Cardiovascular Disorders Flashcards
ASCVD 10-yr risk scores ages 40-79 by category
Low risk <5%; Borderline risk 5 - 7.4%; Intermediate risk 7.5 - 19.9%; High risk > or = 20%
Characteristics of a “heart healthy” diet
Mediterranean, DASH, or plant-based diets. Specifically, high in vegetables, fruits, nuts, whole grains, lean animal protein (preferably fish), vegetable fiber
Diets associated with higher ASCVD risk (3)
high in carbohydrates, animal fat, and animal proteins
The most potent risk factor for ASCVD over age 50yo is:
diabetes
Define: T2 Diabetes Mellitus
T2DM is a metabolic disorder characterized by insulin resistance leading to hyperglycemia. The development and progression of this condition is highly affected by diet, physical activity, and body weight.
HgbA1c diagnostic of T2DM
> 6.5%
Physical activity recommendation
150 minutes of moderate to vigorous intensity exercise per week
First line therapy in T2DM to improve gylcemic control and improve ASCVD risk
metformin
T2DM medications with favorable ASCVD risk reduction profiles (3)
metformin, SGLT2 inhibitors, GLP1 receptor antagonists
Important patient education prior to lipids lab work
Fast for 6-8 hours before blood draw. You can still take your morning medications, you can only have water or black coffee.
Before starting someone on lipids medications, draw these baseline labs (2)
CMP (for BL liver function), fasting lipid panel (also consider a BL creatinine kinase in case of rhabdo)
FUP schedule for patients on lipid therapy
Recheck in 4-12 weeks after initiation of therapy, repeat after 4-12 weeks anytime changing a medication or dose. Once on a stable dose with lipid control, can fup annually.
Your patient on lipid therapy develops myalgias and ascites. What labs do you need to draw?
CMP (liver function, CK (rhabdomyelosis risk)
Lipid and ASCVD screening recommendations for adults
Lipid panel Q5 years >20yo. Estimate 10-yr ASCVD Risk Q4-6 years
If triglyceride lab comes back super high, first question to ask the patient…
did you have anything to eat? (triglyceride results very affected by fasting status)
Total cholesterol lab results
Optimal <200 mg/dL; High >240 mg/dL
LDL lab results
Optimal <100 mg/dL; Very high >190 mg/dL
Triglyceride lab results
Optimal <150 mg/dL; Very high >500 mg/dL
HDL lab results
Optimal >60; Very low <40 mg/dL
DIAGNOSE: Fasting serum triglycerides >400 mg/dL
hypertriglyceridemia
First line therapy for hypertrigylceridemia
Fibrates - decrease triglyceride levels by 35-50% and raise HDL by 5-20%
Priority lab monitoring when prescribing fibrates
LFTs
Top 3 most common causes of pancreatitis
alcohol, gall stones, hypertriglyceridemia
Your pt’s recent lab results demonstrate fasting serum triglycerides at 900 mg/dL. Worry about…..
acute pancreatitis
If ASCVD risk decision making is uncertain as far as whether or not to start a statin, consider ordering…..
