Module 4 (a) Flashcards
Cardiovascular Dz Prevention
-Recommendations?
Look at article**
CVD
-Modifiable Risk Factors
- Smoking
- Dyslipidemia
- DMT2
- Increased waist to hip ratios
- Physical inactivity
- Poor diet
- HTN
- Psychosocial stress
ASCVD Risk Assessment
-What is it?
- Estimate a patients initial 10-year ASCVD risk in ages 40-79 yrs old ***
- You can only do LIFETIME risk not 10 year risk outside of the age range
- Low risk (<5%)
- Borderline Risk (5-7.5%)
- Intermediate risk (>/=7.5-20%)
- High risk (>/=20%)
ASCVD
-Risk?
- Most Potent risk factor for ASCVD over age 50 is diabetes
Diabetes T2DM Med Management
-SGLT-2 & GLP-IR
- SGLT-2
- Significant reduction in ASCVD events and HF
- “Flozin” meds - GLP-IR Agonists
- Found to significantly reduce ASCVD events w/ T2DM and high risk
- “utide” meds
Lipids
-Labs to monitor
- Fasting Lipid panel and CMP
- Follow up in 4-12 wks to check adherence and for med changes
- Check yearly once stable
- Check CMP and CK if pt is symptomatic of liver dz or has myalgias
Lipid Labs
-Total cholesterol?
- Total cholesterol below 200 mg/dl is Optimal; High is above 240 mg/dl
Lipid Labs
-LDL-C?
- LDL below 100 mg/dl is Optimal; VERY HIGH is above 190 mg/dl
Treat to the LDL
Lipid Labs
-HDL?
- HDL above 60 is optimal; Very low is below 40
Lipid Labs
-Triglycerides
- Below 150 is Optimal; Very high is above 500
If Triglycerides come back high, question if patient was fasting**
Hypertriglyceridemia
-FIBRATES
- Fasting serum Triglyceride level > 400mg/dl
- FIBRATES decrease triglyceride values by 35-50% and increase HDL levels 5-20%
- NO FIBRATES to pt’s with severe hepatic or renal dysfunction
- Complication risk is Increased when used with Statins
- MONITOR LFT’s to detect and prevent liver damage
Hypertriglyceridemia
-Complications
- HTG is the 3rd most common cause of acute pancreatitis after alcohol and gallstones
- If Triglyceride level is persistently above 886 mg/dl, start drug therapy to lower risk of pancreatitis
Hypertriglyceridemia
-Management
- Statins
- Bile Acid sequestrants
- Nicotinic acid
- Fibric acids
- Cholesterol absorption inhibitors
Hyperlipidemia
-Primary Prevention
- Assess risk factors beginning in childhood
- Age <19 w/ familial hypercholesterolemia = START STATIN
- Age 20-39 = estimate lifetime risk and promote healthy lifestyle
- Consider statin in those w/ family hx of premature ASCVD and LDL-C >/= 160
Hyperlipidemia
-Treatment Guideline (High Intensity)
- Ages 20-75 + LDL-C >/=190 mg/dl = high intensity statin w/out risk assessment
- T2DM >/= 10 yrs, T1DM >/=20 years, renal dz, retinopathy, PVD with ABI <0.9
- High intensity statin w/ aim to lower LDL by 50%
Hyperlipidemia
-Treatment Guideline (Moderate Intensity)
- Ages 40-75 + T2DM = Moderate intensity statin
- Use risk assessment to see if patient needs high intensity statin
Hyperlipidemia
-Treatment Guideline CAD
If a patient has known coronary disease, they need to be on a statin.
Treatment guidelines are for patient w/out known coronary artery disease
Breakdown of Risk and Treatment
-Borderline Risk
- 5-7.5%
- Reduce present modifiable factors
- Discuss moderate intensity statin
- Consider coronary artery calcium score
Breakdown of Risk and Treatment
-Intermediate Risk
- > 7.5-20%
- Use moderate intensity statin
- Use High intensity statin if Pt has increased Risk factors (Risk stratification w/ CAC if risk is uncertain
*Coronary artery calcium score (CAC)
Breakdown of Risk and Treatment
-High Risk
- > /= 20%
- Risk discussion to initiate high intensity statin
- Goal to reduce LDL by >/=50%
Coronary Artery Calcium Score (CAC)
-CAC scores?
