Module 7: CV Risk Assessment Powerpoint Flashcards
Benefits of assessment for CV risk and management of risk factors?
- reduce a person’s chances of developing CV disease, diabetes, and other diseases of aging and lifestyle inc cancer, arthritis, and obesity
- Assessment of cardiovascular risk plays an extremely important part in determining an individual’s lifetime health status CV risk assessment looks at all the risk factors present in an individual, including family history and blood parameters, to make an overall estimate of risk and plan for management
2 reasons why the first interaction with a patient is critical during CV assessment?
- Assess general appearance including apparent compared to chronologic age, weight, fitness level, mood, receptiveness, smell (e.g., cigarette smoke)
- Develop rapport w/patient to let them know u are
there to help them
What should the Initial interaction with patient consist of
- Start w/discussion of reason for assessment:
–> to help the person reduce their risk of heart attacks
and strokes as well as diabetes, and help them improve
lifestyle factors that will keep them healthy
Thus ask GENERAL QUESTIONS: age, occupation, marital status, children and REASONS(s) they are here for ASSESSMENT
When asking for the presence of vascular disease symptoms or history, what specific diseases should be asked?
- Any history of heart attack, bypass surgery or angioplasty, stroke, mini-stroke (transient ischemic attack or TIA), pancreatitis?
- Have any tests shown evidence of CHD or other vascular disease (exercise stress test, MIBI scan, carotid ultrasound, leg blood flow studies)?
What is secondary prevention vs. primary prevention?
- Secondary Prevention = trying to prevent further progression or recurrence of disease once it is already present
- Primary Prevention = No known disease
When asking for the presence of dyslipidemia or history, what specific factors should be asked?
- Any history of cholesterol or triglyceride elevation? What were highest levels? Has HDL been low?
- If so, what has been done about it? (diet changes, lipid
medications, changes in weight, exercise routine) - What are the recent lipid profile results if done? (need lab report)
What should be documented in terms of medications?
Document all medications and doses, including
prescriptions, ASA, over-the-counter meds and nutritional
supplements
1. Document all treatments tried (mention names such as
Zocor, Lipitor, Crestor, niacin, Lipidil, Lopid, Ezetrol, fish
oil/omega-3 fatty acids, flax oil, over-the-counter lipid
treatments)
2. Document side effects
3. Did side effects disappear after stopping, and how long did it take for symptoms to resolve?
About 1 in ____ people has an inherited lipid disorder
1 in 40
How to know if you are likely dealing with an INHERITED lipid disorder
If total cholesterol is > 6.5 mmol/L, or LDL-C > 4.5 mmol/L, or triglycerides > 4 mmol/L, or HDL-C < 0.7 mmol/L
What questions to ask about smoking?
- If a current smoker, how much and how long (pack years)?
- Same for previous smokers plus quit date
- Is the person contemplating quitting?
- Have they tried to quit previously?
- If so, what methods did they use (cold turkey, cutting
down and quitting, nicotine patch or gum, Zyban/Wellbutrin, Champix)? - Do they want to quit now?
- If quit, are they “well quit”?
What is the #1 priority in reducing their risk of vascular disease
Emphasize quitting smoking
Emphasize very dangerous combination of smoking and
_____ as a cause of early heart attacks and strokes
elevated cholesterol
When asking for the presence of elevated blood sugar or known diabetes, what specific factors should be asked?
- Any prior known blood sugar elevation?
- Women: any gestational diabetes?
- If diabetic, when diagnosed? Home glucose testing?
Typical numbers? Attendance at a diabetes education
program? Medications used - Recent fasting blood glucose/HbA1c
- Any diabetes in family?
You should emphasize ___% risk of diabetes if it’s in the family, and ability of healthy diet/regular exercise to prevent development of diabetes
50%
When asking for the presence of high blood pressure, what specific factors should be asked?
- Any history of high BP?
- If so, since when and how long using medication for it?
- Does patient do home BP or pharmacy BP monitoring?
- If so, what are typical recent values?
When asking for the current exercise regime, what specific factors should be asked?
- Is patient doing regular exercise? Is this for exercise sake, or part of daily activities?
- If so: type, duration, frequency? If it is “daily”, how many days per week?
- If not, how come? What are things preventing person from exercising?
- What are possible ways for person to start walking or some other simple exercise?
- How will they fit this into their daily/weekly work and life routine?
- Any limitations in exercise capacity due to other diseases?
What is a good way to start exercise?
Classes including a Cardiac Rehab Program may be a good way to start exercise
When asking for the weight history, what specific factors should be asked?
- Is the person’s weight stable?
- If overweight, how long has that been present?
- Attempts at weight loss
- Emphasize healthy eating and regular exercise are more important than focusing on weight
When asking for the stress history, what specific factors should be asked?