Coronary artery calcium scoring (CAC)
CAC scores and subsequent statin recommendation
0: low risk, repeat testing in 5-10 years. only consider statin if diabetes, family hx of coronary heart disease, or tobacco use
1 - 99: favors statin (particularly >55yo)
> or = 100: initiate statin
(2) examples of high intensity statin regimens and expected benefit
Atorvastatin 40-80mg QD; Rosuvastatin 20-40mg QD. Daily dose of high intensity statin is expected to lower LDL by >50%
What therapy would you consider for your 15yo new pt who relays hx of familial hypercholesterolemia
start statin, refer to specialist
Therapy recommendation for any pt ages 20-75 with an LDL >190 mg/dL
initiate high intensity statin
Therapy recommendation for pt age 40-75 with normal lipid panel and T2DM
initiate moderate intensity statin
Coronary Artery Calcium (CAC) testing: Overview
CAC is a CT scan of the coronary arteries to show existing calcium deposits. These calcifications are an early sign of CAD. Not recommended for pts younger than 40yo or those with high ASCVD 10-yr risk. May benefit clinical decision-making for pts who are reluctant to start statin therapy or ASCVD 10-yr borderline risk (5-7.5%). A CAC of 0 indicates very low risk and no role for statin therapy (unless diabetic, fam hx of premature heart disease,or tobacco use), with repeat testing in 5-10 years. CAC scores 1-99 favor moderate intensity statin therapy, particularly for folks >50-55yo. CAC scores 100 or greater definitively indicate a role for statin therapy to reduce risk with the addition of 81mg ASA (excepting those at high risk for bleeding)
Guidelines regarding primary prevention of ASCVD with aspirin therapy
May consider low dose ASA use (70-100mg) for primary prevention in adults ages 40-70 who are at high risk for ASCVD with no increased bleeding risk. ASA is NOT recommended as routine primary prevention in adults over 70 (still appropriate in secondary prevention, i.e., h/o heart attack)
BMI Criteria
Underweight <18.5; Healthy 18.5 - 24.9; Overweight 25 - 29.9; Obese > or = 30
METs: Overview
METs, or metabolic equivalent, is a score used to represent the intensity of an exercise. Generally speaking, MET 1 - 1.5 is sedentary, 1.6 - 2.9 is Light exercise, 3.0 - 5.9 is Moderate exercise, and 6 or greater is vigorous exercise. Light activity includes activities such as walking, light house work, and cooking. Moderate exercise includes brisk walking, biking, dancing, yoga, and recreational swimming. Vigorous exercise includes jogging, running, biking >10mph, swimming laps, or tennis
BP and HTN diagnostic categories (ACC/AHA)
Healthy <120/<80; Elevated 120-129/<80; Stage 1 HTN 130-139/80-89; Stage 2 HTN > or = 140/ > or = 90
BP and HTN diagnostic categories (JNC 8)
Healthy < or = 120/80; Pre-hypertension 120-139/80-89; Hypertension > or = 140/ > or = 90
What constitutes hypertensive urgency or emergency
> 180/>120 OR >160/>100 with s/s of end organ damage
Your pt without any pertinent PMH has a BP today of >130/80 but less than 160/100. What is your next step in determining if they have HTN?
Recommend at home monitoring for the next 7 days. Take BP 2x per day, and toss the first day, then average those 12 readings.
Initial work-up of a new diagnosis of HTN would include what labs/diagnostic tests and why?
CMP: BUN/Cre, and potassium tells you about kidney function. Glucose tells you about underlying diabetes. Calcium helps you r/o underlying thyroid or parathyroid condition.
TSH: R/o underlying thyroid condition.
CBC: Particularly, the hematocrit tells you about kidney function and potential end-organ damage.
Lipid panel: Tells you about contributing hyperlipidemia, metabolic syndrome, and overall CVD risk.
Urinalysis: Proteinuria can tell us about kidney function, glucosuria about diabetes.
Uric acid: Elevated levels can lead to HTN and indicate kidney disease.
ECG: Important to establish BL and to look for any underlying cardiac events
Renal artery ultrasound: r/o renal artery stenosis cause
Essential (Primary) HTN: Overview
Condition of increased peripheral vascular resistance with no underlying identifiable cause. Primary hypertension represents the vast majority of hypertension diagnoses at 95%.
DIAGNOSE: Abrupt, severe onset of elevated BP in your pt who is <35 yo with no pertinent fam hx and failure to respond to therapy despite compliance
Secondary hypertension
Causes of secondary hypertension
1 most common cause is renovascular disease (such as renal artery stenosis), renal parenchymal disease (polycystic kidney disease), alcohol, illicit drugs, medications, primary hyperaldosteronism (suspected in pts with unprovoked hypokalemia), or obstructive sleep apnea