CVDRA Flashcards
When to screen gen population for cardiovascular risk (no sx or known risk factors)
Men - 45yo - 74yo
Women - 55yo - 74yo
When to screen Māori, Pacific or South-Asian for cardiovascular risk
Men - 30yo - 74yo
Women - 40yo - 74yo
When to screen people with personal or family risk factors for cardiovascular risk
Men - 35yo - 74yo
Women - 45yo - 74yo
When to screen people with diabetes (type 1 or 2) for cardiovascular risk
From diagnosis
When to screen people with severe mental illness for cardiovascular risk
From 25yo
What counts as severe mental illness for CVDRA early screening
Schizophrenia
Depression
Bipolar
Schizoaffective disorder
Addiction
Family risk factors for CVD
Hospitalisation or death from MI or stroke < 50 years in a first-degree relative
Diabetes in a first-degree relative
Familial hypercholesterolaemia
Patients with ________ (what conditions etc.) are at high risk of CVD and do not require screening but do require aggressive risk management
Prior cardiovascular event e.g. angina, CABG, MI, PCI, PVD, stroke, TIA
Familial hypercholesterolaemia
CHF
Diabetes with eGFR < 45
Stage 4 CKD (eGFR <30)
Asymptomatic carotid (plaque on carotid USS) or coronary disease (coronary artery calcium score >400 or plaque on CT angiography)
Modifiable risk factors for CVD
Smoking
BP
Alcohol
Nutrition
BMI > 30, or waist circumference >102 cm in men or >88 cm in women
Physical activity level
HbA1c 41 to 49
Non modifiable risk factors for CVD
Age and sex
Known CVD, asymptomatic carotid disease or cardiac disease, or at high risk of developing diabetes
Family history of CVD younger than 50 years
Genetic lipid disorder
eGFR < 60
AF
Diabetes
Gestational diabetes
Māori, Pasifika, or South Asian
HIV
Systemic lupus erythematosus (SLE)
Serious mental illness
Cut offs for low, intermediate and high CVD risk
Low <5%
Intermediate 5-15%
High >15%
General recommendations for management of low risk CVD
Medication not recommended (harm likely to exceed benefit)
General recommendations for management of intermediate risk CVD
Benefits & risks of BP and lipid lowering meds should be discussed and initiation of treatment considered
General recommendations for management of high risk CVD
BP and lipid lowering meds recommended
Consider aspirin for primary prevention of CVD if <70yo
If a patient has elevated BP, every 10 mmHg reduction in SBP = _____ relative reduction in CVD events
20%
Benefits of lowering BP greatest if ________ rather than those with highest BP
Multiple risk factors
Home BP readings are generally ______ lower than clinic-based measurements
5 – 10 mmHg
Home BP monitoring should be considered when…
White-coat hypertension is suspected
Marked variation between clinic measurements or between clinic and home
Medicine-induced hypotension is suspected
The patient is not responding to treatment, i.e. resistant hypertension is suspected
Advise patients performing home-based blood pressure monitoring to
Take BP after sitting for five minutes
Record two consecutive measurements, one minute apart
Take morning measurements before breakfast and before taking any medicines
Take evening measurements before going to bed and after taking medicines
Record obvious reasons for variations, e.g. illness, caffeine, smoking or recent exercise
A home BP level can be calculated using…
Average of their home measurements
Risk based approach to managing BP
Risk <5% = lifestyle modifications if BP ≥ 130/80. Medicines not recommended.
Risk 5-15% = discuss benefits and harms of medication if BP persistently ≥ 140/90
Risk ≥15% = medication strongly recommended if BP persistently ≥ 130/80
≥ 160/100 with any level of CVD risk = medication recommended
Lifestyle interventions for reducing BP
Reducing salt intake
Regular exercise of moderate intensity (e.g. 30min walk per day)
Alcohol intake within guidelines
Reducing salt intake can result in clinically significant reductions in BP in _________ (timeframe). The ideal daily intake of salt is thought to be _______.
