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Cholesterol Screening

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Cholesterol Screening

Cholesterol Screening

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    Cholesterol Screening Cholesterol Screening Presentation Transcript

    • Cholesterol screening Dr Liesl Brown Department of Pharmacy University of Limpopo (Medunsa Campus) Module 2.2: Cardiovascular Pharmacy (2011)
    • AimHow to screen for cholesterol in Community Pharmacy setting
    • ObjectivesAfter this practical experience, you will be able to provide the answers to the following questions: WHAT is a cholesterol-screening test? WHO should have their cholesterol tested checked? HOW frequent should cholesterol be screened? WHAT is the importance of a cholesterol screening test? WHAT are the normal (reference) values of a cholesterol screening test? WHAT are the precautions that need to be taken by a pharmacist (operator) and by the subject (patient/volunteer)? HOW reliable are the results of a cholesterol screening test? WHAT factors can affect the screening results?
    • Hyperlipideamia (HLD)Definition: Hyperlipideamia is a term used to describe all conditions characterized by high cholesterol levels Characterized by an increase in blood conc. of 1 / > types of lipids (fats) in the blood (e.g. cholesterol, cholesterol esters, triglycerides, phospholipids) One of the main causes of:  Atherosclerosis  Coronary heart disease
    • Drugs that give rise to drug-induced HLD Thiazide diuretics (LDL and total CHOL (TC) increase) Certain β-blockers (TG increase and HDL decreases) Progestins (TC increases) Glucocorticoids (TC increases) Anabolic steroids (TC increases and HDL decreases) Cyclosporine (TG and LDL increases) Isotretinoin (TG increases and HDL decreases) Large amounts of alcohol (TG increases) Oestrogen in oral contraceptives
    • Other factors that give rise to HLD Very high KJ diet Diet rich in (unsaturated) fats Diet rich in cholesterol Very low fibre diet Lack of exercises Smoking Moderate / high alcohol abuse High androgen levels (men > premenopausal women)
    • Determination & screening ofcholesterolDetermined in a: Clinical environment (e.g. blood taken and TG is determined) Community Pharmacy (screening for CHOL)Clinical environment  Blood is drawn and lipoprotein / full lipogram (incl. TG) be determined  Blood drawn after 12 hrs of fasting and 24 hrs of alcohol avoidance
    • Determination & screening ofcholesterolCommunity pharmacy (Screening for CHOL)  CHOL is screened  Only total CHOL is determined  Units: mmol/L; mg/100 ml/ mg/dl (1 mmol = 387 mg)  Total CHOL represented as:  Desired  Moderately high  Seriously high  Above is linked to age
    • Determination & screening ofcholesterolOther application locations:  Doctor’s offices  Medical clinics  Homes  Field Hospitals
    • Which persons’ total CHOL should betested? Patients with a personal history of CV disease Should there be a family history of CV disease – esp. in patients < 50 years Children, should there be a family history of hyperlipoproteinemia Should there be evidence of DM, hypertension, serious obesity (BMI > 30), gout / smoking Women: 35-59 years of age with two/> risk factors* (*smoking, hypertension, obesity, DM, family history of CV disease & hypercholesterolemia) Men 35-59 years of age with one risk factor* Men: 20-34 years and 60-69 years of age, with 2/> risk factors* Adults > 20 years of age – non fasting CHOL screen done once every 5 years
    • Patient factors which influence TClevels Posture/position of patient Food and alcohol ingestion Physical activity Recent cardiac conditions Pregnancy Gender Age Trauma/infection Biological (‘time of the day’) variation
    • Patient factors which influence TClevels Posture/position of patient  TC increases in the standing position  Determinations done in the same position (sitting)  Sitting for at least 5 min. prior to test, so that the effect can be stabilized Food and alcohol ingestion  TC can be determined without patient fasting  Dietary cholesterol will cause a small/insignificant increase in TC  Alcohol ingestion will give rise to a modest decrease in TC Physical activity  Strenuous physical activity 24 hrs prior to the screening lowers TG levels  Above influences TC levels
