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Chapter 2. Guidelines for Primary and Secondary Prevention Flashcards

1
Q

Asymptomatic carotid stenosis (60-99%) disease in primary prevention

A

CEA + Medical management reduces 5 year stroke risk from 11% to 5%

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2
Q

High intensity is has an LDL lowering effect of how many percent

A

> 50%

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3
Q

The following increases the risk of developing LV mural thrombi in 1-2 weeks

A

Large anterior wall MI
LVEF <40%
Apical wall motion abnormality

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4
Q

What is the result of Insulin Resistant Intervention after Stroke (IRIS STUDY)

A

Pioglitazone can be used in patient who do not have diabetes but with insulin resistance and is associated with lower risk of DM but high risk of edema, weight gain and fracture

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5
Q

Carotid Artery Disease accounts how many percent of all stroke

A

15-20%

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6
Q

What are the nutritional deficiency or excess that increases the risk for stroke

A

Elevated homocysteine levels
Deficient VIT B6 and B12
Elevated Na and Ca

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7
Q

Risk reduction of thromboembolic stroke

A

48%

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8
Q

In secondary prevention of stroke CEA + medical management in 70% stenosis without near occlusion the absolute risk reduction is

A

16% per 5 years

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9
Q

What is the age-adjusred prevalence of hypertension

A

20.6%

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10
Q

2nd generation valve INR requirement

A

Depends on poston
MR: 3-3.5
Aortic 2.5-3.0

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11
Q

Recommendation for Primary prevention with dyslipidemia

A
  1. 21 yo with >190 LDL should be treated with statin
  2. Low fat diet
  3. 40-75 without DM and ASCVD but with LDL 80-189 should received HIST
  4. < 70yo with ASCVD should received HIST
  5. 40-75 with DM but without ASCVD should be given with MIST or HIST if AIC is >7.15
  6. Patient with CSAD and low HDL: give niacin or fenofibrate
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12
Q

Gemfibrozil is associated with how many risk reduction for stroke

A

40%

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13
Q

How many percent VKA reduces risk for stroke with MI

A

19%

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14
Q

This study compare the outcome between CEA vs CAS

A

Carotid Revascularization Endarterectomy vs Stent Trial (CREST trial)

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15
Q

Fatal bleeding rate of ASA per year

A

0.17/year

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16
Q

Ideal waist circumference

A

35 in men 31 in women

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17
Q

Stroke risk for Carotid artery disease

A

13-15%

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18
Q

Recommendation for stroke prevention in patient with MVP and Aortic Valve Disease in the absence of AF

A

Use ASA

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19
Q

The incidence of stroke is greatly reduced by Metform by how many

A

31%

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20
Q

This is a study on Gemfibrozil on stroke

A

VA-HIT

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21
Q

What is the result of cochrane collaboration of CAS vs CEA trials

A

CAS - associated with increased with periprocedural stroke or death compared to CEQA

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22
Q

AHA/ASA indication fro statin

A 
Clinical atherosclerosis cardiovascular disease
LDL >190mg/dl
LDL 70-189 (40-75 years old)
History of DM
Or consider other factors: ABI and CRP
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23
Q

Result of WASID

A

ASA is safer and effective as VKA for stroke prevention in 50-99% stenosis
Rate of ischemic events was high regardless of therapy (antiplatelet or anticoagulant)

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24
Q

What is the result of Extracranial-Intracranial Bypass trial

A

Failed to show clinical benefit in patient with CAD and MCA anastomosis

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25
Q

How many patient with ischemic stroke with overt DM

A

25-45%

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26
Q

Ideal antihypertensive in Primary prevention in patient with DM

A

ARB and ACEi

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27
Q

This study has proven that metformin as a first line therapy for overweight type 2 DM appears to decrease diabetes related end points such as stroke

A

United Kingdon Prospective Diabetes Study

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28
Q

What is the result of Asymptomatic Carotid Surgery Trial (ACST)

A

in patient with >60% stensosi

11.8% (medical) vs 6.4% (CEA+medical) stroke risk reduction

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29
Q

Gemfibrozil lowers cholesterol by what mechanism

A

PPar activation leads to increase synthesis of lipoprotein lipase increases clearance of TAG

