Cardiovascular risk Flashcards
1
Q
Cardiovascular disease causes what percentage of premature deaths?
A
25%
2
Q
What is cardiovascular disease?
A
Umbrella term which encompasses:
Stroke, MI, CHD, Hypertension, atherosclerosis and diseases of arteries, DVT nad diseases of veins, Heart valve disease (rheumatic heart diease) and vascular dementia.
3
Q
Why is the incidence of CHD decreasing?
A
Better management of risk factors esp smoking. But may rise again in future as obesity and diabetes are rising
4
Q
CVD is very strongly associated with health inequality. Is health inequality rising or falling?
A
Rising
5
Q
What are the non modifiable risk factors for CVD?
A
Age, gender, ethnicity and family history
6
Q
What are the modifiable behaviour risk factors for CVD?
A
Physical inactivity, smoking, high cholesterol, hypertension, diet and harmful drinking
7
Q
WHat are the modifiable social risk factors for CVD?
A
Housing, employment, poverty and pollution
8
Q
What is the relative risk reduction for CVD of a reduction in blood pressure of 10mmHg?
A
20-30%
9
Q
What is the relative risk reduction for CVD of a 1mmol/L decrease in total cholesterol?
A
25%
10
Q
What percentage of hypertension is linked to alcohol misuse?
A
20% but only 1 in 5 with hypertension are assessed for their alcohol consumption
11
Q
What is the relative risk reduction for CVD of meeting physical activity guidance?
A
20-35%
12
Q
What is primary prevention for managing cardiovascular risk?
A
Reduce the population incidence. Adresses the entire population
13
Q
What is secondary prevention for managing cardiovascular risk?
A
Detection and treatment of presymptomatic disease
14
Q
What is tertiary prevention for managing CV risk?
A
Reducing incidence/recurrence of CV event in those with symptomatic disease
15
Q
WHich risk score in Scotland is used for CV risk and what does it consider?
A
ASSIGN
Age, sex, smoking, Systolic BP, total cholesterol, LDL cholesterol, family history, diabetes, rheumatoid arthritis and deprivation
16
Q
What is a high risk ASSIGN score?
A
> 20% risk of a CV event in the next 10 years
17
Q
What is the absolute risk?
A
The chance of an individual having an event in a given period of time
18
Q
WHat is relative risk?
A
The risk of someone having a CV event compared to someone else
19
Q
In which risk category, Low moderate or high risk, do most CV deaths occur?
A
Moderate risk- this is the largest population group
But those at high risk have the most to gain from risk factor modification and clinically given the highest priority
20
Q
What factors not considered in ASSIGN can increase your CV risk?
A
AF, specific ethnic groups, women with premature menopause
21
Q
WHo is considered at high CV risk?
A
Assymptomatic with an assign score >20%
Established CVD
Familial hypercholesterolaemia
Stage 3 or more kidney disease, micro or macroalbuminuria
>40 years old and diabetic
<40 years old with diabetes for >20 years or have end organ damage or other CV risk factors
22
Q
What is the recommendation regarding weight for reducing CV risk?
A
If overweight or obese aim to reduce weight by 3kg and maintain
23
Q
What is the recommendation regarding physical activity for reducing CV risk?
A
moderate intensity recommended for all
24
Q
What is the recommendation regarding smoking for reducing CV risk?
A
Offer support to quitusing varenicline (champix) or NRT
25
What is the recommendation regarding lipid lowering for reducing CV risk?
Atorvastatin 20mg od and modify diet
26
What is the recommendation regarding antiplatlets for reducing CV risk?
Asprin is NOT recommended for primary prevention eg in those who do not have CV disease
27
What is the recommendation regarding alcohol for reducing CV risk?
Reduce as even light-moderate consumption can increase CV risk. <14 units/week
28
How is someones alcohol intake assessed in A&E?
FAST
29
What are the FAST questions?
How often do you usually have 6 orr more units in one occasion?
How often in the last year are you unable to remember the night before?
How often in the last year have you been unable to do what is expected of you due to alcohol?
In the last year, has a relative, friend or doctor expressed concern about your drinking?
