CVD prevention Flashcards
What is cardiovascular disease?
CVD is a group of heart and blood vessel disorders, including CAD, stroke, hypertension, heart failure, PAD, and arrhythmias.
What is the CVD impact on the UK?
Leading cause of death (~160,000 annually), major hospital admissions, disability, and healthcare costs.
Stages of atherosclerosis
1️⃣ Fatty streak formation: LDL accumulation infiltrates arterial wall, foam cell formation.
2️⃣ Plaque development: Continued lipid accumulation and inflammation, thickens arterial wall.
3️⃣ Plaque progression: Smooth muscle cells migrate, fibrous cap formation over fatty core.
4️⃣ Rupture: If fibrous cap weakens, clot formation, leading to heart attack or stroke.
Key processes in atherosclerosis stages
Endothelial dysfunction: Inner blood vessel lining damage reduces nitric oxide, increasing stiffness.
LDL oxidation: LDL becomes oxidised, triggers immune response, foam cell formation.
Inflammation: Mediated by macrophages and cytokines promote plaque growth.
CVD risk factors
⚠️ Modifiable: Hypertension, high cholesterol, smoking, diabetes, obesity, inactivity, poor diet, alcohol, stress.
⏳ Non-Modifiable: Age, sex, family history, ethnicity, genetics.
Absolute CVD risk assessment definition and importance
📉 Definition: Probability of a CVD event in 10 years.
🔍 Importance: Identifies high-risk individuals for early intervention.
CVD risk calculators
QRISK3: 10-year risk, includes risk factors like chronic kidney disease and mental illness.
JBS3: Estimates lifetime risk, useful for younger individuals.
ASSIGN: Includes social deprivation as a risk, used in Scotland.
CVD primary vs secondary prevention
Primary: Prevents first CVD event via lifestyle changes (statins for high risk individuals).
Secondary: Prevents further events in diagnosed patients via meds (statins, beta-blockers, antiplatelets).
What are the differences between QRISK3 and JBS3 risk calculators?
QRISK3: 10-year risk, considers additional conditions.
JBS3: Lifetime risk, ideal for younger individuals not showing high short-term risk.
Why is smoking cessation crucial in CVD?
Damages blood vessels, promotes atherosclerosis, raises BP.
Reduces oxygen delivery via carbon monoxide in blood.
Benefits seen within a year of quitting.
How does hypertension cause CVD?
Damages endothelium, increasing arterial stiffness.
Speeds up atherosclerosis, raising heart attack/stroke risk.
Chronic HTN leads to left ventricular hypertrophy, impairing heart function.
Role of statins in CVD prevention:
Primary
Secondary
Primary: Lowers cholesterol, slows atherosclerosis.
Secondary: Reduces recurrence risk, lowers cholesterol, stabilizes plaques.
How many people in the UK estimated to have CVD? Approx. how many prescriptions are dispensed for statins in the UK? What is the estimated annual cost of CVD in England?
7 million
70 million
£7.4 million
According to the NHS long term plan, what percentage risk should people aged 40-74 have to be considered for lipid lowering regimen?
20% or greater risk
What is the underlying cause of CVD?
Atherosclerosis and thrombosis
What disorders are included under the umbrella term “cardiovascular disease (CVD)”?
- Coronary heart disease
- Ischemic heart diseases (IHDs)
- Acute coronary syndrome (ACS)
- Stroke
- Peripheral arterial disease
- Aortic disease
What are the two categories preventative strategies for CVD are described under?
- Primary Prevention: Preventing CVD in patients who have not yet developed clinical cardiovascular disease.
- Secondary Prevention: Preventing recurrent events in patients who have already suffered a clinical CV event.
What process primarily causes cardiovascular disease? What process often exacerbates cardiovascular disease related luminal narrowing of arteries?
Luminal narrowing of arteries by atherosclerosis
Superimposed thrombosis
What is the function of high-density lipoproteins (HDL) in maintaining healthy arteries?
Reverse cholesterol transport
Atherosclerosis is initiated by a combination of what two types of injury?
Metabolic: increased levels of LDL-cholesterol and oxidative stresses (smoking)
Physical: hypertension
In atherosclerosis, the oxidation of lipoproteins in the sub-endothelial space leads to what type of response?
What does plaque fissure expose, leading to platelet aggregation?
