Coronary Heart Dz

Question 1

How often should patients be screened for coronary heart disease?

Answer 1

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

Question 2

AHA 2006 statement on diet and lifestyle modifications

Answer 2

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.

Question 3

How often should smoking status be assessed?

Answer 3

Every 2 years & preferably at every visit for active smokers.

Also ask about secondhand smoke exposure.

Question 4

How often should weight and waist circumference be assessed?

Answer 4

Every 2 years.

Question 5

How often should BP screening be done?

Answer 5

Assess at every visit and at least once every 2 years.

Question 6

How often should Lipids be screened?

Answer 6

Every 5 years

Question 7

Statin Meta-analysis..do they reduce total mortality?

Answer 7

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? :)

Question 8

Aspirin Use…When to recommend?

Answer 8

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..”

Question 9

Blood Pressure Goals

Answer 9

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

Question 10

Statins in DM patients? CKD patients? (Primary Prevention)

Answer 10

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.

Question 11

ACCF/AHA guidelines- Aspirin Therapy for patients NOT undergoing PCI

Answer 11

NSTE & STEMI 162-325mg loading, then 75-100mg/day

Question 12

P2Y12 Inhibitor Therapy for Secondary Prevention in patients NOT undergoing PCI (ACCF/AHA)

Answer 12

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.

Question 13

Management of Dual antiplatelet therapy in patients undergoing an invasive or surgical procedure. (with no prior PCI/stent)

Answer 13

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

Question 14

Risk Factors for bleeding.

Answer 14

These things are factored into the REACH bleeding Risk Score

Age, PAD, HF, DM, HLP, HTN, SMOKING, antiplatlelets prescribed, oral anticoagulant prescribed.

Question 15

Statins after ACS events?

Answer 15

Recommended before hospital discharge regardless of LDL level.

Question 16

True or False. Prospective trials have randomized patients into LDL goal groups?

Answer 16

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.

Question 17

Beta-blockers after ACS events? ACE-I?

Answer 17

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.

Question 18

When to use Aldosterone Antagonists?

Answer 18

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.

Question 19

True or False. Nitrates have been shown to decrease morbidity and mortality post ACS events?

Answer 19

False, not indicated for secondary prevention. Are indicated for treatment of chronic stable angina.

Question 20

Calcium Channel Blocker Role in ACS f/u?

Answer 20

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.

Question 21

BP goal for HTN (JNC-7)

Answer 21

Less than 140/90 mmHG

ACS patients use ACE or Beta-blocker therapy.

Question 22

Aspirin Recommendations in PCI

Answer 22

BMS & DES: 325 before PCI, then 81mg indefinitely

Question 23

Bare Metal Stent (BMS) P2Y12 Inhibitor Therapy

Answer 23

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.

Question 24

Drug Eluding Stent (DES) P2Y12 Inhibitor Therapy

Answer 24

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.

Question 25

STEMI nonprimary PCI

Answer 25

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.

Question 26

Surgery on Dual Anti-platelet therapy post PCI-2012 ACCP Chest Guidelines

Answer 26

1. Aspirin should be continued.
2. Elective surgery should be deferred if possible for at least 6 weeks after BMS and 6 months have DES placement.
3. Patients with BMS who require surgery w/i 6 weeks, should continue clopidogre/prasugrel.
4. If >6 weeks after BMS stent, but not 6 months, just continue aspirin and discontinue clopidogrel/prasugrel 5 days before sugery.
5. DES patients who require surgery w/i 12 months of placement should continue clopidogrel/prasugrel.