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eTG > Cardiovascular > Flashcards

Cardiovascular Flashcards

1
Q

Risk factors for cardiovascular disease?

A

Modifiable:
* smoking
* elevated blood pressure
* dyslipidaemia
* diabetes
* central obesity
* poor nutrition
* sedentary lifestyle
* excessive alcohol intake
* mental health disorders (eg depression)
* obstructive sleep apnoea
* insomnia
* shift work
* drugs that worsen cardiovascular risk factors (eg drugs that increase blood pressure)
* migraine
* nonalcoholic fatty liver disease
* preeclampsia, pregnancy-related hypertension and gestational diabetes
* erectile dysfunction
* social deprivation
* psychosocial stress including vital exhaustion / burnout
* chronic immune-mediated inflammatory disorders
* atrial fibrillation

Non-modifiable:
* age
* male sex
* left ventricular hypertrophy
* family history of premature cardiovascular disease
* cultural identity and ethnicity (eg Aboriginal and Torres Strait Islander, South Asian, Māori and Pacific Islander, Middle Eastern peoples)
* lower socioeconomic status
* chronic kidney disease
* familial hypercholesterolaemia
* polycystic ovarian syndrome
* treatment for human immunodeficiency virus infection

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2
Q

What cardiovascular risk factors are included in the absolute risk calculator?

A
  • smoking
  • elevated blood pressure
  • dyslipidaemia
  • diabetes
  • age
  • male sex
  • left ventricular hypertrophy
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3
Q

Who should have their absolute atherosclerotic cardiovascular disease risk estimated?

A

estimate absolute ASCVD risk in
* all adults aged 45 years or older, and
* Aboriginal and Torres Strait Islander adults aged 30 years or older

Note: People who have established ASCVD or any of the other risk factors are already known to be at high risk of a cardiovascular event, so do not need formal risk calculation before starting therapy.

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4
Q

People with what risk factors are already at high risk of cardiovascular events and do not require risk calculation?

A

People with any of the following risk factors are at high risk of a cardiovascular event and do not require risk calculation:
* established atherosclerotic cardiovascular disease
* type 1 diabetes mellitus of early onset and duration of greater than 20 years
* diabetes and any of the following:
1. age older than 60 years
2. persistent microalbuminuria (more than 20 micrograms/min, or urinary albumin: creatinine ratio more than 2.5 mg/mmol for males or more than 3.5 mg/mmol for females)
3. at least 3 major risk factors (diabetes, smoking, elevated blood pressure, dyslipidaemia and central obesity)
4. end-organ damage
5. no end-organ damage, with diabetes greater than 10 years duration or an additional risk factor
* moderate or severe chronic kidney disease (persistent proteinuria or eGFR less than 45 mL/min/1.73 m2)
* a prior diagnosis of familial hypercholesterolaemia
* systolic BP 180 mmHg or more, or diastolic BP 110 mmHg or more
* serum LDL-C concentration more than 4.9 mmol/L
serum total cholesterol more than 7.5 mmol/L
* Aboriginal and Torres Strait Islander adults older than 74 years

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5
Q

When should Aboriginal and Torres Strait Islander adults be screened for atherosclerotic CVD risk factors?

A

age 18 years

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6
Q

When should Aboriginal and Torres Strait Islander adults be formally assessed for absolute atherosclerotic CVD risk?

A

from age 30 years

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7
Q

What should be included when screening for atherosclerotic risk factors?

A
  • smoking status
  • diabetes
  • blood glucose concentrations
  • serum lipids
  • estimated glomerular filtration rate (eGFR)
  • urine albumin-to-creatinine ratio (ACR)
  • blood pressure
  • familial hypercholesterolaemia.
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8
Q

Is it valid to reassess cardiovascular risk using risk calculators if a patient has been started on pharmacotherapy?

A

No. Cardiovascular risk calculators are only validated for an untreated population, so reassessment of ASCVD risk with a risk calculator after starting drug therapy (lipid-modifying or blood pressure–lowering) is not appropriate and may underestimate actual risk.

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9
Q

What is coronary calcium scoring and when is it useful?