- Score of 0
- Can avoid statins and recheck CAC in 5-10 yrs. (Make sure pt doesn’t smoke) - Score 1-100
- Reasonable to initiate moderate intensity statin - Score >100
- >75th percentile; Use a statin at any age
Coronary Artery Calcium Score (CAC)
-More Info
- A score of ZERO does not imply zero risk
- ALWAYS incorporate w/ other known risk factors
- Doesn’t replace a stress test
Primary Prevention of ASCVD
-Aspirin Use?
- Consider low dose aspirin (75-100mg daily) for
- 40-70 yr old adults who have higher risk for ASCVD but NO increased risk of bleeding
Primary Prevention
-Weight Control
- Obesity BMI >/= 30
- Overweight BMI 25-29.9
- Both Obesity and overweight increase risk for ASCVD, HF, A fib, compared to normal weight - Meaningful weight loss is considered >/= 5% of initial weight
- 5-10% loss can result in improvement in BP, lipids, glucose and can delay T2DM
- Document DMI and waist circumference during each visit.
Primary Prevention
-Physical activity recommendation
- 150 min/wk of moderate intensity
- 75 min of vigorous-intensity exercise
- 50% of patients are considered sedentary
Moderate activity = brisk walking, biking, dancing, yoga, swimming recreationally
Vigorous activity = Jogging/running, biking >10 mph, tennis, swimming laps
HTN
-Non-modifiable (Relative) Risk Factors
- CKD
- Family Hx
- Increased Age
- Low socioeconomic status
- Male
- Obstructive Sleep apnea
- Psychosocial stress
HTN
-Risk Factors
- Obesity
- Metabolic Syndrome
- High dietary Fat
- Smoking
- Stress
- Genetic
HTN Can be a Risk Factor for?
- CVA
- MI, HF
- Aneurysms
- PAD
- Cognitive dysfunction
- Dementia
- Nephropathy (renal Failure)
- Retinopathy
Secondary HTN
-Causes
- # 1 Cause of Secondary HTN is RENOVASCULAR DZ (Renal artery stenosis)
Secondary HTN
-Common Causes
- Obstructive sleep apnea
- Renal parenchymal dz
- Primary aldosteronas
- Renal artery stenosis
Secondary HTN
-Uncommon Causes
- Pheochromocytoma
- Cushing’s dz
- Hyperparathyroidism
- Aortic coarctation
HTN
-Medication and Substances that increase BP
- Alcohol
- Amphetamines
- Antidepressants (SNRI’s NOT SSRI’s)
- Herbal supplements (St. John’s wart
- Oral contraceptives
- NSAIDS
- Cocaine, meth
- Systemic steroids
True Resistant HTN
-Definition
- Pt is on max doses of all meds + a spironolactone
HTN
-Initial Treatment Non-Black
- Non-Black patient + or - DM:
- Start Diuretic, CC or ACE/ARB
HTN
-Initial Treatment Black Patients
- Start Thiazides-like diuretics or a CCB
2. Add an ACE-I/ARB later if they have DM
HTN
-Initial Treatment w/ HFrEF, or CAD
- BB
- ACE/ARB
- Amlodipine
HTN
-Most likely Initial Treatment
- Thiazide diuretic (HCTZ
- CCB’s
- ACE-I or ARB’s
Start with one of these and MAX the dose then add a second one if needed
HTN
-Follow up
- See patient every 3-6 months
2. Yearly if BP is under control
HTN
-BP treatment goal?
<130/80 **
Apparent Resistant HTN
-Definition
Uncontrolled clinic BP despite being prescribed 3 or more anti-HTN meds or require prescriptions of four or more drug to control BP
True Resistant HTN
-Definition
- Uncontrolled clinic BP w/ med adherence
AND - Uncontrolled BP confirmed by 24-hr ambulatory BP monitoring
Pseudo-resistant HTN
Poorly-controlled HTN that appears resistant but is actually other factors:
- Inaccurate Cuff size (Small = high; Large = low)
- Poor adherence to meds
- Suboptimal med therapy
- Poor adherence to lifestyle and dietary approaches
- White coat HTN
Refractory HTN
- Uncontrolled on maximal medical therapy
-Defined as 5 or more medications including Chlorthalidone and MRA
—Spironolactone
HTN
-When to Refer
- Uncontrolled on 3 full doses or maximum tolerance
- Secondary causes
- Autonomic failure w/ or tho static hypotension but HTN when supine
