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Audit of the diagnosis of familial hypercholesterolaemia in primary care
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Abstracts / Atherosclerosis 236 (2014) e303ee309
Methods: In this randomised double-blind cross over trial we studied the effect of ERN/LRP compared to placebo in 27 statin treated dyslipidaemic patients. The primary endpoint was to determine whether treatment with ERN/LRP leads to a >15% increase in high density lipoprotein cholesterol (HDL-C) compared with placebo. We measured lipid profile, apolipoproteins, cholesteryl ester transfer protein (CETP) activity, paraoxonase 1 activity (PON1), small dense LDL apoB (sdLDL-apoB), oxidised LDL (oxLDL), glycated apoB (glyc-apoB), lipoprotein phospholipase A2 (Lp-PLA2), lysophosphatidyl choline (lyso-PC), macrophage chemoattractant protein (MCP1), serum amyloid A (SAA) and myeloperoxidase (MPO). We also examined the capacity of HDL to protect LDL from in vitro oxidation and percentage cholesterol efflux. Results: The primary endpoint was achieved and treatment with ERN/LRP was associated with significant reductions in total cholesterol, triglycerides, LDL cholesterol, total apoB, lipoprotein (a), CETP activity, oxLDL, Lp-PLA2, lyso-PC, MCP1 and SAA but there were no significant changes in glyc-apoB or sdLDL-apoB. ERN/LRP treatment led to a modest increase in cholesterol efflux function of HDL (29% vs 27%, p¼0.045) but not its antioxidant capacity in vitro or PON1 activity. Conclusion: ERN/LRP reduces LDL associated mediators of vascular inflammation but has varied effects on HDL functionality and LDL quality. ETHNIC DISPARITIES IN THE QUALITY OF DIABETES CARE A. Jain, Nandini Rao, Nadia Hoshi, Sabina Shamsad, Nirav Bhatt*, Payal Patel*, J.W. Persaud, Devaki R. Nair Department of Clinical Biochemistry, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
* Corresponding authors. BAPS Healthcare, Shri Swaminarayan Mandir, Neasden, London NW10 8 LD, UK.
Background: The National diabetes Audit 2011 on the Diabetes ‘core care’ showed only 54.3 % of the diabetics received all the nine care processes. There was significant variation between various Clinical Commissioning Groups as well as amongst the individual care processes. South Asians have a higher prevalence, worse outcomes and high rates of diabetes related complications. An initiative was set up between the Royal Free London NHS Foundation Trust and Hindu Temples in North London to see if a ‘one stop shop model’ increases the engagement of subjects with diabetes in their care in a culturally friendly environment. An initial evaluation of their care process was assessed during their first visit. Method: A total of 68 individuals of Gujarati Indian origin underwent assessment. Measurements included anthropometry, blood pressure lipid profile, HbA1cand Urine ACR. In addition a pharmacy review, lifestyle counselling was carried out and their compliance with the NICE care processes was assessed. Results: The results (45 men, 23 women) with mean age 63± 9 years are tabulated below. Target
HbA1c < 48mmol/mol HbA1c 58mmol/mol HbA1c 86mmol/mol Cholesterol< 4mmol/L Low density cholesterol < 2 mmol/l Target BP <140/80
MEN (n ¼ 45)
Women (n¼23)
National Average
46% 55% 97% 69% 62.2% 36%
44% 73% 96% 45% 54% 45.4%
26.2% 64.9% 92.6% 40.7% e 44.8
73% of women had HbA1c 58mmol/mol well above the national average but not for men.. 90% of the individuals registered for the retinal screening programme. Less than 1 % individuals went for foot examination. Only 3% received one to one dietary advice. Conclusion: Majority of the subjects with diabetes were to target for 3 risk factors in contrast to dietary advice and foot examination. We believe that if focus is laid on improving the frequency, consistency of, dietary advice, foot examination to a levels achieved for other checks
there would be huge step up in completion of the nine care process bundle. AUDIT OF THE DIAGNOSIS OF FAMILIAL HYPERCHOLESTEROLAEMIA IN PRIMARY CARE K.E. Shipman a, *, S. Ganeshamoorthy b, M. Labib a a Department of Clinical Biochemistry, Russells Hall Hospital, Dudley DY1 2HQ, UK; b General Practice VTS, West Midlands Deanery, UK