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30
Q

What is the annual risk for stroke in asymptomatic intracranial artery disease

A

1.4%

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31
Q

First generation valves INR requirement

A

3-4.5

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32
Q

What type of obesity is the more positively associated with stroke

A

Abdominal obesity

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33
Q

How many percent VKA with ASA reduces risk for stroke with MI

A

29%

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34
Q

What is the criteria for diagnosis of Diabetes Mellitus

A

A1C 6.5%
CBG >126
Randome plasma glucose 200
2-hour PG of 200 during OGTT

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35
Q

What is the result of SPARCL trial

A

16% risk reduction with high dose statin
No significant ICG among control and statin groups
No clinical benefit to SAH

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36
Q

Risk of stroke that can reach the level of non-smoker

A

5 years

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37
Q

Recommendation for utilization of CDUS

A
  1. For asymptomatic patient at risk for significant disease
  2. To detect carotid stenosis in symptomatic patients
  3. Not routine for screening pf asymptomatic without vascular risk factors
  4. If CDUS is inconclusive do MRA or CTA
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38
Q

What additional medication is recommended to antiplatelet to ASA that shows to improve symptoms and increase walking distance

A

Cilostazol

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39
Q

What is the most important dose dependent risk factor for PAD

A

cigarette smoking

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40
Q

CEA is not considered in the following situation

A
  1. stenosis <50%
  2. Chronic total carotid occlusion
  3. Severe disabling stroke
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41
Q

Major independent risk factor for stroke and stroke-related mortality

A

Hypertension

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42
Q

Lowering the BP in this age group reduces how many risk of developing stroke: < 60yo, 60-69yo, >70 yo

A

< 60 yo: 40-50%
60-69 yo: 30-40%
> 70 yo: 20-30%

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43
Q

CEA is harmful in what situation

A

<30% stenosis

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44
Q 
Risk for thromboembolism in valvular heart disease without AF
Prothetic valve \_\_\_
Rheumatic MR \_\_\_
Rheumatic MS\_\_
MVP\_\_
Aortic valve\_\_
A 
PV: 20%
RMR: 7.7%
RMS: 1.5-40%
MVP: < 20%
Aortic valve: not a risk
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45
Q

a 5% of decline of EF will have how many increase risk of risk in developing stroke

A

18%

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46
Q

CEA has no effect in what circumstances

A

30-49% stenosis

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47
Q

Risk of stroke for:
Obesity
Overweight

A
  1. 43% overweight

1. 7-2% Obese

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48
Q

This result to reduction of recurrent stroke by 12% and all stroke by 21%

A

Lowering of LDL by 1mmol/L with statin

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49
Q

K intake is associated with ____ lower risk of stroke

A

24%

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50
Q

What is the recommended risk factors modification in ICAD

A

SBP <140

HIST

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51
Q

Recommendation of VKA use in stroke prevention in patient with MI

A

Persistent AF
Decreased LV function (< 28% LVEF)
LV thrombi is detected within several months

52
Q

Lowering this reduces major cardiovascular events (primary and secondary stroke(

53
Q

Protective effect of alcohol

A 
Increased HDL
Increased Apolipoprotein A1
Adiponectin 
Reduced platelet aggregation
Lower fibrinogen level
54
Q

Recommendation for Stroke prevention in rheumatic heart disease

A

Anticoagulate with VKA
Additional of antiplatelet is not recommended
However patient who had stroke despite adequate VKA treatment aspirin might be considered

55
Q

Light to moderate drinking is associated to

A

Reduce risk of First ever stroke

56
Q

What is the result of SAMMPRIS trial

A

PTA 14.7 vs 5.8 medical

Discontinued because of high rates of stroke in patient with percutaneous transluminar angioplasty

57
Q

How many percent of rtpa patient with DM had bleed

58
Q

What is the result o Post-Stroke Antihypertensive Study (PATS)

A

Relative risk reduction of 30% using indapamide

59
Q

The result of CLAIR Study

A

Clopidogrel + ASA is associated with fewer microembolic signal at day 2 and 7

60
Q

Objective test in detecting PAD

A

ABI

<0.9: arterial obstruction disease

61
Q

What is the recommended physical activity in patient with stroke/TIA based on AHA?ASA