Inflammatory
Sub-endothelial tissues
What is the first step in the simplified process of atherosclerosis? In the development of atherosclerosis, LDL that enters damaged areas is engulfed by macrophages, forming what? During plaque formation, which cells create a fibrous cap over the fatty deposit? Ruptured plaque triggers what process, leading to heart attacks and stroke?
Endothelial injury
Foam cells
Smooth muscle cells
Thrombosis
What are the major modifiable risk factors for cardiovascular disease?
- Smoking
- Dyslipidaemia
- Hypertension
- Diabetes mellitus
- Obesity
- Physical inactivity
What are the non-modifiable risk factors for the development of CV Disease?
- Age
- Gender (M>F)
- Ethnicity (e.g. South Asian)
- Family History
- History of a previous cardiovascular event
In CV disease prevention, what kind of assessment guides decisions about lifestyle or drug treatment?
Absolute cardiovascular risk (risk of major CV event in 5-10 years)
Management of CV conditions
Which risk calculator is recommended by NICE clinical guideline 238? What additional risk factors are included in the calculator?
QRISK®3
CKD, SLE, migraine, and others
Which risk assessment tool is endorsed by the Joint British Society and calculates heart age? What is an advantage of this risk assessment if a patient has a 10-year CVD risk of less than 10%?
JBS3 risk
Assess lifetime risk
What population is the ASSIGN risk calculator tailored to? What factors are used in the ASSIGN calculator to estimate cardiovascular risk? What other factors should you consider that are not included in the ASSIGN CVD risk assessment calculator?
Scottish
Age, sex, smoking, systolic BP, lipid profile
Ethnicity, BMI, AF, psychological wellbeing, inactivity
Why is it important to use absolute risk assessment in cardiovascular risk management?
Factors can be cumulative or additive
What percentage of Britons have 3 or more modifiable risk factors for CVD?
Over 65%
What factors are targeted in primary prevention strategies?
- Smoking
- Diet
- Dyslipidaemia
- Hypertension
- Diabetes mellitus
- Physical activity
- Low dose Aspirin? (N.B. NOT for primary prevention?)
What factors are considered in secondary prevention?
- Antiplatelet therapy (Low dose aspirin or other antiplatelets)
- Statin therapy
- Beta blocker therapy
- ACE Inhibitor therapy
Which Scottish Intercollegiate Guidelines Network (SIGN) guideline addresses risk estimation and the prevention of cardiovascular disease?
SIGN 149
What lifestyle advice should be given to a patient with high CVD risk (>15% abs CV risk)?
- Frequent and sustained specific advice and support about diet and exercise.
- Appropriate advice and pharmacotherapy about smoking cessation.
- Advice given simultaneously about BP and lipid lowering drug treatment.
What pharmacological intervention is recommended for high-risk CVD patients (>15% abs CV risk), unless contraindicated?
Lipid and BP lowering agents
Is aspirin routinely recommended for primary prevention in high-risk CVD patients?
No
What is the general BP target for people with CKD? What is the BP target for people with diabetes?
<140/90 mmHg
<130/80 mmHg
What are the lipid targets?
<4mmol/L Total Cholesterol
<2mmol/L LDL Cholesterol
>1mmol/L HDL Cholesterol
<2mmol/L Triglycerides
How often should response to lifestyle and medication be reviewed until targets reached? How often should CV risk be reviewed in moderate risk (10-15% abs CV risk) individuals? For low-risk individuals (<10% abs CV risk), how often should CV risk be reviewed?
Every 6-12 weeks
Every 6-12 months
Every 2 years
What dietary advice should be given to patients?
Consume varied diet rich in vegetables, fruit, wholegrains, lean meat, poultry, fish, eggs, nuts and seeds, legumes and beans, low fat diary (n.b. care re:low fat but high sugar products)
What is the recommended daily salt intake? What is the recommended upper limit of alcohol intake? What duration of moderate intensity physical activity is recommended most days? What are the recommended weight goals?
<6g per day
<2 standard drinks per day
30 mins
BMI <25, waist circumference <94cm male (<90cm Asian males) or <80cm female (including Asian females)
What should be offered alongside lipid-lowering therapy if a patient’s BP is persistently >160/100mmHg?
Lifestyle advice
What are the effects of smoking on atherosclerosis risk?
Decreased HDL, increased platelet aggregation, etc.
