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%
2
Q
High intensity is has an LDL lowering effect of how many percent
A
> 50%
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
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
5
Q
Carotid Artery Disease accounts how many percent of all stroke
A
15-20%
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
7
Q
Risk reduction of thromboembolic stroke
A
48%
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
9
Q
What is the age-adjusred prevalence of hypertension
A
20.6%
10
Q
2nd generation valve INR requirement
A
Depends on poston
MR: 3-3.5
Aortic 2.5-3.0
11
Q
Recommendation for Primary prevention with dyslipidemia
A
- 21 yo with >190 LDL should be treated with statin
- Low fat diet
- 40-75 without DM and ASCVD but with LDL 80-189 should received HIST
- < 70yo with ASCVD should received HIST
- 40-75 with DM but without ASCVD should be given with MIST or HIST if AIC is >7.15
- Patient with CSAD and low HDL: give niacin or fenofibrate
12
Q
Gemfibrozil is associated with how many risk reduction for stroke
A
40%
13
Q
How many percent VKA reduces risk for stroke with MI
A
19%
14
Q
This study compare the outcome between CEA vs CAS
A
Carotid Revascularization Endarterectomy vs Stent Trial (CREST trial)
15
Q
Fatal bleeding rate of ASA per year
A
0.17/year
16
Q
Ideal waist circumference
A
35 in men 31 in women
17
Q
Stroke risk for Carotid artery disease
A
13-15%
18
Q
Recommendation for stroke prevention in patient with MVP and Aortic Valve Disease in the absence of AF
A
Use ASA
19
Q
The incidence of stroke is greatly reduced by Metform by how many
A
31%
20
Q
This is a study on Gemfibrozil on stroke
A
VA-HIT
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
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
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)
24
Q
What is the result of Extracranial-Intracranial Bypass trial
A
Failed to show clinical benefit in patient with CAD and MCA anastomosis
25
How many patient with ischemic stroke with overt DM
25-45%
26
Ideal antihypertensive in Primary prevention in patient with DM
ARB and ACEi
27
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
United Kingdon Prospective Diabetes Study
28
What is the result of Asymptomatic Carotid Surgery Trial (ACST)
in patient with >60% stensosi
| 11.8% (medical) vs 6.4% (CEA+medical) stroke risk reduction
29
Gemfibrozil lowers cholesterol by what mechanism
PPar activation leads to increase synthesis of lipoprotein lipase increases clearance of TAG
30
What is the annual risk for stroke in asymptomatic intracranial artery disease
1.4%
31
First generation valves INR requirement
3-4.5
32
What type of obesity is the more positively associated with stroke
Abdominal obesity
33
How many percent VKA with ASA reduces risk for stroke with MI
29%
34
What is the criteria for diagnosis of Diabetes Mellitus
A1C 6.5%
CBG >126
Randome plasma glucose 200
2-hour PG of 200 during OGTT
35
What is the result of SPARCL trial
16% risk reduction with high dose statin
No significant ICG among control and statin groups
No clinical benefit to SAH
36
Risk of stroke that can reach the level of non-smoker
5 years
37
Recommendation for utilization of CDUS
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
38
What additional medication is recommended to antiplatelet to ASA that shows to improve symptoms and increase walking distance
Cilostazol
39
What is the most important dose dependent risk factor for PAD
cigarette smoking
40
CEA is not considered in the following situation
1. stenosis <50%
2. Chronic total carotid occlusion
3. Severe disabling stroke
41
Major independent risk factor for stroke and stroke-related mortality
Hypertension
42
Lowering the BP in this age group reduces how many risk of developing stroke: < 60yo, 60-69yo, >70 yo
< 60 yo: 40-50%
60-69 yo: 30-40%
> 70 yo: 20-30%
43
CEA is harmful in what situation
<30% stenosis
44
```
Risk for thromboembolism in valvular heart disease without AF
Prothetic valve ___
Rheumatic MR ___
Rheumatic MS__
MVP__
Aortic valve__
```
```
PV: 20%
RMR: 7.7%
RMS: 1.5-40%
MVP: < 20%
Aortic valve: not a risk
```
45