~4 weeks
3 g
Frequent alcohol consumption may increase SBP by ________
5 – 10 mmHg
Regular exercise of moderate intensity, e.g. walking for 30min/day, can reduce SBP by ________ mmHg and diastolic by ______ mmHg
SBP 4 – 10
DBP 3 – 8
Alcohol recommended intake
Women: 2 std drinks/day; ≤ 10 std drinks/ week; ≥ 2 alcohol free days/week
Men: 3 std drinks/day; ≤ 15 std drinks/week; ≥ 2 alcohol free days/week
A standard drink is approximately how much beer/wine
330 mL of 4% beer
100 mL of 12.5% wine
Meta-analyses of RCTs show that every 1 mmol/L reduction in LDL from statin treatment =______reduction in the relative risk of major CVD events over five years
~25%
Who to treat with statins regardless of their CVD risk
TC:HDL ≥ 8
Familial hyperlipidaemia
Triglycerides ≥ 11 mmol/L
Which part of lipids is used when calculating CVD risk and which is used as a target once treatment started
TC:HDL is used when calculating CVD risk and to guide treatment decisions. Once treatment started, LDL levels are used to inform decisions about the intensity of lipid-lowering medicines.
Most effective dietary approach to lowering LDL while continuing to maintain/improve HDL is _________
Substitute saturated fats with mono- and polyunsaturated dietary fats.
Lipid management recommendations for CVRA <5% (low risk)
Lifestyle interventions recommended
Lipid-lowering medicines are not recommended
Lipid management recommendations for CVRA 5-15% (intermediate risk)
Benefits of treatment likely outweigh adverse effects. Discuss benefits/harms of statins and encourage dietary changes. If statins started, aim reduction in LDL ≥ 40%
Lipid management recommendations for CVRA >15% (high risk)
Statins strongly recommended + dietary changes. LDL target of < 1.8mmol/L
1st line treatment to lower lipids
Statins
Atorvastatin generally used first line in NZ
Blood test monitoring after starting lipids
Check lipids (non-fasting) every 6-12 months until target reached, then annually
LFTs not routinely required.
When to consider rosuvastatin in primary prevention
Maori/Pasifika peoples at risk of CVD
High CVD risk not meeting LDL target (<1.8) with max tolerated dose of atorvastatin/simvastatin
When to consider rosuvastatin in secondary prevention
If meets SA critera after treatment with max tolerated dose of atorvastatin/simvastatin:
Familial hypercholesterolemia not meeting LDL <1.8
Known CVD and not meeting LDL <1.4
Recurrent major cardiovascular event (MI, ischaemic stroke, coronary revascularisation, hospitalisation for unstable angina) in the last 2 years and LDL not <1.0
Is statin intolerance common?
Most people tolerate statins well and serious adverse effects are rare
Statin intolerance (esp myalgia) is over-diagnosed
Is there evidence of link between statins and cognitive impairment
No
What to do if adverse effects occur when starting statin?
Stop statin until sx resolves (e.g. 2-3 weeks) then re-start and monitor for return of sx.
If symptoms recur consider lowering the dose, alternate day dosing or switching to an alternative statin (rosuvastatin generally better tolerated)
Statins can have serious interactions with other medicines; be aware of the interaction between simvastatin and ________ which can result in rhabdomyolysis
Potent CYP3A4 inhibitors e.g. erythromycin, clarithromycin, azole antifungals and ciclosporin
When would you check CK in a patient on statins?
Only check CK if muscle pain, tenderness or weakness which could indicate myopathy
What to do if muscle pain & no rise in CK while on statin
Consider reducing the dose or discontinuing the statin but also consider re-challenging once symptoms subside
What to do if CK rise 3–10x above normal with symptoms while on statin
Reduce the dose or discontinue the statin and monitor symptoms and CK weekly
What to do if CK rise > 10x above normal with symptoms while on statin
Discontinue the statin immediately
When to worry about abnormal LFTs secondary to statin and what to do about it
Transaminases >3x upper limit → stop statin. Once LFT normalised consider re-trialing at lower dose or switching statin.
When to consider aspirin for primary prevention
< 70yo if five-year CVD risk is ≥ 15%
Asymptomatic carotid/coronary disease or plaque
When to consider aspirin for secondary prevention
Aspirin is recommended in all patients with established CVD for secondary prevention
If established CVD and needing aspirin but at high risk of GI bleed what should you do
Consider PPI
Aspirin contraindications
Active peptic ulceration, uncontrolled BP and other major bleeding risks
Aspirin hypersensitivity/intolerance
Severe hepatic or renal impairment
CVRA follow up = _______ review for people at high risk or intermediate risk managed with medication
Annual
CVRA follow up timing if not on medication
< 3% - 10 years
3 - 9% - 5 years
10 - 14% - 2 years
≥ 15% - 1 year
CVRA follow up if severe mental illness
CVDRA every 2 years (or annually if ≥ 15%)