A

3-4x session per week of moderate to vigorous intensity aerobic for 40 minutes

62
Q

What is the result of Secondary Prevention of Small Subcortical Stroke (SPS3)

A

No difference with composite outcome in 2 groups (<130mmHg and <150mmHg)

63
Q

Increase of how many SBP and DBP is associated with increased fatal events in stroke

A

SBP 20mmHg

DBP 10mmHg

64
Q

What is the recommended LDL

A

< 100 (DM)
70 high risk
<160 in normal individual

65
Q

AHA/ASA guidleines on nutrition

A
  1. DASH diet
  2. Mediterranean diet
  3. Multivitamins is not recommended
  4. Reduced Na intake by <2.4; <1.5 is associated with greater BP reduction
66
Q

Recommendation for CEA

A

CEA can be used in the following circumstances:

  1. Stenosis >70%
  2. With recent TIA and non-disabling stroke with severe Carotid stensosis (70-99)
  3. Symptomatic 50-69% stenosis
  4. preferred treatment in high risk patient with stenosis of >70%
67
Q

MR without AF and with AF increases risk for stroke by:

A

(-) AF: 7.7%

(+) AF: 22%

68
Q

The 1 year stroke risk for asymptomatic in WASID

69
Q

Therapeutic trial of what medication should be considered in all patient with lifestyle limiting claudication

A

Cilostazol

70
Q

This is defined as lowest consumption of alcohol

A

2 drink/day in men

1 drink/day in women

71
Q

Mechanism of action of Niacin

A 
Increase HDL
Lowers Lp (a)
72
Q

An EF of < 28 increases the annual stroke rate by

73
Q

What is the result for Carotid Revascularization Endarterectomy vs Stent Trial (CREST trial)

A

CAS - greatest efficacy among younger patient less than 70 years old
CEA slight superior than CAS when used in older patient
3 day perioperative risk: Stroke CAS/ MI: CEA

74
Q

What parameters in lipid profile increases the risk of stroke

A

Increased LDL, LP(a), HyperTAG,

Low HDL

75
Q

Reduction death rates based on SBP

A

2mmHg - 6%
3mmHg - 8%
5mmHg - 14%

76
Q

American College of Chest Physician INR requirements of prosthetic valve

A

Mechanical 2.5-3.5

Bioprosthetic valce 2.0-3.0

77
Q

In secondary prevention of stroke CEA + medical management in 70% stenosis with near occlusion the absolute risk reduction is

A

5,6% per 2 years

78
Q

The recurrence rate of stroke in rheumatic mitral valve disease in first year

79
Q

This risk factor has dose dependent effect on hemorrhagic stroke

80
Q

How many percent stroke risk reduction in using statin

81
Q

Risk for stroke in patient with PAD

82
Q

Distribution of annual risk depends on the location of intracranial stenosis

A

Carotid siphon 7.6%
MCA 7.8%
Basilar artery 11%

83
Q

When considering carotid revascularization, how will you stratify the patient

A

Based on NASCET
Symptomatic/Asymptomatic
Low, moderate or high risk

84
Q

Acute MI increases the risk of stoke within 2 weeks by how many percent

A

5%
Increased in anterior wall
and increased by 20% by anteroapical infarct

85
Q

A 60gm of alcohol per day is related to how many percent of stroke risks

A

64% increased risk for stroke
69% risk for ischemic stroke
Double in hemorrhagic stroke

86
Q

What is the risk in extensive lowering of cholesterol

A

Increases the risk of bleeding

87
Q

What is the recommended exercise in patient with PAD

A

Supervised exercise 30-45mins/3x/week/12 weeks

88
Q

What is the function of cholesterol

A

Maintain vascular integrity

89
Q

Target INR of VKA in patient with MI

90
Q

Intracranial stenosis is a cause of how many percent of stroke in ASIANS

91
Q

Statin in the presence of renal disease will reduce total mortality by ____ and stroke reduction by _____

A

Mortality 21%

Strpke 30%

92
Q

This study evaluate the annual stroke risk treated with anticoagulant and antiplatelet