A

Coronary artery calcium (CAC) scoring is a computed tomography (CT) scan evaluating the amount of calcified plaque in the coronary arteries. It is of most benefit in people stratified as moderate absolute ASCVD risk, but can also be considered in people stratified as low absolute ASCVD risk who have additional risk factors that are not accounted for in the risk calculator

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10
Q

Is aspirin or other antiplatelet therapy recommended for primary prevention of atherosclerotic cardiovascular disease?

A

No

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11
Q

Lifestyle modification strategies to reduce atherosclerotic cardiovascular disease?

A
  • Stopping smoking
  • Adopting a healthy diet
  • Minimising the consumption of alcohol and salt
  • Undertake regular physical activity
  • Maintaining healthy weight
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12
Q

What are the waist circumferences at which cardiometabolic risk is increased?

A

Male:
* Caucasian: 94 cm
* South Asian, Chinese or Japanese: 90 cm

Female:
* 80 cm

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13
Q

Smoking related modifications to reduce atherosclerotic cardiovascular disease?

A
  • Aim cessation/reduction
  • Avoid second hand smoking
  • Cessation can be associated with weight gain - educate and assist in minimising this
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14
Q

Nutrition related strategies to reduce atherosclerotic cardiovascular disease?

A
  • Refer to dietitian for individualised eating plan
  • Eat fresh whole foods
  • Minimise intake of energy-dense, low-nutrient foods (ie foods high in sugar or fat)
  • Drink water rather than soft drinks or fruit juice.
  • Reduced-salt diet - especially beneficial for hypertension and heart failure
  • Fish provides healthier fats than other animal protein - Recommend eating oily fish 2or 3times each week
  • Traditional Mediterranean diet supplemented with extra-virgin olive oil or nuts has been shown to be beneficial in reducing the risk of cardiovascular events
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15
Q

Physical activity related strategies to reduce atherosclerotic cardiovascular disease?

A
  • At least 30minutes of moderate-intensity physical activity (eg brisk walking) on most, if not all, days of the week (ie at least 150minutes per week), including muscle-strengthening exercise at least twice per week
  • Minimise episodes of prolonged sitting, and to frequently break up long periods of sitting
  • Refer patients with established heart disease or other serious comorbidities to an exercise physiologist (or a structured physical activity program) for a tailored plan that is appropriate for their clinical condition
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16
Q

What behavioural interventions are available for weight loss management?

A
  • Coping skills
  • Stimulus control
  • Goal setting
  • Self-monitoring
  • Cognitive behavioural interventions to modify aversive thinking patterns
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17
Q

What options for bariatric surgery are there?

A
  • Adjustable gastric banding - results in fewer deaths and shorter hospital stays, but more frequent long-term complications (eg reflux, oesophageal dysmotility, band slippage, band erosion) and greater rates of surgical revision
  • Roux-en-Y gastric bypass (RYGB) - results in greater weight loss and greater resolution of glucose abnormalities, but a higher incidence of immediate surgical complications and a higher mortality rate within 30 days
  • Sleeve gastrectomy
18
Q

When is bariatric surgery usually recommended?

A
  • BMI more than 40 kg/m2
  • BMI more than 35 kg/m2 with other comorbidities such as diabetes or obstructive sleep apnoea
19
Q

How do you assess whether to start lipid-modifying therapy?

A

The decision to start lipid-modifying drug therapy should be based on the patient’s absolute ASCVD risk +/- coronary artery calcium scoring

20
Q

Patients with established ASCVD and those at high absolute ASCVD risk require lipid-modifying drug therapy in addition to lifestyle modification. What are the cholesterol thresholds to commence therapy?

A

LDL-C concentration above 4.9 mmol/L or a total cholesterol concentration above 7.5 mmol/L qualify as high risk

21
Q

When should lipid-modifying drug therapy be considered in patients at moderate or low absolute ASCVD risk?

A

After a trial of lifestyle risk factor and diet control to lower cholesterol where LDL-C target is not met

22
Q

When triglycerides are significantly elevated, what should be used to reflect atherosclerotic cardiovascular disease?

A

non–high-density lipoprotein cholesterol (non–HDL-C) concentration may better reflect ASCVD risk (compared with LDL-C alone), because it includes atherogenic triglyceride-rich lipoproteins in addition to LDL-C

23
Q

When should lipid concentrations be checked after commencing lipid-modifying therapy?

