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CVD Part 1 Flashcards

1
Q

D.C is an 82 year old woman with hypertension, stable ischemic heart disease (MI in 2021), and rheumatoid arthritis. First-line options to manage her hypertension include:
a. ACEI or ARB, beta-blocker, nitroglycerin patch
b. ACEI or ARB, CCB, thiazide diuretic
c. ACEI or ARB, beta-blocker
d. CCB, beta-blocker
e. ACEI or ARB, beta-blocker, spironolactone

A

c.

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2
Q

What to know about HTN in older adults? (4)
(Incidence, ISH, physiological changes, BP reduction)

A
  1. Incidence ↑ with age
    - Framingham study – lifetime risk of developing hypertension is > 90%
  2. Primarily Isolated Systolic Hypertension (ISH)
    - SBP more closely correlated with CV risk in pts > 50 y
  3. Physiological changes
    - ↓ Baroreceptor response
    - Impaired cerebral autoregulation
  4. Avoid overly-aggressive BP reductions
    - Risk of tissue hypoperfusion and ischemia
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3
Q

There is good evidence from multiple epidemiological and clinical studies that lowering high blood pressure (>160mmHg) decreases risk of: (6)

A
  1. Heart attacks
  2. Strokes
  3. Sudden cardiac death
  4. Heart failure
  5. Peripheral artery disease
  6. End-stage renal disease
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4
Q

How is HTN related to dementia? (2)

A
  1. Epidemiological studies have shown that elevated blood pressure in middle-age ↑ risk for cognitive impairment in later life
  2. Short-term clinical intervention studies of treating hypertension in older adults have not shown ↓ dementia risk
    - Often stopped early due to superiority in CV-endpoint risk reduction (SPRINT-MIND)
    - SPRINT-MIND showed ↓ risk of mild cognitive impairment with intensive (<120) vs standard (<140) BP control over 5 years
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5
Q

What health behaviour management can be done to help reduce HTN in older adults? (5)

A
  1. Reduce alcohol intake (abstain)
  2. DASH diet
  3. Smoking cessation
  4. Others may be somewhat less practical in older adults, particularly if frail
    - Caution when advising weight reduction
    - Sodium restriction may result in hyponatremia, orthostatic hypotension
  5. Physical activity should continue to be encouraged
    - Consideration for necessary safety modifications
    - PT consultation?
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6
Q

How to take blood pressure properly? (9)

A
  1. Sitting position
  2. Back supported
  3. Arm bare and supported
  4. Use a cuff size appropriate for your arm
  5. Middle of the cuff at heart level
  6. Lower edge of cuff 3cm above elbow crease
  7. Do not talk or move before or during the measurement
  8. Legs uncrossed
  9. Feet flat on the floor
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7
Q

Someone aged 75+ years is considered a high-risk patient. What is the BP threshold for initiation of antihypertensive therapy? What is the BP treatment target?

A

Threshold: >=130 SBP mmHg
Target: <120 SPB mmHg

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8
Q

What is orthostatic hypotension defined as?

A

> =20 mmHg systolic and/or >=10 mmHg diastolic decrease in BP within 1-3 minutes of standing

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9
Q

What risk factors are associated with orthostatic hypotension? (4)

A
  1. Falls
  2. Hospitalizations
  3. CV events
  4. Functional decline
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10
Q

Orthostatic hypotension is associated with: (5)

A
  1. Increased age
  2. Diabetes
  3. Parkinson’s disease
  4. Dementia
  5. Medications
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11
Q

SPRINT Elders excluded patients with SBP of:

A

< 100 mmHg after 1 min of standing

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12
Q

What is our diastolic BP cutoff when decreasing?

A

Avoid decreasing DBP to <= 60 mmHg in individuals with established coronary artery disease.

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13
Q

How should we take fraility and functional status into account when decreasing blood pressure? (4)

A
  1. Older adults with severe functional impairment and dementia have been excluded from trials like SPRINT
  2. Risks and treatment burden of intensive BP control may outweigh benefits in these patients
  3. Also consider time to benefit of more intensive treatment (~2.5 years)
    - Is this timeframe applicable to your patient?
  4. Patient/family preference
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14
Q

Clinical frailty score of 1-3, how are we treating HTN? (4)

A
  1. Therapeutic approach similar to younger adults with treatment goal: SBP 120-140mmHg
  2. Start with monotherapy and titrate antihypertensive medication cautiously
  3. Always check for orthostatic hypotension
  4. Optimize treatment for global CVD prevention
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15
Q

Clinically frailty score of 4-5, how are we treating HTN?

