Coronary Heart Dz Flashcards
How often should patients be screened for coronary heart disease?
Assess every 5 years. All men 35-80 y/o and women 45-80 with 1 risk factor for CHD.
Risk factors: DM Cigarette Smoking BP >140/90 or prescribed anti-HTN drug Untreated cholesterol of >240 or on lipid lowering therapy HDL less than 40 in men, ,50 in women Family Hx of premature CHD
AHA 2006 statement on diet and lifestyle modifications
Cosume diet rich in fruits and veggies
choose whole grain, high fiber foods
consume fish, preferably oily fish at least 2 x week.
Limit intake of saturated fats to less than 7% of energy
Minimize foods with added sugars
Limit alcohol to 1 drink/day or less for women, 2 drinks for men.
How often should smoking status be assessed?
Every 2 years & preferably at every visit for active smokers.
Also ask about secondhand smoke exposure.
How often should weight and waist circumference be assessed?
Every 2 years.
How often should BP screening be done?
Assess at every visit and at least once every 2 years.
How often should Lipids be screened?
Every 5 years
Statin Meta-analysis..do they reduce total mortality?
No…2 Meta-analysis, 7 studies with at least 80% free of CVD at baseline, reduce MI and stroke, but not total mortality or CHD mortality.
11 studies (included Jupiter data) statins did not reduce all cause mortality, NO RELATIONSHIP between baseline LDL and relative reduction in mortality. hmmm? :)
Aspirin Use…When to recommend?
All patients with CAD, Stroke, PAD should be taking ASA 81 mg day.
Otherwise only use ASA for primary prevention if Framingham score is >20% (general primary care guidelines)
DM guidelines say >10% risk. If no risk assessment, men over 50, women over 60 with risk factors for CHD.
CKD statement says.”Aspirin may be useful for primary prevention of CVD in dialysis patients..”
Blood Pressure Goals
ADA/DM Guidelines target less than 130/80, initail therapy ACE or ARB. Administer one or more antihypertensive med at bedtime.
CKD goals 130/80, also preferred therapy ACE or ARB
Statins in DM patients? CKD patients? (Primary Prevention)
Statins should be recommended for patients with DM regardless of LDL concentrations in those >40 y/o and have at least 1 major risk factor for CVD.
ie FH, HTN, Smoking, Dyslipidemia, Alubminuria >30mg/24 hours.
CKD: insufficient evidence for statins for primary prevention in CKD.
ACCF/AHA guidelines- Aspirin Therapy for patients NOT undergoing PCI
NSTE & STEMI 162-325mg loading, then 75-100mg/day
P2Y12 Inhibitor Therapy for Secondary Prevention in patients NOT undergoing PCI (ACCF/AHA)
NSTE ACS: Clopidogrel 300 loading, then 75 mg daily for at least 1 month ideally up to 1 year.
Ticagrelor 180mg loading, then 90 mg twice daily for 6-12 months.
STEMI:
Clopidogrel 75 mg (if <75 y/o could use 300mg loading), then 75 mg day on days 2-14.
Management of Dual antiplatelet therapy in patients undergoing an invasive or surgical procedure. (with no prior PCI/stent)
Low risk of bleeding and CV events 1) continue low dose ASA, discontinue clopidogrel/prasugrel 7-10 days prior.
High risk of bleeding
Discontinue ASA
Discontinue clopidogrel 5 days prior or prasugrel at least 7 days before surgery.
High Risk of CV events and CABG
1) Continue ASA, Discontinue clopidogrel 5 days prior or prasugrel at least 7 days before surgery.
Discontinue ticagrelor at least 5 days prior to surgery
Risk Factors for bleeding.
These things are factored into the REACH bleeding Risk Score
Age, PAD, HF, DM, HLP, HTN, SMOKING, antiplatlelets prescribed, oral anticoagulant prescribed.
Statins after ACS events?
Recommended before hospital discharge regardless of LDL level.
True or False. Prospective trials have randomized patients into LDL goal groups?
FALSE!! No prospective trials have randomized patients to lower LDL treatment goals only higher and lower dose. Which is why the goals are crazy!! New guidelines will likely go with % lowering if LDL is even still our target.
Beta-blockers after ACS events? ACE-I?
Indicated for all patients after MI to be continued indefinitely.
ACE-I recommended for all patients with MI, continued indefinitely. Largest benefit seen for patients with reduced LVEF less than 40%. Those patients should be initiated on ACE-I w/i 24 hours.
When to use Aldosterone Antagonists?
For patients already receiving an ACE-I who have an LVEF of 40% or less and either heart failure or DM.
Often initiation occurs after hospital discharge at first outpatient appointment.
True or False. Nitrates have been shown to decrease morbidity and mortality post ACS events?
False, not indicated for secondary prevention. Are indicated for treatment of chronic stable angina.
Calcium Channel Blocker Role in ACS f/u?
Not indicated unless patient with contraindication to a b-blocker. Diltizem/Verapamile have evidence for decreasing proteinuria in DM…but if patient post ACS still probably more important to keep them on B-blocker if possible. Sometimes used in combo but use caution.
BP goal for HTN (JNC-7)
Less than 140/90 mmHG
ACS patients use ACE or Beta-blocker therapy.
Aspirin Recommendations in PCI
BMS & DES: 325 before PCI, then 81mg indefinitely
Bare Metal Stent (BMS) P2Y12 Inhibitor Therapy
Clopidogrel 600 mg loading, then 75 mg daily for at least 1 month ideally 1 year. unless increased bleeding risk then should be given for 2 weeks.
Prasugrel 60 mg loading, then 10mg daily for 12 months unless patient at increased bleeding risk then 2 weeks. Consider dose reduction to 5mg daily for patients <60 Kg. C/I in patients with prior stroke or TIA
Ticagrelor 180 mg loading, then 90 mg BID for 12 months unless increased bleeding risk then should be given for 2 weeks.
Drug Eluding Stent (DES) P2Y12 Inhibitor Therapy
Clopidogrel 300-600 mg loading, then 75 mg daily for at least 1 year.
Prasugrel 60 mg loading, then 10mg daily for 12 months. Consider dose reduction to 5mg daily for patients <60 Kg. C/I in patients with prior stroke or TIA
Ticagrelor 180 mg loading, then 90 mg BID for 12 months.
STEMI nonprimary PCI
Clopidogrel 300-600 mg loading if fibrinolytic administered. If fibrinolytic not administered initiate therapy as above for PCI. Length of treatment per stent type DES or BMS.
Surgery on Dual Anti-platelet therapy post PCI-2012 ACCP Chest Guidelines
- Aspirin should be continued.
- Elective surgery should be deferred if possible for at least 6 weeks after BMS and 6 months have DES placement.
- Patients with BMS who require surgery w/i 6 weeks, should continue clopidogre/prasugrel.
- If >6 weeks after BMS stent, but not 6 months, just continue aspirin and discontinue clopidogrel/prasugrel 5 days before sugery.
- DES patients who require surgery w/i 12 months of placement should continue clopidogrel/prasugrel.
