Cholesterol Screening

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Cholesterol Screening

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Cholesterol Screening

  1. 1. Cholesterol screening Dr Liesl Brown Department of Pharmacy University of Limpopo (Medunsa Campus) Module 2.2: Cardiovascular Pharmacy (2011)
  2. 2. AimHow to screen for cholesterol in Community Pharmacy setting
  3. 3. 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?
  4. 4. 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
  5. 5. 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
  6. 6. 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)
  7. 7. 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
  8. 8. 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
  9. 9. Determination & screening ofcholesterolOther application locations:  Doctor’s offices  Medical clinics  Homes  Field Hospitals
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Examples of different types of GTC-meters
  18. 18. 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
  19. 19. Cholesterol screening done in aCommunity Pharmacy
  20. 20. Cholesterol screening done in aCommunity Pharmacy
  21. 21. 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)
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Cholesterol screening done in aCommunity Pharmacy
  26. 26. 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
  27. 27. 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
  28. 28. Cholesterol screening done in aCommunity Pharmacy STEP 10: Close the flap after applying the drop
  29. 29. 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
  30. 30. Cholesterol screening done in aCommunity Pharmacy
  31. 31. Cholesterol Action Limits
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Hands on screening of cholesterol levels inblood plasma using photometers
  38. 38. Hands on screening of cholesterol levels inblood plasma using photometersDE 519 CE S522 CE 302BTA N309 VA 520C

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