Macrovascular Flashcards
What four classes of anti hypertensives are preferred? In no particular order and in patients with no CV disease or CKD.
Thiazides
ACE
ARB
Dihydropyridine Ca blockers. Ie: amlodipine, nifedepine, felodipine
If a patient is already on an ACE and needs BP therapy intensified, what is the drug of choice?
CCB rather than thiazides
Why should all patients with ACS be screened for diabetes prior to discharge?
More than 2/3 patients with an MI have diabetes or pre-diabetes
What particular treatments for ACS are different for people with diabetes?
None. They should be treated the same and have the same interventions as a non-diabetic
Which is preferred in diabetic patients with ACS:
Clopidogrel
Ticagrelor (brillinta)
Prasugrel (Effient)
Undergoing PCI:
Ticagrelor or prasugrel Preference to ticagrelor as
Prasugrel only use if 65kg and no Hx of stroke.
What are the BP
TARGETS and Thresholds?
Both 130/80
Why should patients with stroke be screened for diabetes?
Because men with D have a 2-3 fold increase and women have a 2-5 fold increase of risk of stroke
Is diabetes a cause of heart failure or only secondary to Ischemia?
Diabetes can cause HF independent of ischemic heart disease by causing diabetic cardiomyopathy that may manifest with normal or reduced left ventricular ejection fraction.
What is the recommendation ace/arb dosing and monitoring in a D patient with heart failure but Also with an eGFR less than 60?
Starting dose of ACE/ARB should be HALVED
Within 7-10 days of initiation or titration of therapy, monitor:
Electrolytes, eGFR, BP, weight and heart failure sx and signs.
Dose up more gradually but target same doses as non diabetics even B Blockers.
People with diabetes have a CV age _____ years in advance of their chronological age.
10-15 years
Reduced life expectancy is __ years due to CVD.
12
ASA for primary prevention?
No reduction of CAD events but increase in bleeding.
MAY be considered if high risk.
At what age should an ACE or ARB be started if signs of microv
Age 55
OR younger if clinical macrovascular disease or microvascular disease
When should a statin be initiated? 4
Age > 40
Age > 30 if diabetes > 15 years.
Microvascular complications
Framingham high risk.
The presence of CAD in type one pts is related to:
Age Duration of D Higher A1C Higher albumin excretion Traditional factors (smoking, weight, total and LDL cholesterol)
Are type 1 diabetics at higher CAD risk than people without D?
Type 1 D is an independent risk factor for premature CV disease and MORTALItY in young adults (20-39)
In secondary prevention, what if ASA cannot be tolerated?
Clopidogrel cAn be used
What is the most common lipid panel seen when a type 2 is tested?
ALSO, What’s the difference in LDL particles in non-D people and D people?
High TG
Low HDL
Normal LDL-C
Note:the atherogenicity of LDL is increased in D due to glucagon and oxidation!!
LDL particles are smaller and denser
If a patient cannot fast for a lipid panel, what markers can be used which are NOT affected by fasting?
Non HDL cholesterol
Apo-B
How often should a lipid panel be done in all patients with D?
Upon dx
Then yearly or as clinically indicated.
OR every 3-6 months if treatment is initiated.
Which pts are automatically high risk Framingham, Ie: >= 20%
Age > 40
Age > 30 if D more than 15 years
Microvascular disease.
Clinical vascular disease
Abdominal aortic aneurysm
CKD
High risk HTN
Low risk Framingham is at what percent?
Less than 10%
When should a baseline ECG be done?
How often should it be repeated?
Age > 40
Age greater than 30 if D more than 15 years
Cardiac risk factors such as HTN, proteinuria, reduced pulses or vascular Bruits (sound heard in artery due to narrowing)
Microvascular or macrovascular damage
Every 2 years!
What is the initial test for investigation of CAD if indicated ?
Exercise ECG stress testing.
Is IFG or IGT more closely associated with CVD outcomes?
IGT
When should fibrates and statins for sure not be used together?
CKD. Increased risk of rhabdo
Which statins need lower doses in eGFR less than 60?
Atorv
Prava
Who should have a stress test done?
Typical or atypical cardiac symptoms. PAD Carotid Bruits TIA stroke Resting ECG abnormalities.
What if a patient CANNOT do an exercise ECG test or if there’s resting ECG abnormalities?
Do pharmacilogic stress echo or nuclear imaging
If a patient is on Max statin and still has low HDL AND LDL Is not at target, what should you add?
Can add niacin.
If a patient is on Max statin and still LDL Is not at target, what should you add?
Can add ezetrol, fibtraye or niacin.
When should non HDL-C be used?
What’s the target?
If patient cannot fast. Should be less than 2.6
Resting ECG should be repeated every 3-5 years in what individuals?
Age > 40
Duration of diabetes >15 yrs and older than age 35
End organ danage
One or more CVD risk factor
Age >40 and planning to undertake very vigorous or prolonged exercise.
What is the Apolipiprtein B target?
What is the non-HDL cholesterol goal?
0.8
<2.6
After initial lipid profile screening is done, hiw often do you retest for
1- patient started on statin
2- patirnt not started on statin
1- wvery 3 to 6 months to verify targets being met
2- wvery 1-3 years depending on risk
What drug do you start if TG >10 and need to reduce risk of pancreatitis
Fibrate
Albuminuria is an indeoendant risk factir for HF. Increased ACR gives a pt an ____ x increase in Risk of developong HF
AND how can we lower the risk with drugs?
2-4 x
RAAS blockade
Do HF patinets with D need to be treated differently than HF pts without D?
No. Same deugs. Eg. Ivabradine is effective regardleas.
