Prevention of Ischaemic Heart Disease and Atherosclerosis

General Measures

Medicine Treatment

Referral

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ICD 10 code: I20.0-1/I20.8-9/I21.0-4/I21.9/I22.0-1/I22.8-9/I24.0-1/I24.8-9/I25.0-6/I25.8-9/I63.0-6/I63.8-9/I64/I65.0-3/I65.8-9/I73.8-9/G45.0-2/G45.8-9

• Patients at risk for cardiovascular diseases (such as stroke or myocardial infarction) may benefit from lifestyle modification and lipid-lowering medicine therapy
• Patients should be managed according to their level of risk, and lipid lowering medicines should be given to those with a high risk of CVD even if cholesterol is within the desirable range

Indications for lipid lowering medicine therapy

Patients with any of the following factors are at a relatively high risk for a cardiovascular event and should receive lipid lowering therapy:

• Established atherosclerotic disease:
  • Ischaemic heart disease
  • Peripheral vascular disease
  • Atherothrombotic stroke
• Type 2 diabetes with age > 40 years
• Diabetes for > 10 years
• Diabetes with chronic kidney disease (eGFR < 60 mL/min)

LoE:IIa¹

Patients with any of the following factors are also potentially at risk for cardiovascular disease (other than the categories above)

• Diabetes mellitus
• Hypertension
• Central obesity: waist circumference ≥ 94 cm (men) and ≥ 80 cm (women)
• Smoking
• Age: men > 55 years of age, women > 65 years of age
• Psychological stress

LoE:IIb²

These patients should be managed according to their 10-year risk of a cardiovascular event (See Appendix III: Cardiovascular risk assessment) as calculated using either:

• a) BMI - based risk assessment, or
• b)  Framingham risk score (cholesterol-based assessment)

Management is based on the patient’s 10-year risk of a cardiovascular event as follows:

• < 10% risk: lifestyle modification and risk assess patient every 5 years
• 10–20% risk: lifestyle modification and risk assess patient annually
• ≥ 20% risk: lifestyle modification and start statin treatment

Screening for familial hypercholesteraemia

In addition to the above cardiovascular risk assessment, measure random total cholesterol in patients with the following features (suggestive of familial hypercholesterolaemia or other heritable dyslipidaemias), regardless of their cardiovascular risk:

• Cardiovascular event < 55 years in men or < 65 years in women
• Family history of early onset cardiovascular disease in male relatives < 55 years of age and in female relatives < 65 years of age
• Skin or tendon xanthomata in patient or first degree relative
• Family history of familial hyperlipidaemia

Refer patients with random total cholesterol > 7.5 mmol/L for further investigation.

GENERAL MEASURES

All people with any risk factors for cardiovascular disease should be encouraged to make the following lifestyle changes as appropriate.

• Maintain ideal weight, i.e. BMI 18 to 25 kg/m². Weight reduction in the overweight patient
• Reduce alcohol intake to no more than 2 standard drinks per day for males and 1 for females (1 standard drink = a can of beer = a glass of wine = a shot of spirits).
• Follow a prudent eating plan i.e. low fat, high fibre and unrefined carbohydrates, with fresh fruit and vegetables
• Regular moderate aerobic exercise, e.g. 30 minutes brisk walking 5-7 times/week (150 minutes/week)
• Stop smoking

LoE:IIIb³

MEDICINE TREATMENT

• Lipid lowering medicines should be given to those with a high risk of CVD even if cholesterol is within the desirable range
• When lipid-lowering medicines are used, this is ALWAYS in conjunction with ongoing lifestyle modification

HMGCoA reductase inhibitors (statins), according to table below:

Indication	HMGCOA Reductase Inhibitor (Statin) Dose
A: Primary Prevention - No Existing CVD
- Type 2 diabetes with age > 40 years - Diabetes for > 10 years - Diabetes with chronic kidney disease - ≥ 20% 10-year risk of cardiovascular event	HMGCoA reductase inhibitors (statins), e.g.: Simvastatin, oral, 10 mg at night.
- Patients on protease inhibitors (Risks as above, after switching to atazanavir – see below)	- Atorvastatin, oral, 10 mg at night
B: Secondary Prevention – Existing CVD
- Ischaemic heart disease - Atherothrombotic stroke - Peripheral vascular disease	HMGCoA reductase inhibitors (statins), e.g.: - Rosuvastatin, 10 mg at night. LoE:Ia4
- Patients on protease inhibitors	- Atorvastatin, oral, 10 mg at night LoE:Ia5
- Patients on amlodipine (and not on protease inhibitor)	- Simvastatin, oral, 10-20 mg at night LoE:IIIb6
- If patient complains of muscle pain	Reduce dose: HMGCoA reductase inhibitors (statins), e.g.: - Simvastatin, oral, 20 mg at night - If 20 mg not tolerated, reduce to 10 mg OR - Consult specialist for further management. LoE:IIIb7

Table 4.1: Management with HMGCoA reductase inhibitors

Protease inhibitor-induced dyslipidaemia

• Certain antiretroviral medication, particularly protease inhibitors, can cause dyslipidaemia. Fasting lipid levels should be done 3 months after starting lopinavir/ ritonavir. Lopinavir/ritonavir is associated with a higher risk of dyslipidaemia (specifically hypertriglyceraemia) than atazanavir/ ritonavir
• Patients at high risk (> 20% risk of developing a CV event in 10 years) should switch to atazanavir/ ritonavir and repeat the fasting lipid profile in 3 months
• Patients with persistent dyslipidaemia despite switching, qualify for lipid lowering therapy. Criteria for initiating lipid lowering therapy are the same as for HIV-uninfected patients. Many statins (including simvastatin) cannot be used with protease inhibitors, as protease inhibitors inhibit the metabolism of the statin resulting in extremely high blood levels
• Patients who fail to respond to lifestyle modification and have dyslipidaemia treat with:
  • Atorvastatin, oral, 10 mg at night

REFERRAL

• Random cholesterol > 7.5 mmol/L (to be evaluated for genetic disorders), after excluding secondary causes such as uncontrolled diabetes, hypothyroidism, or protease inhibitor use
• Tendon or skin xanthomata (except xanthelasma around the eyes)
• Statins not tolerated by patients, despite lower dose (for consideration of alternative treatment)

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_1 November 2024

Chapter 4: Cardiovascular Conditions_4.1 Prevention of Ischaemic Heart Disease and Atherosclerosis