Cardiovascular risk management Flashcards
indications for clinically determined high risk
moderate-severe kidney disease
familial hypercholesterolaemia
for which age groups should you use the risk calculator
all people aged 45-79
people with diabetes 35-79
first nations 30-79
modifiable risk factors on the CVD check
smoking
cholesterol
blood pressure
non modifiable risk factors on the CVD check
age
sex
postcode (socioeconomic)
diabetes
chronic kidney disease
familial hypercholesterolaemia
evidence of atrial fibrillation
people who are already at known increased risk and do not need an absolute CVD risk assessment
moderate or severe CKD
a previous diagnosis of familial hypercholesterolaemia
what are some additional factors to consider in people with diabetes
uACR (urine albumin:creatinine)
eGFR
BMI
HbA1c
Insulin
Time since diagnosis
reclassification factors
ethnicities that may raise risk
First Nations
maori people
pacific islander people
south asian (indian, Pakistani, bangladeshi, sri lankan, nepali, bhutanese, maldivian)
ethnicities that may lower risk
east asain (chinese, japanese, korean, taiwanese, mongolian)
what is coronary artery calcium score
performed via CT, does not require contrast or IV access
low radiation exposure, similar to mammogram
provides a score related to the amount and density of calcified plaque for each coronary artery
is coronary artery calcium score recommended
not recommended for generalised population screening for CVD risk
not covered by medicare
ankle brachial index
not used for CVD risk calculation as it provides little risk discrimination beyond existing CVD risk calculators
useful for assessing people with suspected PVD
high sensitivity CRP
non specific marker of inflammation
not used for CVD risk calculation
persistently elevated CRP in people with chronic inflammatory conditions (eg. SLE, RA, psoriasis) but no known CVD may be a useful predictor of increased risk of CVD events
chronic autoimmune inflammatory conditions
RA, systemic sclerosis, addison’s, SLE, T1DM are all asssociated with increased CVD risk but are not useful reasons to change CVD risk prediction level
for people <5% (low) 5-year risk
lifestyle measures
pharmacotherapy not usually used
reassess at least every 5 years or 2 for First Nations
5-9% 5-year risk
lifestyle measures
consider blood pressure lowering and lipid-modifying pharmacotherapy, depending on clinical context
reassess everyone at least every 2 years
10+% 5-year risk
lifestyle measures
lipid lowering and antihypertensives
formal reassessment generally not required as calculated risk is unlikely to go down
should these guidelines be followed rigidly
more about shared decision making
mediterranean diet
supportive RCTs with clinical CV outcome reduction in both secondary and primary prevention - probably the best evidence we have
hypertension symptoms
usually asymptomatic - you need to look for it
major risk factor for IHD, heart failure, stroke, renal failure
treatment lifelong
how to check blood pressure
seated, relaxed, take 3 readings and average the last two
home or ambulatory BP should be offered to reduce white coat
hypertension thresholds
hypertension initial evaluation
full Hx/PMHx/Meds etc.
end organ disease? evidence of secondary HT causes? medicines that may raise BP? anything to contraindicate certain anti-hypertensives
Ex: pulse rate/rhythm/ JVP/ cardiomegaly/failure signs, vasculopathy signs, fundi, near signs, palpable kidneys, endocrine abnormalities, BMI
hypertension Ix
U&E + GFR
ACR
lipids
fasting glucose
Hb
ECG (?AF, ?LVH, ?IHD)
antihypertensives
in patients with uncomplicated hypertension, ACEI/ARB or CCB or thiazide diuretics are all suitable first line antihypertensive drugs, either as monotherapy or in some combinations as indicated
adverse effects of ACEI
cough, angioedema, postural hypotension
adverse effects of CCB
headache, flushing, peripheral oedema, constipation, postural hypotension
adverse effects of thiazides
gout, glucose, electrolyte abnormality, ED, postural hypotension
less at low doses
examples of thiazides
chlorthalidone
hydrochlorothiazide
Indapemide
adverse effects of beta blockers
lethargy, ED, dyspnoea
the balance between safety and efficacy for beta blockers is less favourable than other first line treatments for hypertension
combinations of anti-hypertensives that are fine
ACEI/ARB, CCB and thiazide in any combination
beta blocker with most of the above
combinations of anti-hypertensives to avoid
beta blocker with verapamil - heart block
ACEI with ARB - no benefit and more adverse events
ACEI/ARB with potassium sparing diuretic - hyperkalaemia
costs of anti hypertensives
thiazides are the cheapest but they’re all getting cheaper with generics
causes of refractory hypertension
- not adherent wth plan, communication/education required
- dose too low
- other drugs/substances
- lifestyle
- white coat
- secondary hypertension
Ix for secondary hypertension
- aldosterone/renin ratio (for primary hyperaldosteronism)
- 24 hour urinary cetacholemine (for pheochromocytoma)
- renal artery duplex US (for renal artery stenosis)
- if suspected Cushing’s - dexamethasone suppression test
statins
lower LDL, have by far the best evidence base in terms of clinical outcomes
eg.
ezetimibe is good for
statin alternative, also used to lower cholesterol but prevents absorption instead of acting on the liver
small absolute benefit after ACS, no outcome studies in primary prevention
other lipid lowering medications
Ezetimibe - small absolute benefit after ACS, no outcome studies in primary prevention
fibrates - lowers TG, may help in people with low HDL
niacin - nicotinic acid, lower LDL
fish oil/omega 3 fatty acids - lowers TG
plant sterols/stanols - privent cholesterol absorption, no outcome evidence
side effects of statin controversies
myalgias - limited evidence
severe myositis/rhabdomyolysis - associated but rare
liver injury - associated but rare
diabetes - risk seems outweighed by CV benefits
do statins cause cancer or dementia?
no
lipid targets
secondary prevention post CVA
lifestyle changes
antihypertensives (any of the usual first-line drugs are good)
antiplatelets - after ischaemic stroke
anticoagulation - not routine unless AF
statin - after ischaemic stroke
consider carotid endarterectomy
manage diabetes if present
usually stop HRT/hormonal contraceptives
what kind of antiplatelet therapy do you use post ischaemic CVA
DAPT for 21 days:
combination aspirin/dipyridamole (PBS) OR aspirin/clopidogrel (non-PBS)
aspirin alone is an option especially if the above is not tolerated
should you use long term combination aspirin and clopidogrel (DAPT)
no
only recommended for 10-21 days after high risk TIA or mild stroke
should you use a statin after a heamorhagic stroke
no
secondary prevention post MI
cardiac rehabilitation
lifestyle changes
ACE inhibitor indefinitely
beta blocker (at least 12 months; indefinitely if LV dysfunction)
high potency statin indefinitely
aspirin indefinitely +/- another antiplatelet medication
which antiplatelet do you use after MI
aspirin indefinitely +/- another antiplatelet agent
- clopidogrel, prasugrel or ticagrelor
especially after stenting, for 12 months
evidence complicated, prescribing guided by cardiologist
stroke prevention in AF
anticoagulation
usually NOACs favoured
anti-hypertensives in older people
commence at low dose and titrate slowly as adverse effects increase with age, including: hypotension, syncope, electrolyte imbalance, acute kidney injury
