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General practice 2023 > Cardiovascular risk management > Flashcards

Cardiovascular risk management Flashcards

1
Q

indications for clinically determined high risk

A

moderate-severe kidney disease
familial hypercholesterolaemia

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2
Q

for which age groups should you use the risk calculator

A

all people aged 45-79
people with diabetes 35-79
first nations 30-79

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3
Q

modifiable risk factors on the CVD check

A

smoking
cholesterol
blood pressure

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4
Q

non modifiable risk factors on the CVD check

A

age
sex
postcode (socioeconomic)
diabetes
chronic kidney disease
familial hypercholesterolaemia
evidence of atrial fibrillation

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5
Q

people who are already at known increased risk and do not need an absolute CVD risk assessment

A

moderate or severe CKD
a previous diagnosis of familial hypercholesterolaemia

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6
Q

what are some additional factors to consider in people with diabetes

A

uACR (urine albumin:creatinine)
eGFR
BMI
HbA1c
Insulin
Time since diagnosis

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7
Q

reclassification factors

A
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8
Q

ethnicities that may raise risk

A

First Nations
maori people
pacific islander people
south asian (indian, Pakistani, bangladeshi, sri lankan, nepali, bhutanese, maldivian)

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9
Q

ethnicities that may lower risk

A

east asain (chinese, japanese, korean, taiwanese, mongolian)

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10
Q

what is coronary artery calcium score

A

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

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11
Q

is coronary artery calcium score recommended

A

not recommended for generalised population screening for CVD risk
not covered by medicare

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12
Q

ankle brachial index

A

not used for CVD risk calculation as it provides little risk discrimination beyond existing CVD risk calculators
useful for assessing people with suspected PVD

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13
Q

high sensitivity CRP

A

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

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14
Q

chronic autoimmune inflammatory conditions

A

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

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15
Q

for people <5% (low) 5-year risk

A

lifestyle measures
pharmacotherapy not usually used
reassess at least every 5 years or 2 for First Nations

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16
Q

5-9% 5-year risk

A

lifestyle measures
consider blood pressure lowering and lipid-modifying pharmacotherapy, depending on clinical context
reassess everyone at least every 2 years

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17
Q

10+% 5-year risk

A

lifestyle measures
lipid lowering and antihypertensives
formal reassessment generally not required as calculated risk is unlikely to go down

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18
Q

should these guidelines be followed rigidly

A

more about shared decision making

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19
Q

mediterranean diet

A

supportive RCTs with clinical CV outcome reduction in both secondary and primary prevention - probably the best evidence we have

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20
Q

hypertension symptoms

A

usually asymptomatic - you need to look for it
major risk factor for IHD, heart failure, stroke, renal failure
treatment lifelong

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21
Q

how to check blood pressure

A

seated, relaxed, take 3 readings and average the last two
home or ambulatory BP should be offered to reduce white coat

22
Q

hypertension thresholds

A
23
Q

hypertension initial evaluation

A

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

24
Q

hypertension Ix

A

U&E + GFR
ACR
lipids
fasting glucose
Hb
ECG (?AF, ?LVH, ?IHD)

25
Q

antihypertensives

A

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

26
Q

adverse effects of ACEI

A

cough, angioedema, postural hypotension

27
Q

adverse effects of CCB

A

headache, flushing, peripheral oedema, constipation, postural hypotension

28
Q

adverse effects of thiazides

A

gout, glucose, electrolyte abnormality, ED, postural hypotension
less at low doses

29
Q

examples of thiazides

A

chlorthalidone
hydrochlorothiazide
Indapemide

30
Q

adverse effects of beta blockers

A

lethargy, ED, dyspnoea
the balance between safety and efficacy for beta blockers is less favourable than other first line treatments for hypertension

31
Q

combinations of anti-hypertensives that are fine

A

ACEI/ARB, CCB and thiazide in any combination
beta blocker with most of the above

32
Q

combinations of anti-hypertensives to avoid

A

beta blocker with verapamil - heart block
ACEI with ARB - no benefit and more adverse events
ACEI/ARB with potassium sparing diuretic - hyperkalaemia

33
Q

costs of anti hypertensives

A

thiazides are the cheapest but they’re all getting cheaper with generics

34
Q

causes of refractory hypertension

A
  • not adherent wth plan, communication/education required
  • dose too low
  • other drugs/substances
  • lifestyle
  • white coat
  • secondary hypertension
35
Q

Ix for secondary hypertension

A
  • 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
36
Q

statins

A

lower LDL, have by far the best evidence base in terms of clinical outcomes
eg.

37
Q

ezetimibe is good for

A

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

38
Q

other lipid lowering medications

A

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

39
Q

side effects of statin controversies

A

myalgias - limited evidence
severe myositis/rhabdomyolysis - associated but rare
liver injury - associated but rare
diabetes - risk seems outweighed by CV benefits

40
Q

do statins cause cancer or dementia?

A

no

41
Q

lipid targets

A
42
Q

secondary prevention post CVA

A

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

43
Q

what kind of antiplatelet therapy do you use post ischaemic CVA

A

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

44
Q

should you use long term combination aspirin and clopidogrel (DAPT)

A

no
only recommended for 10-21 days after high risk TIA or mild stroke

45
Q

should you use a statin after a heamorhagic stroke

A

no

46
Q

secondary prevention post MI

A

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

47
Q

which antiplatelet do you use after MI

A

aspirin indefinitely +/- another antiplatelet agent
- clopidogrel, prasugrel or ticagrelor
especially after stenting, for 12 months
evidence complicated, prescribing guided by cardiologist

48
Q

stroke prevention in AF

A

anticoagulation
usually NOACs favoured

49
Q

anti-hypertensives in older people

A

commence at low dose and titrate slowly as adverse effects increase with age, including: hypotension, syncope, electrolyte imbalance, acute kidney injury

50
Q
A

General practice 2023 (49 decks)

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