    • Patient factors which influence TClevels Recent cardiac conditions  TC levels decrease sign. following a MI (for various days, until about 8 weeks)  CHOL levels can also decrease following cardiac catheterization Pregnancy  TC increases by 20 to 35% Gender  After puberty: HDL levels are lower in men than women TG and VLDL levels are higher in men than women  After puberty: Oestrogen lowers LDL levels and increase HDL (women) Androgens increase LDL and decreases HDL (men)  During menstruation: TC lower during luteal phase than other stages of the menstrual cycle
    • Patient factors which influence TClevels Age  Birth to six months: plasma levels rise rapidly Childhood: plasma CHOL levels stay reasonably constant After puberty: plasma CHOL rises Adulthood: plasma CHOL reaches a peak:  men: 50 to 60 yrs of age  women: 60 to 70 yrs of age Trauma/infection  Trauma: CHOL levels decrease by 40% and remain lowered for 5 to 6 weeks after the event  Infection (bacterial / viral)/bad pain/operation: CHOL levels are lowered and remain lowered for 8 weeks after such events
    • Patient factors which influence TC levels Biological (‘time of the day’) variation  During the day: TC variation of 2 to 3% during the day  Seasonal variation: TC levels lower in summer than winter
    • Cholesterol screening done in aCommunity PharmacyItems needed: Reflex photometer (e.g. GCT meter) Finger pricking apparatus / lancing device Lancets Reagent test strips (glucose, cholesterol, triglycerides) Control solutions
    • Examples of different types of GTC-meters
    • Cholesterol screening done in aCommunity PharmacyCalibration Calibration with a code strip serves to adjust the meter to a specific characteristics of the CHOL / GLUC / TG test strips used Code strips are wrapped individually in the pack of test strips purchased (!! Storage of the test strip in its wrapping and not in the test-strip vial – print on the code strip may impair the test strip quality and lead to erroneous results !!) Calibration must take place when:  The meter is switched on for the first time  Whenever new test strips are used
    • Cholesterol screening done in aCommunity Pharmacy
    • Cholesterol screening done in aCommunity Pharmacy
    • Cholesterol screening done in aCommunity PharmacyMeasurement procedures STEP 1: Wash and dry hands thoroughly. Rinse with clear water before commencing measurement (!! TG measurements – all creams and many soap products e.g. shower gels, shampoos) contain fat – leads to false results !!) STEP 2: Prepare lancing device  Select penetration depth (e.g. ‘soft skin’ hands vs. ‘hard skin’ hands)
    • Cholesterol screening done in aCommunity PharmacyMeasurement procedures STEP 3: Switch on apparatus  Word CHOL / GLUC / TG appears  Corresponding code no., time, and date appears  When word CODE appears, the apparatus is ready for measurements STEP 4: Remove the test strip from its wrapping. Close vial immediately
    • Cholesterol screening done in aCommunity PharmacyMeasurement procedures STEP 5: Cover flap and insert test trip into slot in the direction of the arrow making sure that it is inserted as far as it can goTest strip successfully read:  two beeps  name the test strip inserted e.g. either CHOL or GLUC or TG will be displayed  CODE stops blinking and EV.0 begins to blink:  Test strip incorrectly read: Error messages appear e.g. E-1 , E-2 or OFF  Act according to procedures stipulated in the booklet
    • Cholesterol screening done in aCommunity Pharmacy STEP 6: Open flap  EV.O blinks on display together with measurement time: 180 sec (max) for TG (reaction time = 174 sec) STEP 7: Rub and kneed a fingertip to facilitate the withdrawal and application of blood STEP 8: Prick the massaged place on the fingertip with the lancing device
    • Cholesterol screening done in aCommunity Pharmacy
