CARDIOVASCULAR DISEASE Flashcards
What is atherosclerosis?
a condition where there is a build-up of fatty deposits (plaques) inside an artery which cause the artery to harden and narrow, restricting blood flow
The plaques result in stiffening = hypertension, stenosis = reduced blood flow, and plaque rupture = thrombus can cause ischaemia
What are the non-modifiable and modifiable cardiovascular risk factors?
Non-modifiable:
Older age >60
FHx
Male
Ethnicity
Modifiable:
Low blood HDL cholesterol and high non-HDL cholesterol
Smoking
Alcohol consumption
Unhealthy diet
Sedentary lifestyle/lack of physical activity
Obesity
Poor sleep
Stress
Diabetes, hypertension, CKD, dyslipidaemia, AF, inflammatory conditions, influenza, serious mental health problems, periodontitis
Others: lack of social support and socioeconomic status
Whats the end result of atherosclerosis?
Angina
MI
TIA
Strokes
PAD
Chronic mesenteric ischaemia
What is primary prevention of CVD?
Preventing for pt who have never had a diagnosis of CVD
What is secondary prevention of CVD?
Prevention in pt after a diagnosis of angina, MI, TIA, stroke or PAD
What are the NICE guidelines for dietary changes to prevent CVD?
Eat unsalted nuts/legumes/seeds at least 4-5 portions per week
Fish twice per week, including a portion of oily fish
At least 5 portions of fruit/veg per day
30-45g per day fibre
Reduce sugar, saturated fat, salt to <6g per day
Increase mono-unsaturated fat intake with olive oils or rapeseed pool or spreads based on these oils
What are the NICE guidelines for exercise to prevent CVD?
At least 75 minutes per week of vigorous intensity aerobic activity, or a mix of moderate and vigorous aerobic activity.
At least 150 minutes per week of moderate intensity aerobic activity (to the point of slight breathlessness), or
Muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
Activity in bouts of 10 minutes or more is as effective as longer bouts so long as the total per week is as above. Moderate intensity activities include those that can be incorporated into everyday life such as brisk walking, using stairs, and cycling.
Encourage people who cannot manage moderate intensity physical activity because of comorbidity, medical conditions or personal circumstances to exercise to their maximum safe capacity.
What scoring system determines what primary prevention should be given?
QRISK3 score - The QRISK score estimates the percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years.
Outline how the QRISK3 score is used to determine primary prevention of CVD?
The NICE guidelines recommend when the result is >10%, they should be offered a statin, initially atorvastatin 20mg at night.
It is also offered as primary prevention to all patients with:
CKD or type 1 diabetes for >10 years or are >40 years
The draft NICE guidelines due for publication in mid-2023 advise that atorvastatin 20mg can be considered for primary prevention in patients with a QRISK3 score below 10%.
What monitoring should be done for a pt on statins?
Before starting treatment with statins, at least one full lipid profile should be measured, including total cholesterol, HDL-cholesterol, non-HDL-cholesterol, and triglyceride concentrations, TSH, and renal function should also be assessed.
Liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs); if the baseline concentration is more than 5 times the upper limit of normal (ULN), a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the ULN, statin treatment should not be started; if concentrations are still raised but less than 5 times the ULN, the statin should be started at a lower dose.
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months.
Whats the moa of statins?
They inhibit HMG CoA reductase (the rate limiting enzyme in the cholesterol biosynthesis pathway) in the liver to reduce cholesterol production
What are the side effects of statins?
Common - arthralgia, asthenia, GI upset, dizziness, headache, sleep disorder, thrombocytopenia
Rare but important - Myopathy (especially if used in combination with fibrates or niacin), rhabdomyolysis, type 2 diabetes, haemorrhagic stroke, interstitial lung disease
May cause hepatotoxicity
What are the significant medications that interact with statins?
Macrolide antibiotics e.g. clarithromycin (stop the statin whilst taking these)
Warfarin - may increase risk of haemorrhagic events
Fibrates - may increase myopathy
What is given for secondary prevention of CVD?
Antiplatelet medications
Atorvastatin 80mg
Atenolol titrated to maximum tolerated dose
ACEi titrated to maximum tolerated dose
Whats thr antiplatelet of choice in PAD or following an ischaemic stroke?
Clopidogrel
After an MI what dual antiplatelet treatment are patients offered?
Aspirin 75mg daily indefinitely
Clopidogrel or ticagrelor for 12 months
What is familial hypercholesterolaemia?
an autosomal dominant genetic condition causing very high LDL-cholesterol levels which, if untreated, may cause early cardiovascular disease. FH is caused by mutations in the gene which encodes the LDL-receptor protein.
Heterozygous means only one copy of the gene is abnormal. This occurs in about 1 in 250 people.
Homozygous means both copies of the gene are abnormal. This very rare condition causes extremely high cholesterol (over 13 mmol/L) and almost guaranteed early cardiovascular disease.
What criteria are used for making a diagnosis of familial hypercholesterolaemia?
Simon Broome criteria
Dutch lipid clinic network criteria
What are the 3 important features of familial hypercholesterolaemia?
Family history of premature cardiovascular disease (e.g., myocardial infarction under 60 in a first-degree relative)
Very high cholesterol (e.g., above 7.5 mmol/L in an adult)
Tendon Xanthomata or these signs in a first/second degree relative
How should you manage familial hypercholesterolaemia?
Specialist referral for genetic testing and testing of family members
High-intensity statin at a dose which there is a reduction in LDL-cholesterol of >40%
If contraindicated try ezetimibe as mono therapy. If not appropriate treatment with a fibrate or a bile acid sequestrant can be considered
Alirocumab and evolocumab can be considered for patients with primary heterozygous familial hypercholesterolaemia whose LDL-cholesterol has not been adequately controlled on maximum tolerated lipid-lowering therapy
Who should you not use QRISK3 with and why?
Adults aged over 85 - consider these people to be at high risk of developing CVD because of age alone, especially smokers and people with high blood pressure.
Existing CVD
T1 diabetes
CKD
Familial hypercholesterolaemia
How often should the QRISK score be done?
Every 5 years
How should you manage a person with a QRISK3 risk of <10%?
Advise that although the risk is low, further reductions in risk can often still be achieved.
Offer advice on any relevant lifestyle factors that can be improved e.g. stop smoking, loss weight if overweight, healthy diet, keep alcohol consumption within recommended limits, be physically active
Consider reviewing any relevant comorbidities that may not be optimally treated.
Advise that a further risk assessment should be considered in 5 years.
How should you manage a person with a QRISK3 risk of >10%?
Lifestyle advise
Optimal management of comorbidities
Atorvastatin 20mg a day for primary prevention
