Return to PJ Online Home Page
The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR22

Development of a pharmacist-led cholesterol screening and lipid-lowering medication review service in coronary-artery bypass graft patients

By D. Alldred, C. Booth and H. Chrystyn*

Introduction Raised total cholesterol, LDL-cholesterol and low HDL-cholesterol are risk factors for the development and progression of coronary heart disease (CHD).1 Hypercholesterolaemia not only predicts progression of artherosclerosis and CHD in native coronary vessels,2 but also in graft vessels following coronary-artery bypass graft surgery (CABG).3 Grafts are at an increased risk of artherosclerosis and this may lead to late graft failure. Lowering cholesterol levels in CABG patients has been shown to reduce the progression and increase the regression of artherosclerosis in native and graft vessels.3
Currently at Leeds general infirmary, pre-surgery cholesterol levels are not measured routinely. Consequently no review of lipid-lowering medication occurs. Statin therapy with dietary advice is the main therapeutic intervention to lower cholesterol. Patients at Leeds general infirmary receive dietary advice at cardiac rehabilitation clinics post-surgery.
The aims of this study were to assess the impact of a pharmacist-led cholesterol screening and lipid-lowering medication review service in CABG patients and to assess the optimisation of therapeutic management.

Method A total cholesterol level was obtained from elective CABG patients attending pre-admission clinic at Leeds general infirmary. Cholesterol levels were assessed against an agreed protocol and lipid-lowering medication was reviewed by the pharmacists. Target total cholesterol levels were <4.8mmol/l for patients with a previous history of myocardial infarction (MI) and <5.2mmol/l for all other patients. Atorvastatin 10mg daily was commenced in patients whose cholesterol levels were not at the desired level providing they were not already receiving statin therapy. Patients who were already prescribed a statin, and whose cholesterol levels were still not optimised, had their current statin dose doubled.
A post-surgery total cholesterol level was obtained six weeks following discharge from hospital: it takes six weeks after CABG surgery for serum lipid values to return to baseline.4 In patients whose cholesterol level was not at the desired level and were not already prescribed statin medication, atorvastatin 10mg daily was commenced. For those already prescribed a statin, doses of their current agent were doubled.
Patients were excluded from the study if they presented at pre-admission clinic within four weeks of statin initiation, if they were known to be intolerant of statins, or if there were any contraindications to statin use.

Focal points

  • Hypercholesterolaemia predicts progression of coronary heart disease in native vessels and graft vessels in coronary-artery bypass graft surgery (CABG) patients
  • No review of cholesterol levels and consequently lipid-lowering medication is currently undertaken in CABG patients at Leeds General Infirmary
  • Initial results show that a significant number of patients do not have optimised cholesterol levels when attending pre-admission clinic for CABG surgery
  • Initial results indicate that pharmacist intervention, by optimising statin use, can reduce cholesterol levels to target values in CABG patients

Results To date, 38 patients have completed the study; 29 (76 per cent) were male. Eighteen (47 per cent) patients did not have cholesterol levels at target values pre-surgery. Five of these patients were commenced on atorvastatin 10mg nocte and 13 had their statin doses doubled. This resulted in 14 of these patients reaching target values. Of the four unsuccessful interventions, maximum recommended statin doses were attained in two patients and further review by the GP was recommended. Doubling of statin doses was recommended to the GP for the remaining two patients. Of the 20 patients who had target cholesterol levels pre-surgery, three no longer had target values post-surgery. Doubling of statin doses was recommended to the GP for these three patients. In total, following completion of the study, 31 (82 per cent) patients had reached target cholesterol levels.

Discussion The initial results indicate that a significant number of patients attending for CABG surgery do not have optimised cholesterol levels. The early findings in this study suggest that routine measurement of pre-surgery cholesterol levels would be of value.
The results indicate that a pharmacist's intervention, by optimising statin use, can reduce cholesterol levels to pre-agreed target values. This will contribute to a reduced risk of progression of artherosclerosis in this population.

Pharmacy department, Leeds Teaching Hospitals NHS trust, Leeds LS1 3EX; *school of pharmacy, University of Bradford, Bradford BD7 1DP

References

1. Pekkanen MD et al. Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med 1990;322:700-7.
2. Pearson et al. Optimal risk factor management in the patient after coronary revascularization. Circulation 1994;90:3125-33.
3. Blankenhorn et a.l Beneficial effects of combined colestipol-niacin therapy on coronary artherosclerosis and coronary venous bypass grafts. JAMA 1987;252:3233-40.
4. Shaukat N et al. A prospective study of serum lipoproteins after coronary-artery bypass surgery. Q J Med 1994;87:539-45.