30
What A&E presentations lead to FAST score for alcohol being used?
Fall, head injury, collapse, assault, accident, unwell, cardia, repeat attendee, non specific GI, Psychiatric, self harm or OD
31
What is the diabetic eye screening programme?
Secondary prevention
Yearly for diabetics over 12
Looking for diabetic retinopathy
32
What is the AAA screening programme?
Men over 65 (1 in 20 men over 65 have a AAA)
Small (1%) => annual screening
Medium (0.5%) => screened every 3 months
Large AAA (0.1%) => referred to vascular surgery
33
What percentage of deaths due to CVD occur indeveloping nations?
57%
CVD is the number 1 cause of death world wide and number 2 in developing nations
It is the leading cause of disability
34
What is primary and secondary prevention?
```
Primary = risk factors but no evidence of disease
Secondary = Evidence of disease trying to prevent progression
```
35
What is atherosclerosis?
Progressive disease characterised by a build up of plaque in arteries
Plaque is formed from fatty substances, cholesterol, cellular waste, calcium and fibrin
36
What are the 2 consequences of progression of atherosclerosis?
1) Bleeding into the plaque to enlarge it and occlude the lumen of the artery
2) Formation of a clot on the surface of the plaque which may break off or rupture
37
What is the pathogenisis of atherosclerosis?
1) endothilial damage
2) protective response results in the production of cellular adhesion molecules
3) Monocytes and T lymphocytes bind to adhesion molecules
4) Transendothilial migration into sub endothilial spae
5) Macrophages take up oxidised LDL cholesterol
6) Become lipid rich foam cells
7) Fatty streak forms
8) Smooth muscle migration formt eh media to the subendothilial space due to pro inflammatory cytokines released from macrophages
9) Smooth muscle hyperplasia and collagen ddeposition => sub endothilial fibrous plaque with a fibrous cap.
38
When in the development of atherosclerosis does it start to produce symptoms?
WHen you have an atherosclerotic plaque eg angina, TIA, claudication, PVD
39
Other than dietary cholesterol, what else can provide a source of lipids for atherosclerosis?
Degraded erythrocyte membranes hat result from rupture of vasovasorum.
40
What is the name of the ongoing cohort study which has identified cardiovascular risk factors?
Framingham study
41
What are the classifications of lipoproteins?
Chylomicrons
| VLDL, LDL, IDL, HDL
42
Which lipids put you at increased risk of CVD?
high LDL cholesterol (associated with low HDL, smoking, hypertension and diabetes)
High triglycerides
Low HDL cholesterol- HDL has a protective factor in CVD. HDL is low when triglycerides are high
43
What are the 2 pathways for lipid metabolism?
Endogeneous and exogeneous (dietary fats)
44
What are the befits of statins?
Reduce CHD end points and reduce LDL and total cholesterol
Prevent endothilial dysfunction, Increase NO bioavailability, antioxidant properties, inhibit inflammatory responses, stabilise atherosclerotic plaques
45
What type of drug is a statin?
HMG CoA reductase inhibator
| Prevent cholesterol being metabolised in the liver
46
What are the clinical signs of dyslipidaemia?
```
Xamthalasma
Tendon xanthomas- diffuse infiltration of tendons by lipid (fingers patella, elbows and achilles tendon)
Tuberous xanthomas- lipid deposits in the dermis and subcutis (large joints, buttocks and heals)
Eruptive xanthomas (due to abrupt increase in triglycerides- red/yellow spots on buttocks/thighs
```
47
What is primary and secondary hypertension?
Primary hypertension- when ther is no underlying cause
| Secondary hypertension- when there is an underlying cause
48
What diseases can hypertension cause?
```
Heart failure
Left ventricular hypertrophy
Coronary heart disease
Eclampsia/pre-eclampsia
Stroke
Blindness
MI
Hypertensive encephalopathy
Cerebral haemorrhage
Chronic kidney failure
Aortic aneurysm
Gangrene of lower extremities
```
49
What are the lifestyle modifications to lower BP?
