ALGORITHM FOR USE OF LIPID THERAPY POST MYOCARDIAL INFARCTION (STEMI, NSTEMI AND UNSTABLE ANGINA)

December 2011

MMGUID03

v1.0

November 2011

Document Control
Doc. Ref. No. Title of document Authors name Authors job title Dept / Service Doc. Status Based on Signed off by Original Publication Date Last Reviewed Next review date Distribution MMGUID03 Algorithm for use of lipid therapy post myocardial infarction (STEMI, NSTEMI and Unstable angina) GMMMG and Greater Manchester and Cheshire cardiac and stroke network Various GMMMG/GM and Cheshire Cardiac and Stroke network FINAL v1.0 GMMMG and Greater Manchester and Cheshire Cardiac and Stroke network original document. Adapted for local use by Johanna Hulme. Clinical Standards Board November 2011 N/A June 2012 Trust Wide / Internet
1. 2. 3. 4. This algorithm applies to all patients who have undergone treatment for the above conditions. The algorithm will ensure that all patients are managed via the same clinical algorithm. The algorithm will aim to reduce inequity across the borough. The policy will apply to all patients regardless or age, gender, ethnicity or socioeconomic status who have a diagnosis as above. The algorithm will primarily apply to Primary care but specialists need to be aware of its existence to ensure clear communications and rationale for change to medication. Specialists can provide information to patients, who require an alternative form of communication i.e. non-English speaking patients, older people or those with learning difficulties, through local interpretation services.

Has an Equality & Diversity Impact Assessment been completed? Yes

5.

Consultation History
Version Final v1.0 Date 5/10/11 10/11/11 Consultation Approved as recommendation by GMMMG Approved by Clinical Standards Board (Bolton Health Economy)

NHS Bolton is the name used to refer to Bolton Primary Care Trust. The legal identity of the organisation remains unchanged.

Algorithm lipid therapy post MI

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GM and Cheshire Cardiac Network GMMMG

MMGUID03

v1.0

November 2011

Background to algorithm
Greater Manchester Medicines Management Group (GMMMG) have worked in collaboration with clinicians in the Greater Manchester and Cheshire Cardiac and Stroke Network to produce guidance for lipid management following a myocardial infarction.

NICE guidance NICE guidance is available to advise on the management of lipids in patients who have had an NSTEMI/STEMI or unstable angina but does not consider when the dose of high dose statin should be reviewed. CG48 MI: secondary prevention http://guidance.nice.org.uk/CG48 CG67 Lipid modification http://guidance.nice.org.uk/CG67 CG94 Unstable angina and NSTEMI http://guidance.nice.org.uk/CG94

Why measure ratio of Total Cholesterol: High-Density Lipoprotein (TC: HDL)? Evidence from the JBS2 guidelines state that: the ratio of the single measure of total cholesterol (TC) to HDL cholesterol (HDL-C) is used to calculate CVD risk. There have been some queries from GPs with regard to QOF and the measurements used within this algorithm, as QOF incentivises total cholesterol measures alone. When the TC/HDL ratio is set at an appropriate level, GPs can still obtain maximum QoF points (and hence payment) it will be unusual for someone who reaches their TC/HDL ratio target not to reach their QOF total cholesterol target which is 25% higher than that recommended by JBS2 guidelines. The QOF target rewards GPs for the % of CHD patients whose notes have a record of their Total Cholesterol (TC) in the previous 15 months. Information above was taken from a report written by Dr. Peter Elton, Director of Public Health, NHS Bury (2007).

Summary Atorvastatin 80mg daily for 12 months, if no further coronary interventions within this timescale switch to simvastatin 40mg nocte (if clinically appropriate). See algorithm and NICE guidance CG67 for full details.

Algorithm lipid therapy post MI

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GM and Cheshire Cardiac Network GMMMG

MMGUID03

v1.0

November 2011

ALGORITHM FOR USE OF Lipid Therapy Post Myocardial Infarction (STEMI, NSTEMI & UNSTABLE ANGINA)

Patient with STEMI, NSTEMI & Unstable Angina Commence Atorvastatin 80 mg daily Check lipid level at 6 months to assess compliance
TC:HDL ratio still decreased by > 25% compared to pre-treatment levels (To confirm compliance) YES

NO

Continue Atorvastatin 80mg & check lipid level at 12 months TC:HDL ratio decreased by > 25% compared to pre-treatment levels

YES

and TC: HDL ratio <3.5

NO

Change to Simvastatin 40mg

Continue Atorvastatin 80mg

Check lipid level at 15 months

Discuss compliance with patient if non-compliance confirmed, discuss ways to improve compliance TC: HDL ratio >4.0 Continue Simvastatin 40mg Consider restarting Atorvastatin 80mg
Algorithm lipid therapy post MI Page 4 of 4

TC: HDL ratio <4.0

If compliant yet have genuine multiple statin intolerance seek advice from a lipid clinic
GM and Cheshire Cardiac Network GMMMG