A

Detailed Frailty/Function assessment in order to tailor antihypertensive treatment and CVD prevention weighing benefits vs. risks. Can split into two paths:
1. Moderately altered functional status –> do frailty 1-3 treatment
2. Significantly altered functional status –> do frailty 6-9 treatment

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16
Q

Clinical frailty score of 6-9, how are we treating HTN? (4)

A

Reconciliation and revision of the antiHTN therapy
1. If antiHTN treatment is considered, start with one drug at low doses and go slow, SBP goal 150mmHg; avoid using more than 3 antiHTNsive medications
2. If SBP < 130 mmHg or orthostatic hypotension under treatment
3. Consider reducing antiHTNsive treatment, especially in the case of combination therapy
4. Identify/correct other factors/medication decreasing BP

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17
Q

To summarize, when do we reconsider intensive BP targets? (5)

A
  1. Functional dependency, limited life expectancy, dementia
  2. Orthostatic hypotension
  3. Diastolic hypotension + CAD
  4. SPRINT Exclusion Criteria: Diabetes, HF, history of stroke, recent MI
  5. Patient/family preference
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18
Q

Choosing antiHTNsives in older adults:
“Is there a compelling indication for one or more of the antiHTNsive agents?”
What do we do when answer is yes? How about no?

A
  1. Yes = choose agent(s) according to compelling indication
  2. No = choose agents for isolated systolic HTN
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19
Q

What are the compelling indications for antiHTNsives? (7)

A
  1. Isolated systolic hypertension
  2. Diabetes with microalbuminuria, CKD, cardiovascular disease or other cardiovascular risk factors
  3. Recent MI
  4. Coronary artery disease
  5. Heart failure with reduced ejection fraction
  6. Previous stroke or TIA
  7. Non-diabetic CKD with proteinuria
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20
Q

What is initial therapy (first-line) antiHTNsive for diastolic HTN with or without systolic HTN? (8)

A

Monotherapy:
1. TZDs or TZD-likes
2. Beta-blockers
3. ACEis
4. ARBs
5. Long-acting CCBs
SPC choices include combinations of:
1. ACEi with CCB
2. ARB with CCB
3. ACEi/ARB with a diuretic

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21
Q

What is initial therapy (first-line) antiHTNsive for isolated systolic HTN without other compelling indications? (3)

A
  1. TZDs or TZD-likes
  2. ARBs
  3. Long-acting DHP-CCBs
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22
Q

What is initial therapy (first-line) antiHTNsive for diabetes mellitus with microalbuminuria, renal disease, CVD, or additional CV risk factors? (1)
How about initial therapy (first-line) for diabetes without factors listed above? (4)

A
  1. ACEi/ARBs
    Without factors:
  2. ACEi
  3. ARBs
  4. DHP-CCBs
  5. TZD and TZD-likes
23
Q

What is initial therapy (first-line) antiHTNsive for coronary artery disease? (4)

A
  1. ACEis
  2. ARBs
  3. Beta-blockers
  4. CCBS for patients with stable angina
24
Q

What is initial therapy (first-line) antiHTNsive for recent myocardial infarction? (1)