```
Lose weight
Reduce alcohol
Reduce salt
Stop smoking
Limit food high in fat and cholesterol
Increase physical activity
```
50
What is the treatment for hypertension if you are under 55?
1) ACE inhibitor/ARB
2) add in Ca++ antagonist
3) add in a thiazide diuretic
4) resistant hypertension
51
What is the treatment for hypertension if you are over 55 or black African/Caribbean?
1) Ca++ agonist
2) add in ACE inhibator/ARB
3) Add in thiazide diuretic
4) Resistant hypertension
52
Why is diabetes a major risk factor for atherosclerosis?
1) Hypercoagulable blood- increased platelet adhesiveness and coagulation and increased plasminogen activator inhibator type 1
2) Increases Oxidised LDL cholesterol, Increased VLDL and decreased HDL
3) Stiff endothilial walls and endothilial dysfunction => increased oxidative stress and endothilial damage
53
What is metabolic syndrome?
The medical term for the combination of hypertension, obesity, hyperinsulinaemia, diabetes hypertriglyceriaemia, high LDL, low HDL and hypercoaguable blood
54
Which inflammatory marker can be used as a predictor of CV events?
CRP as it is raised in atherosclerosis but is also raised in infection and many other things
55
What is the lifetime risk of hypertension?
90%
56
CV risk doubles with each 20/10mmHg rise in BP. T of F?
true
57
What is hypertension?
The level of BP where treatment does more good than harm
58
What is the most accurate BP device?
Murcurey but not used anymore
59
How should you take a BP reading?
Patient should be quiet and seated
Ensure the device is validated and use the correct cuff size
Check the pulse before measuring to check the rhythm as electronic machines do not measure BP accurately in AF
60
At what BP is ambulatory monitor blood pressure offered?
140/90mmHg (>2 measurements/hour during waking hours
61
What is the disadvantage with HBPM?
There are no night time readings
62
How would you explain to a patient how to do a HBPM?
2 consecutive measurements, 1 minute appart
Record twice a day for 4-7 days
Discard measurements on day 1 and average the rest
63
What is stage 1 hypertension?
Clinic BP >140/90mmHg AND ABPM or HBPM daytime average >135/85mmHg
64
What is stage 2 hypertension?
Clinic BP >160/100mmHg AND ABPM or HBPM daytime average > 150/95mmHg
65
What is severe hypertension?
Clinic systolic BP >180mmHg or clinic diastolic BP >110mmHg
66
What is Sustained hypertension?
Hypertension in clinic and at home
67
What is white coat hypertension?
Hypertensi oinn clinic but normatensive at home
68
What is masked hypertension?
Normatensive in clinic but hypertension at home. However they never receive ABPM because their clinic pressure is normal => late diagnosis and treatment
69
If hypertension is diagnosed how should cardiovascular risk be checked?
Test urine for protein and albumin (kidney damage or diabetes)
Bloods for glucose, electrolytes, creatinine, cholesterol and estimated glomerular filtration rate
12 lead ECG fr evidence of LV hypertrophy
Examine fundi for hypertensive retinopathy
Use a risk calculator ASSIGN
70
What happens if your BP is normal but you have established vascular disease (IHD, PVD, diabetes, cerebrovascular disease or ASSIGN >20%)?
You must be treated
71
WHy is fundi examination performed?
Changes in the vasculature of the eye will reflect changes in the vasculature in the brain
Some of these changes occur naturally with age
72
What is grade 1, 2 3 and 4 hypertensive retinopathy?(Keith, Wagener and Barker classification)
Grade 1 = slight narrowing of retinal arteriole with an arteriovenous ratio >1:2
Grade 2 =Modest-severe narrowing of retinal arteriole with an arteriovenus ratio of <1:2 or evidence of arteriovenus nicking
Grade 3 = Bilateral soft exudates or flame shapped hemorrhages
Grade 4 = Bilateral optic nerve oedema
73
When would you do a fundi examination?
Only if a hypertensive emergency is suspected
74
What is permanent ST depression a sign of on a ECG?
Permanently ischemic myocardium
75
What is the next step according to NICE if you're stage 1 hypertensive with target organ damage or increased CV risk?
