Cardiovascular Risk Management

Question 1

Approach

Answer 1

• Identify the patient’s absolute cardiovascular disease risk, probability of having a cardiovascular event (e.g. MI, stroke) within the next 5 years
• Identify modifiable risk factors and reduce his CVD risk with lifestyle and pharmacological methods.

absolute CVD risk should be conducted every 2 years in all adults ≥45 years old (≥35 years old in ATSI), unless they are already high risk

Question 2

History

Answer 2

1) Cardiovascular risk
- Symptoms: cardiac symptoms, peripheral vascular disease, CVA symptoms
Contributing/RF: SNAP RF, CVD RF (smoking, previous IHD, CKD, FHX, DM, ATSI),
2) General medical history, GP screening

Question 3

Examination

Answer 3

• Vital signs, height/weight/BMI, waist circumference (<94cm men, <80cm women)
• Cardiovascular exam + diabetes exam -hypercholesterolaemia, signs of LVF/RVF, peripheral vascular exam

Question 4

Investigations

Answer 4

Bedside: ECG (previous ACS, LVH, arrhythmia),
Risk assessment tools (absolute CVD risk)
Absolute CVD risk – Australian CV Risk chart.
Non-modifiable (age, sex), modifiable (smoking, SBP)
Score ≤9% (low risk), 10-15% (moderate risk), ≥16% (high risk of CVD event in next 5 years)

Bloods: Fasting DM + lipids: fasting BSL (± HbA1c) TC, HDL-C, LDL-C, TG
CKD: EUC, eGFR.

Question 5

Management

Answer 5

1. Uncomplicated Hypertension
   - Consider secondary causes
   a. Primary hyperaldosteronism (Conn syndrome in 5-10%), phaeochromocytoma, thyrotoxicosis, Cushing’s
   b. Aortic coarctation, renal artery stenosis, renal disease/PCKD, medications (COCP, NSAID, steroids)

• [1] Monotherapy with ACE inhibitor/ARB, dihydropyridine CCB
• [2] Combination therapy
  a. ACEI/ARB + dihydropyridine CCB (nifedipine)
• [3] Triple therapy ± specialist referral ± secondary causes of HTN/poor compliance/high salt intake/OSA

2. Treatment for Dyslipidaemia
   a. [1] Monotherapy with statins
   b. [2] Combination therapy
   i. Statin + ezetimibe (ezetimibe 10mg PO daily)
   ii. Statin + bile acid binding resin
3. Treatment for T2DM
   - Non-pharmacological
   a. Patient education + monitoring BSL/Ketones
   b. Lifestyle modification (diet, exercise, weight loss 5-20%)
   c. Referral to endocrinologist, dietician, exercise physiologist, diabetes educator (small regular meals)
   d. Manage comorbidities (BP, lipids, MH health)

• Glycaemic target Hb1Ac ≤7%, fasting BSL 4-7 mmol/L
• [1] Metformin
• [2] Metformin + DPP-IV inhibitor (sitagliptin) /GLP-1 anagonist (Exenatide)/sulphonylurea
• [3] Metformin + basal insulin (e.g. long-acting Lantus/Levemir)

Question 6

Long-term management

Answer 6

3-6 months
-	Maintaining sugar levels (self-monitored BSL, HbA1c)
-	Maintaining BP target, lipids 
-	Weight ± waist circumference
Microvascular disease
-	Neuropathy – foot exam 

6-12 months
General
-Review management goals, medications, SNAP risk factors

Microvascular disease

• Retinopathy – eye review (2-yearly if no retinopathy)
• Nephropathy – microalbuminuria, EUC/GFR
• Neuropathy – foot exam (if low risk of complications)

Macrovascular- Fasting lipids