A

Warfarin-Aspirin in Symptomatic Intracranial Disease (WASID)

93
Q

What is the result of TOSS trial

A

Adding of Cilostazol to ASA was superior to ASA monotherapy at 6 months

94
Q

The incidence of stroke in DCM is indirectly proportional to

A

decline of EF

95
Q

Pharmacologic therapy in hypertension in patient without stroke will reduce the risk by

96
Q

What is the result of TOSS-2 Trial

A

Non-significant trend toward ICAD progression observed in:

ASA+Cilostazol compared with clopidogrem (9.9 vs 15.46%)

97
Q

The effect of angioplasty and stenting despite aggressive medical therapy in ICAD

A

unknown and under investigational

98
Q

This study confirmed the benefit of ACEi-based regimen in reducing the incidence of secondary stroke and MI

A

Perindopril Protection Against Recurrent Stroke Study

99
Q

What anti cholesterol agent is not recommended

A

Fenofibrates

100
Q

The following increases the risk of stroke risk beyond 3 months

A

Persistent myocardial disruption
CHF
AF
Mobile and protruding thrombus

101
Q

What is the result of CLAIR study

A

Study on Clopidogrel + Aspirin for Infarction Reduction

102
Q

An EF of 29-25 increase the annual stroke rate by

103
Q

The percentage of ischemic stroke patients who has pre-DM

104
Q

MS without AF and with AF increases risk for stroke by:

A

(-) AF: 1.5-4.7%

(+) AF: 7-18 folds

105
Q

Over-all risk for embolization in patient with MI

A

11% if with thrombus

2% if without thrombus

106
Q

The risk of stroke in patient with MVP without AF

107
Q

Fatal bleeding rate of VKA per year

108
Q

DM increases the risk of ischemic stroke by

109
Q

in 50-69% occlusion what is the benefit of CEA

A

Marginal benefit esp in male and elderly

110
Q

What is the recommended agent used in patient with ICAD to prevent recurrent stroke

A

ASA

additional of cilostazol and clopidogrel is reasonable

111
Q

What BP is associated with continuos association with stroke

A

> 140/90mmHg

112
Q

Recommendation for secondary prevention with dyslipidemia

A

< 70 with clinical ASCVD: start on HIST or MIST

>70 with clinical ASCVD: MIST or HIST

113
Q

What medication is recommended for Lower extremity PAD

A

Antiplatelet

114
Q

What is the result of Warfarin vs ASA in Reduced Cardiac EF (WARCEF)

A

no difference in event rate on primary outcome between the 2 groups

115
Q

What is the preferred antihypertensive combination

A

Thiazide + ARB or ACEi or CCB

CCB + ARB or ACEi

116
Q

Recommendation for DCM in stroke prevention

A

Anticoagulate with VKA for patient who had stroke with LVEF <35% or RCM withouth LA or LV thrombus

if intolerant to VKA, NOACS effectiveness is uncertain

117
Q

What is the preoperative risk of stroke on the following:”
> 70% stenosis
70-99% stenosis

A

> 70% : 3%

70-99% : 6%

118
Q

If there is a stroke or TIA in the setting of acure MI complicated by LV mural thrombus, apical wall abnormality LVEF <40 and intolerant to VKA

A

Treat with LMWH or NOACs for 3 months

119
Q

What is the first trial to investigate the effect of BP treatment for secondary stroke prevention

A

Post-Stroke Antihypertensive Study (PATS)

120
Q

Niacin reduces stroke by how many percent

121
Q

Obesity is defined as

A

BMI >30

WHR: > 1 men and >0.85 women

122
Q

What is the management of patient who had stroke or TIA attributed to 50-69% ICAD

A

Medical management only

Stenting and angioplasty not recommended

123
Q

Management for restrictive cardiomyopathy

A

Systemic anticoagulation

124
Q

The annual risk for thromboembolism among patient with prosthetic heart valve

125
Q

Mechanism of action of Statin

A

Reduce Cholesterol
Reduce inflammation
Promotes angiogenesis and neurogenesis
Upregulates endogenous TPA

126
Q

Annual risk for stroke of intracranial stenosis

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