CVD

Question 1

What is the CHA2DS2-VAS score?

Answer 1

• a risk of stroke in those with non-rheumatic AF:
  
  • Congestive HF = 1
  • Hypertension = 1
  • Age >75 = 2
  • DM = 1
  • Stroke = 2
  • Vascular disease (MI, PAD, aortic plaque) = 1
  • Age 65-74 = 1
  • Sex category = 1
• Warfarin or NOAC if CHADVASc score >2
• If zero use aspirin alone or no antithrombotic therapy If it’s 1 oral anticoagulant (not aspirin)

Question 2

What are some HTN treatments? What are the classes and their side effects?

Answer 2

• ACE I (conversion of ang 1- ang 2)
  
  • cough common
  • renal impairment
  • angioedema
  • low sodium
• ARB
  
  • not with ACE I as increases hypotensive symptoms without BP effect)
• CCB (verapamil - central action non-dihydropyridines)
  
  • contraindicated in beta-blockers (already ionotropic) - heart block
  • can’t use in HF - oedema,
  • flushing
  • can cause constipation
  • palpitations, bradycardia
• Beta-blockers
  
  • useful in heart failure and AF
  • can’t use in asthma
  • bradycardia
  • weight gain and insulin resistance
• Thiazide diuretics
  
  • in fluid retention
  • increased risk of new onset diabetes
  • kidney trouble (care in gout)

1. Most effective - ACEI + Ca2+ channel blocker (best profile) Likely side effects/concerns? Cough, peripheral oedema and bradycardia
2. If she had heart failure - use ACEI + thiazide
3. If she has MI/HF - use ACEI + Beta blocker
4. If she has angina - use Beta blocker + Ca2+ channel blocker
5. In Diabetics - avoid thiazides and Beta blockers - (affect glucose metabolism)

Question 3

What are the treatments for Heart Failure?

Answer 3

Non-pharm:

• limit alcohol
• monitor weight
• educate patient
• MDC meetings - dietician, rehab, palliative care

Proven medications:

• normalise volume - ACE I early and ARB if they can’t take i
• Beta-blockers (chronic not acute)
• digoxins and nitrates
• new - sacubitril/valsartan - ARB and neprilysin inhbitor (inhibits bradykinin)

Question 4

a 35 year old women is referred with hypertension. She is thin and has a blood pressure of 168/100mmHg and her potassium is 3.0mmol/L. What is the diagnosis?

Answer 4

Conn’s syndrome

• young
• HTN
• low potassium
• primary hyperaldosteronism

Question 5

A 48 year old man is seen is hospital with malaise. HTN and previously started on ACE I by GP. Now his serum urea is 30.0 and creatinine 250. Whats the diagnosis?

Answer 5

Renal Artery Stenosis

• often precipitates declining renal function by ACEI

Question 6

Talk through the screening for CVD for different populations

Answer 6

• absolute cardiac risk assessment every 2 years from 45 in normal or 35 for indigenous
• BP every 2 years or 6-12months if higher risk 18 onwards.
• cholestrol every 5 years or every 2 years for increased risk. (45 or 35 if indigenous)
• diabetes every 3 years or every 12mths if IGT (18 for indigenous, 40 onwards for normal).

Question 7

Warfarin Counselling, what would you the tell and advise the patient?

Answer 7

• large doses of vitamin K will reverse the effects of warfarin
• initially affecting Protein C and S (shorter half life) might have a progulation (5-7 day process) - especially if you have a congenital deficiency of these. Anticoagulation in initial phase.
• daily INR in the initial phase but once stabilised can measure 1x a month
• CI - liver inability to synthesize clotting proteins, thrombocytopenia, oesophageal varices
• CYP2C9 drug interference i.e. metronidazole
• antibiotics affect the normal flora and therefore the normal vit K production
• they are on it for:
  
  • prosthetic valves
  • AF
  • DVT prophylaxis
• teratogenic (avoid in pregnancy)
• history of falls is a strong Relative CI

Question 8

What are the GP targets for cholestrol? Whats a good way to remember them?

Answer 8

Lipid Lowering therapy should be aiming for:

• total cholestrol <4mmol/L
• LDL cholestrol <2mmol/L
• TG <2mmol/L
• HDL >1mmol/L

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