a 5% of decline of EF will have how many increase risk of risk in developing stroke
18%
46
CEA has no effect in what circumstances
30-49% stenosis
47
Risk of stroke for:
Obesity
Overweight
1. 43% overweight
| 1. 7-2% Obese
48
This result to reduction of recurrent stroke by 12% and all stroke by 21%
Lowering of LDL by 1mmol/L with statin
49
K intake is associated with ____ lower risk of stroke
24%
50
What is the recommended risk factors modification in ICAD
SBP <140
| HIST
51
Recommendation of VKA use in stroke prevention in patient with MI
Persistent AF
Decreased LV function (< 28% LVEF)
LV thrombi is detected within several months
52
Lowering this reduces major cardiovascular events (primary and secondary stroke(
LDL-C
53
Protective effect of alcohol
```
Increased HDL
Increased Apolipoprotein A1
Adiponectin
Reduced platelet aggregation
Lower fibrinogen level
```
54
Recommendation for Stroke prevention in rheumatic heart disease
Anticoagulate with VKA
Additional of antiplatelet is not recommended
However patient who had stroke despite adequate VKA treatment aspirin might be considered
55
Light to moderate drinking is associated to
Reduce risk of First ever stroke
56
What is the result of SAMMPRIS trial
PTA 14.7 vs 5.8 medical
| Discontinued because of high rates of stroke in patient with percutaneous transluminar angioplasty
57
How many percent of rtpa patient with DM had bleed
25%
58
What is the result o Post-Stroke Antihypertensive Study (PATS)
Relative risk reduction of 30% using indapamide
59
The result of CLAIR Study
Clopidogrel + ASA is associated with fewer microembolic signal at day 2 and 7
60
Objective test in detecting PAD
ABI
| <0.9: arterial obstruction disease
61
What is the recommended physical activity in patient with stroke/TIA based on AHA?ASA
3-4x session per week of moderate to vigorous intensity aerobic for 40 minutes
62
What is the result of Secondary Prevention of Small Subcortical Stroke (SPS3)
No difference with composite outcome in 2 groups (<130mmHg and <150mmHg)
63
Increase of how many SBP and DBP is associated with increased fatal events in stroke
SBP 20mmHg
| DBP 10mmHg
64
What is the recommended LDL
< 100 (DM)
70 high risk
<160 in normal individual
65
AHA/ASA guidleines on nutrition
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
Recommendation for CEA
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
MR without AF and with AF increases risk for stroke by:
(-) AF: 7.7%
| (+) AF: 22%
68
The 1 year stroke risk for asymptomatic in WASID
3.5%
69
Therapeutic trial of what medication should be considered in all patient with lifestyle limiting claudication
Cilostazol
70
This is defined as lowest consumption of alcohol
2 drink/day in men
| 1 drink/day in women
71
Mechanism of action of Niacin
```
Increase HDL
Lowers Lp (a)
```
72
An EF of < 28 increases the annual stroke rate by
1.7%
73
What is the result for Carotid Revascularization Endarterectomy vs Stent Trial (CREST trial)
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
What parameters in lipid profile increases the risk of stroke
Increased LDL, LP(a), HyperTAG,
| Low HDL
75
Reduction death rates based on SBP
2mmHg - 6%
3mmHg - 8%
5mmHg - 14%
76
American College of Chest Physician INR requirements of prosthetic valve
Mechanical 2.5-3.5
| Bioprosthetic valce 2.0-3.0
77
In secondary prevention of stroke CEA + medical management in 70% stenosis with near occlusion the absolute risk reduction is
5,6% per 2 years
78
The recurrence rate of stroke in rheumatic mitral valve disease in first year
60-65%
79
This risk factor has dose dependent effect on hemorrhagic stroke
Alcohol
80
How many percent stroke risk reduction in using statin
48%
81
Risk for stroke in patient with PAD
40%
82
Distribution of annual risk depends on the location of intracranial stenosis
Carotid siphon 7.6%
MCA 7.8%
Basilar artery 11%
83
When considering carotid revascularization, how will you stratify the patient
Based on NASCET
Symptomatic/Asymptomatic
Low, moderate or high risk
84
Acute MI increases the risk of stoke within 2 weeks by how many percent
5%
Increased in anterior wall
and increased by 20% by anteroapical infarct
85
