LDL

''In primary prevention''
trials show dec risk of cardiovascular events
but side effect and cost make use controversial

//When// 
immediate post acute event or within 3-6/12 - evidense both ways
//How// 
fixed dose - so few blood tests but may under/ over treat some
in primary prevent - fire and forget - start Rx and don't remeasure
in secondary prevent - inc dose to gain target reduction ....
relate dose to LDL levels (aim for <2.8/2,6)
relate dose to average Cholesterol reduction (18-25% reduction over base)

''Side effects''
Myopathy - mild pains - common - severe pains with raised Creatinine Kinase (>10x) - rare but must stop as risk of rhabdomyolysis, mild is more common in ... women, smaller, 70+years, multisystem disease, hypothyroid, organ transplant, peri-op, polypharmacy esp alcohol, amiodarone, grapefruit juice, verapamil, PI, .....
Hepatotoxicity - raised ALT/AST - effects 05-2% people are dose dependent and progression to liver failure is rare

South-Asians
Inc risk of CVS events
generally higher TG and lipoprotein a and lower HDL
statins less useful - ? need low dose - more info needed