- On a scale of 0 to 10, w/10 being the worst, what is their
current level of stress, anxiety, or depression (one score
for each)? - If present, what are the main reasons for that stress/anxiety/depression?
- If scores are high, how are they dealing with it?
- What are sleep patterns like? Sleep apnea is common and a CV risk factor as well
When asking for the alcohol history, what specific factors should be asked?
- How many drinks per week or per month?
- If intake high, discuss any problems associated w/drinking prevention
- Mention need to reduce intake to help control lipids,
reduce weight, improve health
Why is alcohol bad for CV risk?
May increase weight, worsen lipids (mainly triglycerides)
When asking history of other major illnesses, what specific factors should be asked?
Specific q’s about: arthritis, thyroid disease, kidney or liver disease, gout, lung disease
Which medications can worsen dyslipidemia
- thiazide diuretics,
- beta blockers,
- estrogen,
- corticosteroids,
- anti-rejection medications,
- anti-HIV medications,
- retinoids (for acne)
When asking for the diet history, what specific factors should be asked?
- General assessment of diet should include any skipping of meals, fruit and vegetable intake (aim for ≥ 5 servings per day), simple carb intake, junk food, portion control
- Helpful to have assessment by a dietitian (see Unit 5) if
available
How is premature vascular disease in a family defined?
defined as a 1st degree male relative(s) (father, brother, son) with known heart disease/stroke before age 55 OR 1st degree female relative(s) (mother, sister, daughter) with known heart disease or stroke before age 65
When asking for the GENERAL FAMILY history, what specific factors should be asked?
General questions:
1. Are your parents living? How old are your parents? If
deceased, how old were they when they died? Questions
regarding cause of death, any known heart attack or stroke? If so, what were that person’s risk factors? Any diabetes known in the family?
2. Same questions for all first degree relatives
3. Further questioning regarding grandparents age at death, risk factors if pertinent, and same for aunts/uncles
- If early heart disease was present in a first degree relative, what were that person’s risk factors (were they known to smoke, have high cholesterol, diabetes, high blood pressure?)
- Also ask about heart disease in grandparents, aunts and uncles and whether it was premature
When conducting a physical examination, what specific factors should be assessed?
- General appearance (well, grey colour, smells of smoke,
looks stated age, abdominal obesity, etc.) - Height, weight, waist circumference, body mass index
(kg/m2) - BP sitting; repeat supine after rest if high
- Pulse
When conducting a physical examination, what factors should be assessed to specifically look for signs of vascular disease or hyperlipidemia?
- Eyes: corneal arcus, xanthelasma, lipemia retinalis
- Carotid arteries: bruits
- Heart sounds, murmurs
- Aortic/renal/femoral artery bruits
- Peripheral pulses: popliteal, ankle, foot
- Tendons: thickening or nodules (hands, Achilles)
- Skin xanthomas: palms, back, feet
When is the Framingham Risk Score conducted?
Only done for people who do not have known vascular
disease or events, i.e., only used in primary prevention
patients
What information is required to conduct the Framingham Risk Score?
Requires knowledge of the patient’s AGE, total CHOLESTEROL lvl, HDL cholesterol level, SMOKING status, and systolic BP (including whether or not the patient is on BP medication)
How is the Framingham Risk Score carried out?
- Points for each category are totalled and converted to a % risk of a coronary event over the next 10 years
- % risk is doubled in the presence of premature vascular disease in any first degree relative in the family (parent, sibling, or child)
- Estimated risk can also be adjusted upward based on the presence of other risk markers such as elevated Lp(a) or elevated high sensitivity C-reactive protein (CRP)
Problems associated with the Framingham Risk Score?
- Only estimates 10-year risk, not lifetime risk
- Women, even those with inherited dyslipidemia and positive family history, have low risk scores
- Based on data from CAUCASIAN men mainly, and may not predict risk well for other groups
- Better risk engines under investigation but not yet in
common use
How does atherosclerosis develop?
a chronic disease developing ASYMPTOMATICALLY and W/OUT WARNING over a LIFETIME until SYMPTOMS or DEATH occur
What does prevention of atherosclerosis entail?
- Prevention ideally involves LIFETIME REDUCTION of RISK
- BENEFITS of risk reduction occur, however, at ANY POINT of INTERVENTION
What are the unmodifiable and modifiable factors of atherosclerosis?
- Unmodifiable: parentage, age, gender
2. Modifiable: Diet, exercise, LDL-C, HDL-C, smoking, stress, BP, blood sugar, weight, alcohol intake
In the interheart study (2004) what were the 9 nine modifiable risk factors accounted for 90% of the population attributable risk of first myocardial infarction in men, and 94% in women?
