Cardiovascular disease in GP

Question 1

Name the 8 components of the absolute cardiovascular risk calculator

Answer 1

Sex
Age
Systolic BP
Smoking
Total cholesterol (levels prior to levels after starting cholesterol lowering medications)
HDL cholesterol
Diabetes
LVH on ECG

Question 2

In what context should you interpret a patient’s BP? What is the recommended management in a patient who is low, medium and high risk?

Answer 2

In the context of their absolute CV risk

Low risk (under 10% CVD risk) - lifestyle advice BP check every 2 years, start drugs if persistently over 160/100

Medium risk (10-15%) - intensive lifestyle advice, BP check every 6-12 months, start drugs after 3-6 months if no change, or start immediately if BP over 160/100, FHx of CVD or racial background

High risk (over 15%) - intensive lifestyle advice, BP check 6-12 weeks, start drugs immediately. Aim for 140/90, or 130/80 in people with diabetes or albuminuria

Question 3

Name 3 aspects of management for hypertension

Answer 3

BP measurement - ideally, should initially measure BP in both arms, and then on use arm that initially recorded higher BP. Do sitting and standing (after 2 minutes) if postural hypotension is suggested. Use ambulatory monitoring if values are variable, white-coat HT is suggested, HT resistant to drug treatment, or postural hypotension suspected

Lifestyle - 30 minutes exercise 5-7 days/week, smoking cessation, healthy weight and waist circumference, less than 4g salt/day, 2 (male) or 1 (female) alcohol drinks/day max

Meds - start with ACEI, ARB, Ca-channel or thiazide diuretic, then add 2nd or 3rd agents from different class

Question 4

Go through management of cholesterol in low, medium and high CVD risk patients

Answer 4

Low (under 10% absolute CV risk) - lifestyle advice, repeat lipids in 5 years

Medium (10-15%) - lifestyle advice, repeat lipids in 2 years, pharmacotherapy if not reaching target in 6 months

High - (over 15%) - lifestyle advice + pharmacotherapy, repeat lipids in 12 months

Question 5

What cholesterol levels should you aim for on someone on cholesterol-lowering medications?

Answer 5

Total cholesterol under 4 mmol/L
HDL over 1
LDL under 2
TG under 2

Question 6

A patient of yours has just been released from hospital after suffering an acute myocardial infarct. As a GP, name 4 things to consider about the management of this patient

Answer 6

1. New medications - review compliance and education about dual antiplatelet therapy, beta-blocker, ACE-I, statins, GTN spray
2. Lifestyle advice to reduce risk of further CHD (SNAP)
3. Have written action plan for chest pain
4. Assess for depression and social supports

Question 7

How long should a patient be on dual antiplatelet therapy for after an MI treated with stent?

Answer 7

At least 12 months

Question 8

Go through guidelines on stopping antiplatelet therapy before elective, non-cardiac surgeries

Answer 8

Delay surgery for 3 months after elective stent insertion, or 12 months following MI
Aspirin should be continued throughout
GPII/III inhibitors (clopidogrel, prasugrel, ticagrelor) should be stopped 5 days prior

Question 9

A patient of yours has recently had a stroke. Name interventions for secondary prevention of stroke recommended for GPs.

Answer 9

1. Lifestyle modifications (SNAP)
2. Adherence to pharmacotherapy - education, reminders, dose administration aids, pharmacy referral
3. BP lowering - should be on antihypertensives regardless of BP (unless at risk of symptomatic hypotension)
4. Long term single antiplatelet therapy (usually aspirin or clopidogrel)
5. Anticoagulation therapy if patient has AF or had cardioembolic stroke
6. Statin - if patient had ischaemic stroke