A 60gm of alcohol per day is related to how many percent of stroke risks
64% increased risk for stroke
69% risk for ischemic stroke
Double in hemorrhagic stroke
86
What is the risk in extensive lowering of cholesterol
Increases the risk of bleeding
87
What is the recommended exercise in patient with PAD
Supervised exercise 30-45mins/3x/week/12 weeks
88
What is the function of cholesterol
Maintain vascular integrity
89
Target INR of VKA in patient with MI
2-3
90
Intracranial stenosis is a cause of how many percent of stroke in ASIANS
33-37%
91
Statin in the presence of renal disease will reduce total mortality by ____ and stroke reduction by _____
Mortality 21%
| Strpke 30%
92
This study evaluate the annual stroke risk treated with anticoagulant and antiplatelet
Warfarin-Aspirin in Symptomatic Intracranial Disease (WASID)
93
What is the result of TOSS trial
Adding of Cilostazol to ASA was superior to ASA monotherapy at 6 months
94
The incidence of stroke in DCM is indirectly proportional to
decline of EF
95
Pharmacologic therapy in hypertension in patient without stroke will reduce the risk by
32%
96
What is the result of TOSS-2 Trial
Non-significant trend toward ICAD progression observed in:
| ASA+Cilostazol compared with clopidogrem (9.9 vs 15.46%)
97
The effect of angioplasty and stenting despite aggressive medical therapy in ICAD
unknown and under investigational
98
This study confirmed the benefit of ACEi-based regimen in reducing the incidence of secondary stroke and MI
Perindopril Protection Against Recurrent Stroke Study
99
What anti cholesterol agent is not recommended
Fenofibrates
100
The following increases the risk of stroke risk beyond 3 months
Persistent myocardial disruption
CHF
AF
Mobile and protruding thrombus
101
What is the result of CLAIR study
Study on Clopidogrel + Aspirin for Infarction Reduction
102
An EF of 29-25 increase the annual stroke rate by
0.8%/year
103
The percentage of ischemic stroke patients who has pre-DM
28%
104
MS without AF and with AF increases risk for stroke by:
(-) AF: 1.5-4.7%
| (+) AF: 7-18 folds
105
Over-all risk for embolization in patient with MI
11% if with thrombus
| 2% if without thrombus
106
The risk of stroke in patient with MVP without AF
2%
107
Fatal bleeding rate of VKA per year
0.62/year
108
DM increases the risk of ischemic stroke by
1.5-3.7%
109
in 50-69% occlusion what is the benefit of CEA
Marginal benefit esp in male and elderly
110
What is the recommended agent used in patient with ICAD to prevent recurrent stroke
ASA
additional of cilostazol and clopidogrel is reasonable
111
What BP is associated with continuos association with stroke
> 140/90mmHg
112
Recommendation for secondary prevention with dyslipidemia
< 70 with clinical ASCVD: start on HIST or MIST
| >70 with clinical ASCVD: MIST or HIST
113
What medication is recommended for Lower extremity PAD
Antiplatelet
114
What is the result of Warfarin vs ASA in Reduced Cardiac EF (WARCEF)
no difference in event rate on primary outcome between the 2 groups
115
What is the preferred antihypertensive combination
Thiazide + ARB or ACEi or CCB
| CCB + ARB or ACEi
116
Recommendation for DCM in stroke prevention
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
What is the preoperative risk of stroke on the following:"
> 70% stenosis
70-99% stenosis
>70% : 3%
| 70-99% : 6%
118
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
Treat with LMWH or NOACs for 3 months
119
What is the first trial to investigate the effect of BP treatment for secondary stroke prevention
Post-Stroke Antihypertensive Study (PATS)
120
Niacin reduces stroke by how many percent
24%
121
Obesity is defined as
BMI >30
| WHR: > 1 men and >0.85 women
122
What is the management of patient who had stroke or TIA attributed to 50-69% ICAD
Medical management only
| Stenting and angioplasty not recommended
123
Management for restrictive cardiomyopathy
Systemic anticoagulation
124
The annual risk for thromboembolism among patient with prosthetic heart valve
20%
125
Mechanism of action of Statin
Reduce Cholesterol
Reduce inflammation
Promotes angiogenesis and neurogenesis
Upregulates endogenous TPA
126
Annual risk for stroke of intracranial stenosis
3-15%