A
  1. Beta-blockers and ACEis (ARBs if ACEi intolerant)
25
What is initial therapy (first-line) antiHTNsive for heart failure? (3)
1. ACEi/ARB 2. Beta-blockers 3. MRA may be added for pts with a recent CV hospitalization, acute MI, elevated BNP or NT-proBNP level, or NYHA Class II to IV symptoms
26
What is initial therapy (first-line) antiHTNsive for left ventricular hypertrophy? (4)
1. ACEi 2. ARB 3. Long-acting CCB 4. TZD and TZD-likes
27
What is initial therapy (first-line) antiHTNsive for past stroke or TIA? (1)
1. ACEi and TZD/TZD-like diuretic combination
28
What is initial therapy (first-line) antiHTNsive for non-diabetic CKD with proteinuria? (2)
1. ACEi (ARBs if ACEi-intolerant) if there is proteinuria 2. Diuretics as additive therapy
29
What is initial therapy (first-line) antiHTNsive for peripheral arterial disease? (1)
Does not affect initial treatment recommendations
30
What are 2 things to evaluate if pt has persistently high BP despite treatment?
1. Adherence 2. Secondary causes of HTN (medications, perhaps NSAIDs)
31
What to watch for/monitor when older pt is on diuretics? (3)
1. Monitor electrolytes, specifically Watch for: 2. Orthostatic hypotension 3. Worsening urinary urgency/incontinence
32
What to know about chlorthalidone and HCTZ? What to know about TZD/TZD-like diuretics?
1. Chlorthalidone (1.5-2x) more potent than HCTZ --> monitor electrolytes 2. TZD/TZD-like diuretics increase gout risk
33
What to monitor when using ACEi/ARBs?
Potassium
34
Should ACEi/ARB be combined?
Not recommended
35
CCBs - all long-acting agents can be considered when? (3)
1. For uncomplicated HTN 2. Stable angina 3. Left-ventricular hypertrophy
36
CCBs and edema. What to know?
Can cause or exacerbate peripheral edema, especially at higher doses - Can try to split dosing or dosing HS to minimize
37
What class is amlodipine?
DHP CCB
38
What class is diltiazem and verapamil?
Non-DHP CCB
39
Beta-blockers not recommended as first-line antiHTNsive for adults _ __ _____
> 60 years
40
Beta-blockers are still recommended in older adults if compelling indications exist: (3)
1. Post-MI 2. HF with reduced ejection fraction (HFrEF) 3. Control heart rate in afib
41
What ADEs can beta-blockers cause? (2)
1. May cause fatigue 2. Decreased exercise tolerance
42
Statins and secondary therapy. Do we use?
General consensus: Statins should be started/continued for secondary prevention of cardiovascular events regardless of age and in mild-moderate frailty
43
Time to benefit of statin for secondary prevention?
~2 years
44
Statins and primary prevention. Do we use?
Lack of evidence to support who should receive statin therapy for primary prevention of CV events - PREVENTABLE and STAREE clinical trials ongoing – will hopefully provide some clarity
45
B/c there is a lack of evidence for using statins and primary prevention, shared-decision making is important. What to take into consideration? (5)
1. CV risk factors 2. Functional status 3. Medication/treatment burden 4. Statin-associated adverse effects 5. Desire to take more/less medications
46
High vs. Moderate intensity statin therapy. What to know? (3)
1. Evidence to support high-dose statins (e.g. atorvastatin 80 mg/d) vs lower doses (e.g. atorvastatin 10 mg/d) for certain high-risk patient groups - Post-MI, post-stroke 2. However, older adults more susceptible to statin adverse effects: - Myalgias, GI upset, fatigue, ↑ risk of acute kidney injury - Rare case reports of statin-associated cognitive impairment -- Reversible on statin discontinuation! 3. Moderate-dose statins may be preferred in this patient population - Especially outside of the acute post-event period (i.e. 1 year) - E.g. rosuvastatin 10 mg/d, atorvastatin 20 mg/d
47
What is stable coronary artery disease? (2) What type of prevention is it considered?
1. Stable angina, previous acute coronary syndrome (STEMI, non-STEMI, unstable angina), previous percutaneous coronary intervention (+/- stents) or coronary artery bypass grafting 2. Signs, symptoms, or complications of inadequate blood flow to heart muscle due to atherosclerosis 3. Considered secondary cardiovascular disease prevention
48
What are 4 considerations for stable coronary artery disease?
1. Time since event 2. Symptom stability 3. Activity level 4. Patient goals and preferences
49
What is the medication cocktail given after an acute coronary syndrome? (6)
1. Aspirin indefinitely 2. Statins 3. Beta-blockers 4. ACEi/ARB 5. CCBs 6. Nitrates
50
What alternatives to aspirin after acute coronary syndrome?
1. Clopidogrel if contraindicated aspirin 2. Consider adding PPI if history of GI bleed
51
What to know about beta-blockers after acute coronary syndrome? (3)
1. Evidence of ↓ cardiovascular risk up to 3 years post-MI 2. Titrate to resting heart-rate of ~60 bpm 3. After this timeframe, re-evaluate based on symptoms and comorbidities - Indicated indefinitely for heart failure with reduced ejection fraction - Reasonable to continue if angina symptoms, atrial fibrillation requiring rate control - If poorly tolerated -> re-evaluate if > 3 y post-MI
52
What to know about ACEi/ARBs after acute coronary syndrome? (2)
1. Recommended for all individuals with stable coronary artery disease and hypertension, diabetes, heart failure with reduced ejection fraction, or chronic kidney disease 2. Continue indefinitely as tolerated
53
What to know about CCBs after acute coronary syndrome? (2)
1. Angina if beta-blockers contraindicated or not tolerated 2. Diltiazem or verapamil may also be used for rate control in atrial fibrillation
54
What to know about nitrates (short-acting and long-acting) after acute coronary syndrome? (2)
1. Short-acting nitroglycerin for rescue or prophylactically prior to activities which provoke symptoms - Watch for dizziness, headache, hypotension, flushing, edema - Ensure using properly 2. Long-acting nitrates may be added when beta-blockers and/or calcium-channel blockers are contraindicated, not tolerated, or not providing adequate symptom relief - Monitor blood pressure carefully - Ensure adequate (12-h) nitrate-free period

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