* Corresponding author. Familial hypercholesterolemia (FH) is characterized by high total cholesterol (TC) and/or low-density lipoprotein cholesterol (LDL-C) concentrations in the blood and is associated with high rates of premature atherosclerotic disease. The identification and management of FH is based on clear guidance published by NICE in 2008 (CG71). The guidance states that FH should be considered in patients with TC>7.5 mmol/L (or LDLC>4.9 mmol/L), if the levels remain high following a period of lifestyle modification and after excluding secondary causes. The guidance does not specify whether the management should occur in primary or secondary care. We have audited whether NICE guidelines have been followed in a large teaching general practice surgery. The electronic notes were searched for adults with TC>7.5 mmol/L in 2010. Thirty nine patients were identified and their notes were audited >15 months after the initial test. TC was repeated in 82% with additional tests performed to exclude secondary causes in 59-72%. Dietary advice was given to 38% and repeat lipid profiles were performed in 28% after the advice. Relevant medical history was documented in 64-67%, smoking status in 56%, stigmata of hyperlipidaemia in 8% and family history of ischaemic heart disease and hyperlipidaemia in 56% and 21%, respectively. None of the patients managed exclusively in primary care was given the diagnosis of FH. The various diagnoses given were: pure hypercholesterolaemia (15%), hyperlipidaemia NOS (13%), serum cholesterol raised (8%) and dyslipidaemia (3%). Our audit showed that FH is poorly identified in primary care. The use of descriptive diagnoses for lipid abnormalities was inappropriate and probably resulted in under-diagnosis of FH and poor compliance with NICE guidance. There is an urgent need to increase the awareness about FH in primary care in order to improve the detection and management of these high risk patients. EVALUATION OF AFINION™ AS100 ANALYSER (POC) IN A COMMUNITY SETTING A. Jain, Nandini Rao, Mahtab Sharifi, Nirav Bhatt*, Payal Patel*, J.W. Persaud, Devaki R. Nair Department of Clinical Biochemistry, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
* Corresponding authors. BAPS Healthcare, Shri Swaminarayan Mandir, Neasden, London NW10 8 LD, UK Background: Social class and ethnic disparities in use of preventive services is well-known in the management of cardiovascular disease (CVD) and diabetes. A “One stop shop” model for multifactorial risk factor management in a culturally sensitive environment is likely to improve outcomes in CVD prevention. A full CVD risk assessment requires a lipid profile, glucose and HbA1c measurements often requiring the use of more than one instrument or additional laboratory measurements. We carried out a three way comparison of Afinion™ AS 100 analyser with Cholestech LDX® and the laboratory to assess its utility as a single instrument to provide a ‘One stop shop’ for CVD risk assessment. Method: Results from 201 subjects who attended the community CVD screening programme and the diabetic care clinic were analysed for the above evaluation. Results: The results (117 men; 84 women) were divided into tertiles and Bland -Altman plots were used to assess the agreement. At high density cholesterol (HDL-C) concentrations <1.0 mmol/L the Affinion (vs
Abstracts / Atherosclerosis 236 (2014) e303ee309
Methods: In this randomised double-blind cross over trial we studied the effect of ERN/LRP compared to placebo in 27 statin treated dyslipidaemic patients. The primary endpoint was to determine whether treatment with ERN/LRP leads to a >15% increase in high density lipoprotein cholesterol (HDL-C) compared with placebo. We measured lipid profile, apolipoproteins, cholesteryl ester transfer protein (CETP) activity, paraoxonase 1 activity (PON1), small dense LDL apoB (sdLDL-apoB), oxidised LDL (oxLDL), glycated apoB (glyc-apoB), lipoprotein phospholipase A2 (Lp-PLA2), lysophosphatidyl choline (lyso-PC), macrophage chemoattractant protein (MCP1), serum amyloid A (SAA) and myeloperoxidase (MPO). We also examined the capacity of HDL to protect LDL from in vitro oxidation and percentage cholesterol efflux. Results: The primary endpoint was achieved and treatment with ERN/LRP was associated with significant reductions in total cholesterol, triglycerides, LDL cholesterol, total apoB, lipoprotein (a), CETP activity, oxLDL, Lp-PLA2, lyso-PC, MCP1 and SAA but there were no significant changes in glyc-apoB or sdLDL-apoB. ERN/LRP treatment led to a modest increase in cholesterol efflux function of HDL (29% vs 27%, p¼0.045) but not its antioxidant capacity in vitro or PON1 activity. Conclusion: ERN/LRP reduces LDL associated mediators of vascular inflammation but has varied effects on HDL functionality and LDL quality. ETHNIC DISPARITIES IN THE QUALITY OF DIABETES CARE A. Jain, Nandini Rao, Nadia Hoshi, Sabina Shamsad, Nirav Bhatt*, Payal Patel*, J.W. Persaud, Devaki R. Nair Department of Clinical Biochemistry, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
* Corresponding authors. BAPS Healthcare, Shri Swaminarayan Mandir, Neasden, London NW10 8 LD, UK.
