CardiologyI Flashcards
What are the 10 steps in the NCEP guidelines?
1: fasting lipid profile for all adults >20 q 5 yrs
2: rule out 5 causes of secondary dyslipidemia via other tests
3: Identify CHD risk equivalents
4: Determine the presence of major CHD risk factors
5: Estimate 10 yr risk with framingham pt scores
6: Determine tx goals and appropriate tx based on risk category
7: initiate TLC
8: consider drug therapy
9: identify metabolic syndrome and treat
what are the causes of secondary dyslipidemia and how do you test for them?
DM (fasting glucose), hypothyroidism (TSH), obstructive liver disease (LFT, UA), chronic renal failure (BUN, creatinine), drugs that increase LDL or decrease HDL (progestins, corticosteroids, alcohol, beta blockers, protease inhibitors, anabolic steroid, thiazide diuretics, isotretinoin)
what are the CHD risk equivalents?
DM, peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid artery disease, multiple risk factors conferring a 10 yr risk for CHD
what are the CHD major risk factors?
ADD 1 RF FOR: current smoking, HTN or on an anti-HTN med, low HDl (60 mg/dL
what is metabolic syndrome and how do you treat it?
includes 3+ of the following: abdominal obesity (waist >40 in men, >35 female), HDL150mg/dL, BP 130/85, glucose >110 mg/dL
tx: weight reduction, increase physical activity, increase unsaturated fats to lower TG and increase HDL, and add pharm measures to lower LDL like statins, niacin, or fibrate
What is the progression of TLC monitoring according to the NCEP guidelines?
1: Begin TLC (up exercise, down saturated fat and cholesterol, consider referral to dietician)
2: 6 wks evaluate LDL response, if not achieved, intensify TLC: reinforce decreasing cholesterol/saturated fats, consider adding plant stanols/sterols, increase fiber, consider referral
3: 6 wks evaluate LDL response, if not achieved consider drug therapy, instensify wt management and physical activity, initiate tx for metabolic syndrome, consider referral
4: 4-6 months monitor adherence to TLC
what is the progression of drug tx monitoring according to the NCEP guidelines?
1: initiate LDL lowering therapy: statin, nicotinic acid, bile acid resin
2: 6 wks check LDL, if not achieved up statin or add BAR or nicotinic acid
3: 6 wks check LDL, if not achieved intensify therapy or refer to lipid specialist, if achieved treat other lipid risk factors
4: 4-6 months monitor response and adherence
What are the “statin benefit groups” according to the ACC/AHA guide lines?
anyone with clinical ASCVD (atherosclerotic cardiovascular disease)
anyone with LDL >190 mg/dL
pts with LDL 70-189 at age 40-75 WITH DM (but WITHOUT ASCVD)
patients with LDL 70-189 WITHOUT DM or ASCVD but with 10 yr risk of >7.5%
If a pt doesn’t fit into one of the statin benefit groups but there is a clinical suspicious they may benefit from a statin, what are other factors that can be used to determine whether or not they should go on a statin?
LDL >160, genetic hyperlipidemia, CVD in a 1st degree male 2 mg/dL), ankle-brachial index
According to ACC/AHA when are high intensity statins used (reducing LDL by >50%)? what are 2 examples?
secondary prevention in adults 190, primary prevention in adults or adults (moderate an option for these, but not for this with DM) with DM ages 40-75 with LDL 70-189 and 10 yr risk of ASCVD 7.5%+
examples: atorvastatin 80mg daily, rosuvastatin 20-40 mg daily
According to ACC/AHA when are moderate intensity statins used (reducing LDL by 30-50%)? what are some examples?
for secondary prevention in adults
According to ACC/AHA when are low intensity statins used (reducing LDL by
for pts who cannot tolerate high or moderate dose statins. examples: fluvastatin 20-40 mg daily, lovastatin 20 mg daily
when are nonstatins recommended according to the ACC/AHA guidelines?
for those who cannot tolerate statin dose or have no response to statins and are at high risk i.e. LDL >190, DM, or clinical ASCVD, for those with high TGs, i.e. >500
Also think about if there is another reason they aren’t responding
don’t add statins to nonstatins, nonstatins may inhibit the effects of statins
what are the TLC recommended by NCEP and ACC/AHA/
heart healthy diet: Mediterranean diet
EAT: vegetables, fruits, whole grains, low fait dairy, poultry, fish, beans, non tropical vegetable oils, nuts,
LIMIT: red meat, sweets and sugary drinks, saturated and trans fats, sodium (
what are the guidelines on monitoring statins according to ACC/AHA?
lipids at baseline, 4-12 wks after, then q 3-12 months; ALT at baseline and again if sx of hepatotoxicity occur; pre existing muscle sx, baseline CRK if risk of myopathy, CRK prn if myopathy, check adherence, consider statin reduction if two LDL measurements
what are the known causes of HTN?
known causes: sleep apnea, drug induced causes, CKD, primary aldosteronism, renovascular disease, chronic steroid therapy and cushing’s syndrome, pheochromocytoma, coarctation of the aorta, thyroid or parathyroid disease; meds that may increase it: NSAIDS, cox2, cocaine/amphetamines, sympathomimetics (decongestants, anorexiants), oral contraceptives, certain dietary supplements (ma haung, bitter oragne, guarana), corticosteroids, cyclosporine (anti rejection), erythopoietin, licorice
what are the things that HTN can cause?
major cardiovascular events 12x higher in those with HTN, MI, stroke, PE, HF, PVD, aortic dissection, afib, end stage kidney disease; target organ damage: left ventricular hypertrophy, angina or prior MI, prior coronary revascularization, HF, stroke or TIA, nephropathy, peripheral arterial disease, retinopathy
what is the equation for BP?
BP=CO X PVR
what are the natural medicines for HTN treatment?
none are considered safe or effective
What kinds of drugs are recommended for the treatment of HTN in nonblacks, blacks, and those with CKD?
TX recommended for general, nonblack, including those with DM: thiazide diuretic, CCB, ACEI, ARB; general blak , including those with DM: thiazide diuretic or CCB; age >18 with CKD: ACEI or ARB (renoprotective)
what are the three strategies for dosing antihypertensive drugs?
1) start one drug, titrate to maximum dose then add a 2nd one 2) start one drug and then add a second drug before achieving maximum dose of the initial drug 3) begin with 2 drugs at the same time, either separate or in single pill
how should HTN be monitored?
4 wks: If goal BP not reached, increase dose or add second drug (thiazide, CCB, ACEI, or ARB), continue to assess and adjust tx until goal BP reached, if cannot be reached with 2 drugs add and titrate a 3rd drug (don’t use ACEI and ARB together though) If more than 3 needed, refer to a hypertension specialist
What percentage of pts stop their anti HTN meds within 6 months
25%
What are some interventions that can improve adherence in anti HTN meds?
identify problems with drug tolerance early and switch, address increased urination with diuretics: start with low doses and advise pts to limit salt to decrease urination and don’t take the med at hs, use generics to decrease cost, educate the pt on the importance of controlling BP, spread out meds: 1 in AM, 1 in PM