CAD Mayo Flashcards
ASCVD risk calculator
Multi-ethnic study of atherosclerosis (MESA)
Adds coronary calcium to cv risk
Helpful with risk stratifications
Testing for low risk patients?
CT coronary / CAC
Testing for intermediate risk patients-asymptomatic without CAD
Stress test (exercise ECG) - Class 2b
NO BENEFIT for stress echo or myocardial perfusion imaging. Class 2b if patient has DM, fam history of CHD, CAC >400
Aspirin as primary pervention
Consider in patients 40-70yo who have high ASVD risk but not at increased bleeding risk
DO NOT GIVE in patients >70yo or increased bleeding risk
Secondary causes of elevated HDL and elevated LDL
Stop statin in pregnancy, resume when done breastfeeding
Cholesterol guidelines
ASCVD present?
LDL >190?
DM present?
Goal LDL:
LDL <55 with ASCVD
LDL <100 everyone else
Lifestyle modifications
PREDIMED-cardiovascular mortality better with Mediterranean diet
DISCO-DASH and activity increase CAD plaque regression
Cardiac rehab (CAD, HF, valve disease) = class 1
Eval in patients with known CAD
Risk strat of stable ischemic heart disease
Low and high risk findings on non-invasive testing
Moderate to severe noninvasive findings
- Rule out LM with CT coronary arteries
- Medical therapy (no LM, ACS, HF, angina)
- If persistent symptoms then cath
Management of stable CAD
BP management
- goal <130/80. Lifestyle. Then ACE/ARB/ beta blocker. Then dihydro-CCB, long thiazide, MRA)
Which noninvasive test?
Low pretest probability:
- Defer, CA or exercise ECG
Intermediate/high pretest probability (no prior CAD):
- any imaging test
Known CAD
- Any stress or ICA if new reduced EF, clinical HF, LM disease, severe angina
GDMT: HF +/- CAD/DM2
Angina Medical Management
Nitrates contraindications:
- HCM
- Critical AS
- with PDEi
Beta blocker recommendations:
After CABG for post-op AF
For: angina, prior MI, ACS, EF <40
Beta blockade contraindiations:
- cardiogenic shock
- decompensated HF
- atenolol contraindicated with pregnancy
CCB recommendations:
Caution with pregnancy
For angina
Ranolazine recommendations:
Second time for angina
QTC prolongation
Anti-platelet therapy recommendations:
antiplatelet without oral AC
- asa 81 indefinitely
- ACS –> DAPT 12 months
- CABG-asa 100-325mg QD within 6hrs and indefinitely to reduce SVG closure. DAPT if DES
- Elective PCI - DAPT 6 months post PCI then SAPT to reduce MACE
antiplatelet with oral AC
- elective PCI - tripple therapy for 1-4 weeks then clopidogrel + DOAC for 6 months
- DAPY for 12 months for ACS regardless of PCI
*CABG - aspirin 100-325mg indefinitely
Cardiac risk assessment
Step approach
1. Emergency surgery?
2. Acute coronary syndrome?
3. Combined clinical and surgical risk-RCRI, NSQIP
4. Estimate functional status>4METS
5. Will further testing impact decision making or periop care? (need/timing/meds for surgery)—>pharmacologic stress testing (reasonable for elevated risk and poor functional capacity if it will change management)
European:
- Test high risk patients with poor functional capacity going for high risk surgery
ECG-pts with known CAD, not routine
Echo-HF, clinical change, undx dyspnea, not routine
CPET-high risk surgery
Cath?
Post op troponin 1-2 days after in high risk patients with high risk surgery
Valvular disease-inc risk with severe AS-intraop hemodynamic monitoring? Regurg better than stenosis
Treat unstable arrhthmias
Optimize GDMT-can hold ACE/ARB/ARNI. Hold SGLT2i 3-4 days before-euglycemic DKA
Pulm HTN-avoid inc RV afterload from hypoxia, hypercarbia, acidosis
Surgical risk
Highest risk of cardiac events:
- vascular, thoracic, transplant
METs
Bridging anticoagulations
Bridging anticoagulation with warfarin in patients with:
1. stroke/TIA last 3 months
2. LV apical thrombus
3. VTE with high recurrence (protein C/S def, AT III def)
how to:
- Last dose of LMWH 24hrs pre-op
- Restart warfarin day of operation
- Start LMWH 24hrs post op (48-72hrs if high bleeding risk)
Perioperative medical therapy
Periop
-dont hold beta blocker, statin, aspirin (unless bleeding risk)
-warfarin-INR 1 week before. INR 2-3, hold 5 days prior.
-bridge not needed for DOAC