Drug therapy
76
What is the next step according to NICE if you're stage 1 hypertensive and under 40?
Specialist referral
77
What is the next step according to NICE if youre stage 1 hypertensive over 40 and no other signs of organ damage or increased risk?
Lifestyle intervention, education and monitoring
78
What is the next step according to NICE if you're stage 2 hypertensive?
Drug therapy and ifestyle intervention, education and monitoring
79
What are the current blood pressure targets for those:
a) under 80?
b) over 80?
a) BP <140/90mmHg or AMBP <135/85mmHg
b) BP <150/90mmHg of AMBP <145/85mmHg
This is likely to be lowered within 5 years due to recent research eg <120/80mmHg
80
What percentage of patients with hypertension are controlled?
46%
81
What causes primary (essential hypertension?
No known cause
30-50% of BP is genetically determined
Environmental/lifestyle determined
82
What are the common causes of secondary hypertension?
Renal disease, OSA, Aldosteronism, renovascular disease
83
What are the uncommon causes of secondary hypert
hypertensionCushings syndrome, pheochromocytoma, hyperthyroidism, Aortic coarctation, Intracranial tumour,
Polycycsic kindey disease, Conn's syndrome and fibromuscular dysplasia
84
How does Conn's syndrome cause severe hypertension?
Severe hypokalemia cause by an adrenal adenoma which produces aldosterone. Sometimes people have microademomas
85
How does pheochromocytoma cause hypertension?
Rare adrenal tumour which releases adrenaline. 100% curable and genetically inherited
86
Who may present with hypertension caused by fibromuscular dysplasia?
Young women- its curable
87
What are the lifestyle interventions for hypertension?
Diet = reduce salt intake and reduce weight
Exercise = post excersize hypotention- just 15min/day
Smoking = stop (also the cause of erectile dysfunction in men over 50
Alcohol consumption = reduce
88
Which drugs CAN be used to treat hypertension?
```
ACE inhibators- Lisinopril
ARBs- Losartan
Beta blockers- Atenolol
Calcium channel blocker- Amlodipine
Thiazide diuretics- bendroflumethiazide
Spironolactone (resistant hypertension)
Alpha blockers (good for prostatism) doxazosin, terazosinq
```
89
Beta blockers are no longer first line treatment for hyphypertension unless its complicated by...?
Arrythmias, increase sympathetic activity, CCF, coronary artery disease
OR pregnancy induced hypertension or women of reproductive age
90
Which hypertensive drugs can you titrate up and which should you not?
ACE inhibators and ARBs have few side effects so you can titrate up
Ca++ antagonists, beta blockers and diuretics have more side effects so don't titrate these up
NB: Adding a drug is 5x more effective than titrating up
91
Why should you never delay intensification of BP treatment?
Increased risk of CV events
92
Starting with 2 drugs for hypertension is always better than starting with one. T or F?
T
93
Combo therapy has fewer side effects than monotherapy. T or F?
T
94
What are the causes of resistant hypertension?
1) non compliance- check with a urine drugs test
2) White coat hypetension
3) Pseudo hypertension (stiff artery walls)
4) Lifestyle factors (can't maintain modified diet)
5) Drug interactions
6) Secondary hypertension? WHat are you missing?
If not these it may be TRUE resistant hypertension
95
How is resistant hypertension trreated?
Spirilactone is the most effective treatment
96
Spirilactone has some risks but how can you make taking the drug safer?
```
Start low and go slow
Caution with diabetics and low glomerular filtration rate
12.5mg/day or 25mg alternate days
Tolerate a 25% rise in K+ and creatinine
Monitoring
```
97
Is it ossible to transplant hypertension in a kidney?
Yes
98
What is renal denervation?
Modification of the nerves between the kidneys and the brain- no evidence for success in hypertension yet
99
What is carotid barroreceptor stimulation?
successful but you must wear it 24/7 and have the barroreceptor constantly stimulated
100
WHat is the Rox coupler?
Arteriovenous anastamosis in the upper theigh. Trying to control hypertension by moving a fixed amount of blood into the venous system.