Background: The National diabetes Audit 2011 on the Diabetes ‘core care’ showed only 54.3 % of the diabetics received all the nine care processes. There was significant variation between various Clinical Commissioning Groups as well as amongst the individual care processes. South Asians have a higher prevalence, worse outcomes and high rates of diabetes related complications. An initiative was set up between the Royal Free London NHS Foundation Trust and Hindu Temples in North London to see if a ‘one stop shop model’ increases the engagement of subjects with diabetes in their care in a culturally friendly environment. An initial evaluation of their care process was assessed during their first visit. Method: A total of 68 individuals of Gujarati Indian origin underwent assessment. Measurements included anthropometry, blood pressure lipid profile, HbA1cand Urine ACR. In addition a pharmacy review, lifestyle counselling was carried out and their compliance with the NICE care processes was assessed. Results: The results (45 men, 23 women) with mean age 63± 9 years are tabulated below. Target
HbA1c < 48mmol/mol HbA1c 58mmol/mol HbA1c 86mmol/mol Cholesterol< 4mmol/L Low density cholesterol < 2 mmol/l Target BP <140/80
MEN (n ¼ 45)
Women (n¼23)
National Average
46% 55% 97% 69% 62.2% 36%
44% 73% 96% 45% 54% 45.4%
26.2% 64.9% 92.6% 40.7% e 44.8
73% of women had HbA1c 58mmol/mol well above the national average but not for men.. 90% of the individuals registered for the retinal screening programme. Less than 1 % individuals went for foot examination. Only 3% received one to one dietary advice. Conclusion: Majority of the subjects with diabetes were to target for 3 risk factors in contrast to dietary advice and foot examination. We believe that if focus is laid on improving the frequency, consistency of, dietary advice, foot examination to a levels achieved for other checks
there would be huge step up in completion of the nine care process bundle. AUDIT OF THE DIAGNOSIS OF FAMILIAL HYPERCHOLESTEROLAEMIA IN PRIMARY CARE K.E. Shipman a, *, S. Ganeshamoorthy b, M. Labib a a Department of Clinical Biochemistry, Russells Hall Hospital, Dudley DY1 2HQ, UK; b General Practice VTS, West Midlands Deanery, UK
* Corresponding author. Familial hypercholesterolemia (FH) is characterized by high total cholesterol (TC) and/or low-density lipoprotein cholesterol (LDL-C) concentrations in the blood and is associated with high rates of premature atherosclerotic disease. The identification and management of FH is based on clear guidance published by NICE in 2008 (CG71). The guidance states that FH should be considered in patients with TC>7.5 mmol/L (or LDLC>4.9 mmol/L), if the levels remain high following a period of lifestyle modification and after excluding secondary causes. The guidance does not specify whether the management should occur in primary or secondary care. We have audited whether NICE guidelines have been followed in a large teaching general practice surgery. The electronic notes were searched for adults with TC>7.5 mmol/L in 2010. Thirty nine patients were identified and their notes were audited >15 months after the initial test. TC was repeated in 82% with additional tests performed to exclude secondary causes in 59-72%. Dietary advice was given to 38% and repeat lipid profiles were performed in 28% after the advice. Relevant medical history was documented in 64-67%, smoking status in 56%, stigmata of hyperlipidaemia in 8% and family history of ischaemic heart disease and hyperlipidaemia in 56% and 21%, respectively. None of the patients managed exclusively in primary care was given the diagnosis of FH. The various diagnoses given were: pure hypercholesterolaemia (15%), hyperlipidaemia NOS (13%), serum cholesterol raised (8%) and dyslipidaemia (3%). Our audit showed that FH is poorly identified in primary care. The use of descriptive diagnoses for lipid abnormalities was inappropriate and probably resulted in under-diagnosis of FH and poor compliance with NICE guidance. There is an urgent need to increase the awareness about FH in primary care in order to improve the detection and management of these high risk patients. EVALUATION OF AFINION™ AS100 ANALYSER (POC) IN A COMMUNITY SETTING A. Jain, Nandini Rao, Mahtab Sharifi, Nirav Bhatt*, Payal Patel*, J.W. Persaud, Devaki R. Nair Department of Clinical Biochemistry, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
* Corresponding authors. BAPS Healthcare, Shri Swaminarayan Mandir, Neasden, London NW10 8 LD, UK Background: Social class and ethnic disparities in use of preventive services is well-known in the management of cardiovascular disease (CVD) and diabetes. A “One stop shop” model for multifactorial risk factor management in a culturally sensitive environment is likely to improve outcomes in CVD prevention. A full CVD risk assessment requires a lipid profile, glucose and HbA1c measurements often requiring the use of more than one instrument or additional laboratory measurements. We carried out a three way comparison of Afinion™ AS 100 analyser with Cholestech LDX® and the laboratory to assess its utility as a single instrument to provide a ‘One stop shop’ for CVD risk assessment. Method: Results from 201 subjects who attended the community CVD screening programme and the diabetic care clinic were analysed for the above evaluation. Results: The results (117 men; 84 women) were divided into tertiles and Bland -Altman plots were used to assess the agreement. At high density cholesterol (HDL-C) concentrations <1.0 mmol/L the Affinion (vs