    • Cholesterol screening done in aCommunity Pharmacy STEP 9:  Cover yellow test field completely with blood (otherwise falsely low results will be measured)  If too little blood is applied, do not rub it in or apply second drip, repeat the measurement with a fresh test strip  Allow hanging blood drop to form without applying too much pressure  Carefully drop blood to yellow test field on top of strip without touching top of strip
    • Cholesterol screening done in a Community Pharmacy STEP 9 (cont.):  If too little blood is applied, do not rub it in or apply second drip, repeat the measurement with a fresh test strip
    • Cholesterol screening done in aCommunity Pharmacy STEP 10: Close the flap after applying the drop
    • Cholesterol screening done in a Community Pharmacy STEP 11: Meter counts down in seconds to 0. Last four sec is heard at the end of the measurement followed by a long beep  Measured value (in mg/dl or mmol/l) appears on the display and EV.O blinks  Measured values only within certain ranges:  CHOL 150 – 300 mg/dl (3.88 - 7.76 mmol/l)  Blood GLC 20 – 600 mg/dl (1.1 – 33.3 mmol/l)  TG 70 – 600 mg/dl (0.80 – 6.86 mmol/l)  Above the ranges : HI shown  Below the ranges: LO shown (also when too little blood is used)  Open flap. Remove test strip  Close flap and switch meter off
    • Cholesterol screening done in aCommunity Pharmacy
    • Cholesterol Action Limits
    • Heart Foundation recommendationsSA Heart Foundation recommends the following classification for TC levels:  <5.0 mmol/L – Desirable  5-6.5 mmol/L – Moderate risk  6.5-7.8 mmol/L – High Risk  >7.8 mmol/L – Very high risk  Recommended that > 1 test be done for confirmation (esp. moderate/high TC)  TC screening can be done – fasting/non-fasting conditions
    • Factors influencing the accuracy ofresultsFactors influencing the accuracy of results Instrumental factors Sampling Quality control procedures Instrumental factors  Apparatus of Community Pharmacies compare well with apparatus in Clinical environments  Comparing results: variation from 1 to 5% (Community Pharmacy results lower than standard operating laboratories results
    • Factors influencing the accuracy of results Sampling  Has a strong influence on the accuracy of results  Personnel have to be trained in the correct procedures  Results of finger pricking sample vary about 4% from the venous puncture sample  !! Finger should not be ‘milked’ at all – blood will then mix with the ECF and result in giving falsely low CHOL levels  Capillary tube should not be pushed into the finger
    • Factors influencing the accuracy ofresults Quality control procedures  Standing correct quality SOP should be adhered to at all times  Accuracy of the sample should be evaluated through the test of std solutions with a known CHOL level  Should be done weekly / after 100 tests (which ever comes first)  Records should be kept of the results and carefully studied  Analyzers that do not comply with ≈ 5% or < standard precision, should be removed from service until repaired  Comparing: venous puncture sample of same patient (screen test done in a Community Pharmacy) vs. laboratory (clinical setting)  Optical system of the apparatus should be cleaned with 70% alcohol  Should not be used within 15 min. after the cleaning procedure  Instruction manual should be strictly adhered to
    • References Davies, A, Blakeley, AGH and Kidd, C. Human Physiology. McGraw- Hill:Boston, Massachusetts Griesel, MS. Primary screening and monitoring services for pharmacists. PSSA Publications: Potchefstroom, Chapter 2, pp. 48-61 Internet resources:  http://www.diavant.com/diavant/CMSFront.html?pgid=3,1,5,0  http://www.diavant.com/diavant/CMSFront.html?pgid=1,3,9,1  http://www.roche-diagnostics.com/products_services/accutrend_gct.html SAMF, 9h edition, Section on Serum lipid-modifying agents
    • Hands on screening of cholesterol levels inblood plasma using photometers
    • Hands on screening of cholesterol levels inblood plasma using photometersDE 519 CE S522 CE 302BTA N309 VA 520C