GEM - cardiovascular risk module part four - some more difficult clinical cases

(1) A 55 year old lady presents with a history of manic depression. She is on treatment with olanzapine and it has been noted that her weight has increased since initiation of her olanzapine treatment. Recent blood tests revealed a fasting glucose of 6.2 mmol/l. Her fasting lipids revealed a cholesterol level of 7.7 mmol per litre and triglycerides of 4.4 mmol/l. Other secondary causes of hyperlipidaemia were excluded.

• (a) What is significant about her fasting glucose?
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• (b) Is olanzapine associated with possible development of diabetes?
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• (c) How might olanzapine affect this lady's lipid levels?
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• (d) If this lady was put on simvastatin 40mg per day and her cholesterol was 5.4 mmol/l. What reference is useful in evaluating the efficacy of different statins and deciding the next step in statin treatment ?
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• (e) What is the significance of raised triglyceride in terms of cardiovascular risk?
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(2) A 79 year old gentleman has a history of a previous CVA last year. His blood pressure is 130/85 mmHg and his lipid profile shows a cholesterol of 6.5 mmol/l and a TG of 1.3 mmol/l. He has a history of osteoarthritis and hypertension. His current medication is bendroflumethiazide 2.5 mg per day, simvastatin 40mg per day, aspirin 75 mg per day, ibuprofen and omeprazole.

• (a) How do non-specific NSAIDs interact with aspirin in terms of cardiovascular risk?
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• (b) Should this gentleman be on dipyridamole?
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• (c) Is there evidence for the effectiveness of lipid lowering in an patient of this age?
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• (d) If there is a past history of stroke then does lipid lowering treatment reduce the risk of a further stroke?
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• (e) How does management of hypertension affect risk of stroke?
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• (f) If this gentleman had a further CVA, what antiplatelet therapy is indicated?
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