A

Recheck lipid concentrations around 6 weeks after starting or adjusting therapy

24
Q

Do lipid concentration targets differ depending on the category of atherosclerotic cardiovascular risk?

A

Yes. The higher the risk, the lower the targets.

25
Q

What are some effective dietary changes to improve lipid concentrations?

A
  • reducing alcohol intake
  • reducing intake of saturated and trans fats
  • replacing saturated fats with monounsaturated and polyunsaturated fats
  • increasing intake of fibre (particularly soluble fibre)
  • introducing plant sterol–enriched milk, margarine or cheese products
26
Q

What are some effective dietary changes to improve triglyceride concentrations?

A
  • cutting out soft drinks and reducing intake of other added sugars
  • reducing alcohol intake
  • reducing intake of fats, particularly saturated and trans fats (reduction of fat intake to less than 15% of total energy intake may be beneficial)
  • reducing intake of carbohydrates, particularly heavily refined carbohydrates
  • increasing intake of fibre (particularly soluble fibre).
27
Q

What are the most effective lifestyle interventions to raise HDL-C?

A

Increasing physical activity and losing weight

28
Q

How should statin therapy be commenced for secondary prevention of cardiovascular events?

A

A more aggressive approach to initial treatment (eg starting a high-potency statin at a high dose) is recommended for secondary prevention of cardiovascular events, and is reasonable for primary prevention in some patients with high absolute ASCVD risk

29
Q

What are the options for lipid-modifying drug therapy?

A
  • Statin
  • Statin + ezetimibe
  • Statin + ezetimibe + PCSK9 inhibitor
30
Q

What are the options for triglyceride lowering drug therapy?

A
  • Statin
  • Statin + fish oil
  • Statin + fish oil + fenofibrate
31
Q

What drug can be used to slow the progression of diabetic retinopathy?

A

Fenofibrate

32
Q

Which statins are high potency?

A
  • Atorvastatin
  • Rosuvastatin
  • Simvastatin
33
Q

Factors that increase the risk of statin-related adverse effects?

A
  • pre-existing muscle, liver or kidney disease
  • acute kidney injury (if using rosuvastatin)
  • high-dose or high-potency statin therapy
  • concurrent drugs that cause myopathy (eg colchicine, gemfibrozil) or inhibit the metabolism of statins (eg amiodarone, diltiazem, clarithromycin, some antiviral drugs)
  • concurrent illness
  • frailty and advanced age
34
Q

Before investigating for statin-associated muscle symptoms, first exclude modifiable predisposing factors for muscle symptoms, such as:

A
  • arthritis
  • alcohol consumption
  • diabetes
  • hypothyroidism
  • obesity
  • strenuous exercise
  • significant vitamin D deficiency.
35
Q

Features suggestive of statin-related muscle symptoms include:

A
  • bilateral pain
  • aching or stiffness (rather than shooting pain or cramping)
  • pain located in the large muscle groups (eg thighs, buttocks)
  • onset 4 to 6 weeks after starting or increasing the dose of a statin
  • high-dose or high-potency statin therapy
  • elevated serum CK concentration that decreases with statin withdrawal.
36
Q

How would you manage statin-induced myopathy?

A

Even if the statin is determined to be the cause of muscle symptoms, avoid completely stopping statin therapy;
- consider trialling an alternative statin,
- a lower dose of the statin, or
- intermittent dosing (eg once or twice weekly, alternate daily)
- retrial of a statin (90% of patients tolerated this)

37
Q

When would you stop a statin temporarily?

A

serum CK concentration exceeding 5 times the upper limit of normal (ULN)

38
Q

Features of statin-induced rhabdomyolysis?

A
  • severe myalgia or myalgia associated with general muscle weakness
  • elevated serum CK concentration (typically elevated by at least 10 times the ULN)
  • myoglobinuria or urinalysis
39
Q

Features of statin-induced necrotising autoimmune myopathy?

A
  • severe proximal muscle weakness, often in the absence of pain;
  • the serum CK concentration may be only mildly elevated
40
Q
A

eTG (21 decks)

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