How does smoking affect the sympathetic nervous system? What kind of relationship exists between smoking and MI? How much higher is the risk of MI for heavy smokers compared to non-smokers?
Inappropriate stimulation
Strong dose link
4x risk
How long does it take for CHD risk to decrease after stopping smoking?After how many years of quitting smoking is the CHD risk approximately equal to that of someone who has never smoked?
2-3 years
Within months
2-3 years
What is the first-line pharmacotherapy for smoking cessation? What pharmacotherapy should be considered if someone smokes >10 cigarettes per day?
Nicotine replacement therapy (NRT)
When are NRT patches considered safe in relation to cardiovascular disease? When are NRT patches not recommended?
In less severe CVD (stable angina, Hx of MI)
Unstable angina, recent MI, etc.
How does hypertension increase sheer stress?
May lead to plaque rupture
What is the blood pressure goal for adults with CHD and/or diabetes and/or CKD and/or proteinuria >300mg/day and/or Stroke/TIA? What is the blood pressure goal for adults with proteinuria >1g/day?
<130/80mmHg
125/75mmHg
What are the believed effects of hypertension on vessels?
Cause endothelial damage, enhance lipoprotein migration
Why do women have a lower rate of CHD than men before menopause?
Higher levels of HDL-cholesterol (protective)
What diseases does obesity increase the risk of?
Type II diabetes, hypertension, dyslipidaemia, etc.
How much higher is the risk of CHD in obese women compared to lean women, according to the Nurses Health Study?
2-3x
What type of obesity is more significant than generalized or peripheral obesity?
Abdominal adiposity
What proportion of total energy intake should come from saturated and trans fatty acids? What types of fats should be eaten in moderation?
No more than 7%
Poly/monounsaturated fats
What is the alcohol intake limit for hypertensive patients?
Two (men) or one (women) standard drinks
How much does diabetes increase mortality with CHD in men? How much does diabetes increase mortality with CHD in women?
2-3x
6x
How might the metabolic effects of NIDDM (non-insulin-dependent diabetes mellitus) affect atherogenesis?
May affect atherogenesis
What medication should be started in patients with diabetes with proteinuria?
ACEI or angiotensin II receptor blocker
To whom does secondary prevention in CHD usually apply?
People who have survived an MI
What conditions can secondary prevention apply to?
Angina, angioplasty, stenting, CABG, nonSTEMI
What antiplatelet agent should all patients be taking for secondary prevention unless contraindicated?
Aspirin (75-150mg per day)
Why should aspirin be taken at a higher dose with caution? When is Clopidogrel an alternative to aspirin? In which patients should clopidogrel be considered in combination with aspirin? And when is it recommended?
Greater risk of SEs
When aspirin is C/I
With recurrent ischaemic events
In the acute management of STEMI and high-risk NSTEACS
How long should Clopidogrel be given after fibrinolytic therapy? How long should Clopidogrel be given after stent implantation?
At least 1 month
Up to 12 months
Secondary prevention: when should ACE Inhibitors be used in post-MI patients? When should chronic therapy with ACE inhibitors be considered?
Treat all patients indefinitely and start early in high risk patients
With or at high risk of other vascular events
Secondary prevention: when should angiotensin II receptor blockers be used? When should Beta Blockers be started in post-acute coronary syndrome patients? Which beta blockers provide survival benefits in mild-moderate heart failure patients already taking ACEIs?
For patients who develop unacceptable side effects with ACEIs
Start in most patients and continue indefinitely
Carvedilol, Bisoprolol and Metoprolol
When are statins recommended for patients with coronary heart disease?
Regardless of total or LDL cholesterol levels
What are fibrates effective for lowering? What are the risks of combining a statin and fibrate? What are fibrates effective for raising?
Triglyceride levels
Hazardous (myopathy) and specialist advice required
HDL-C levels
When is Warfarin recommended for survivors of MI? Why isn’t Warfarin used in ALL patients post MI? When might Warfarin be used in combination with aspirin?
High risk of systemic thromboembolism
Because only recommended for high risk patients
For high risk patients - monitor closely for bleeding
Why is routine use of antiarrhythmics post-acute coronary syndrome not recommended? What should be carefully balanced when considering antiarrhythmics?
Potential fatal pro-arrhythmic effect
Benefits with risks