- Elevated ApoB/Apo A-I ratio rr
- Smoking 2.87
- Psychosocial factors (depression, stress, life events)
- Diabetes
- Hypertension
- Abdominal Obesity
- Regular Alcohol Consumption
- Regular Physical Activity
- Daily consumption fruits/vegetables
How is age a major risk factor for atherosclerosis?
- Atherosclerosis is a disease of aging, representing the accumulated net damage to the endothelium and the consequent infiltration of cells, build up of plaque, and inflammatory reaction in the artery wall
- Longer lifespans represent a major reason for the relative importance of atherosclerosis as a cause of death, along w/cancer
How is gender a major risk factor for atherosclerosis?
- Estrogen made by the female ovary has protective effects on lipoprotein levels (higher HDL-C, lower LDL-C), and on the artery wall
- Men have lower HDL-C, higher average LDL-C, smoke more, and have greater tendency to accumulate visceral (abdominal) fat than women
- Loss of protective effect of estrogen in women at menopause
How is high LDL-C a major risk factor for atherosclerosis?
- LDL particles deliver excess cholesterol to cells in the artery wall
- Endothelial damage enhances LDL infiltration into the intima
- The greater the # of risk factors damaging the endothelium, the greater the infiltration of LDL, and the more harm even lower levels of LDL-C can do
How is smoking a major risk factor for atherosclerosis?
- Many harmful chemicals from cigarette smoke dissolve in blood and damage the endothelial lining of blood vessels
- Cause vasoconstriction and reduced BF to tissues
- Risk reduced quickly upon stopping smoking
- Drop in death rate from heart attacks has been in part due to reduced rates of smoking
How is stress a major risk factor for atherosclerosis?
- Psychosocial stress found to be 3rd best predictor of risk for MI in INTERHEART Study
- Difficult to quantify clinically w/out standardized questionnaires
- Increased cortisol, adrenaline levels w/stress correlated w/increased lvls of endothelial damage; connection not yet clear
- Stress reduction is a major factor in reducing CV risk
How is hypertension a major risk factor for atherosclerosis?
- High BP damages endothelium and leads to
arterial wall thickening; heart pumps against higher
resistance - Reduced BP through salt restriction, exercise, weight loss and medication reduces risk of CV death inc stroke
How is diabetes a major risk factor for atherosclerosis?
- Diabetics have a 2-4-fold increased risk of myocardial
infarction, and have a higher death rate with M - Alterations in lipid levels, particularly small dense LDL, thought to explain a lot of this risk
- Reduction of lipid levels in diabetics is as or more important for reducing CV events than glucose control
How is abdominal obesity a major risk factor for atherosclerosis?
- Fat surrounding intestines (visceral fat) more harmful than subcutaneous fat
- Visceral fat secretes more inflammatory cytokines, that somehow damage blood vessel endothelium
- Measurement of waist circumference gives accurate estimate of visceral obesity
How is family history a major risk factor for atherosclerosis?
- Known inherited factors including inherited lipid disorders [e.g., high LDL-C, high Lp(a)] inc risk for early CAD and result in a pattern of early CAD in families
- Diabetes and hypertension also largely predicted by
inherited factors, many of which are not yet identified - Other inherited factors leading to high rates of heart disease in families still to be identified
What are some newer markers of CAD currently under investigation?
- Lp(a)
- C-Reactive Protein (CRP)
- Others: Inflammatory cytokines, myeloperoxidase,
oxidized LDL, genetic polymorphisms (SNPs), interleukins
What is Lp(a)
LDL particle crosslinked to apo (a)
What does high levels of Lp(a) indicate?
High levels predict increased risk for CAD in some but not all people with high Lp(a)
How can Lp(a) be lowered?
- Lowered by NIACIN
2. Risk of high Lp(a) reduced by LOWERING LDL-C
How to determined Lp(a)?
Lab test
What is C-Reactive Protein
Nonspecific marker of inflammation in the body
When is C-Reactive Protein elevated?
Elevated in abdominal obesity, presence of atherosclerosis, cancer, infection, arthritis, smoking, poor diet
High level of CRP adds to risk associated with high ____
LDL-C
As a marker of inflammation, helps to identify individuals at higher risk of atherosclerosis even with lower levels of ____
LDL-C
Novel biomarkers will likely be available to help predict risk within next ___ years
5-10
Evaluation of CV risk requires assessment of what 10 major CV risk predictors
age, gender, dyslipidemia, smoking, stress, BP, blood sugar, waist circumference, family history, diet, and exercise level
What is secondary prevention
defined as efforts to prevent further disease or events in the presence of known vascular disease
What is primary prevention
the assessment and management in the absence of known previous vascular disease or events,
The ____, _____, and ____ of the individual all relate to risk for vascular disease and should be obtained during the Initial interaction and history of ischemic vascular disease
age, marital status, and occupation
