Risk assessment Flashcards
What is Qrisk2?
Score used to work out the risk of having a heart attack or stroke over the next 10 years
Only valid if you do not already have a diagnosis of coronary heart disease (angina/MI) or stroke/TIA
What factors does Qrisk2 take into account?
i) Age
ii) Sex (M)
iii) Ethnicity
iv) BMI - should actually ask weight and height (or if they know their BMI)
v) UK postcode
vi) Smoking status
vii) Systolic BP
viii) On treatment for HTN
ix) Cholesterol/HDL ratio
x) AF
xi) Angina/MI in 1st degree relative younger than 60yrs
xii) DM status
xiii) CKD stage 4 or 5
xiv) RA
What is diabetes risk score?
Risk of developing T2DM in the next 10 years
What factors does the diabetes risk score take into account?
i) Age (>70=+++, 60-70=++, 50-60=+)
ii) Sex (male=++)
iii) Ethnicity (non white british +++)
iv) BMI (>35=+++, 30-35=++)
v) Waist size (>110=+++, 100-109=++)
vi) Hx HTN or treatment for it (++)
vii) 1st degree relatives with DM (++)
What is the FRAX score?
The 10 year probability of bone fracture
What does FRAX take into account?
i) Age
ii) Sex
iii) Weight + height
iv) Current smoking status
v) Alcohol intake >3units/day (greater intake = greater risk, same said for smoking and glucocorticoids)
vi) Glucocorticoid status (currently taking or has done in the past for >3 months)
vii) Previous fracture (in adult life occurring spontaneously or after trauma which in a normal individual shouldn’t be enough to cause a break) (vertebral and hip fracture are particularly significant)
viii) Parent fractured hip
ix) Bone mineral density (from DXA scan of femoral neck)
x) RA diagnosis
xi) Disease associated with osteoporosis – T1DM, osteogenesis imperfecta, untreated chronic hyperthyroidism, hypogonadism, menopause <45, chronic malnutrition/malabsorption, chronic liver disease)
What is the CHA2DS2VASc risk score?
The risk of having a stroke within the year if diagnosed with AF
What does CHA2DS2VASc take into account?
i) CCF (LF or both failure)
ii) HTN (resting >140/>90 on 2 occasions or on BP management
iii) Age >75
iv) Diabetes
v) Stroke/TIA/thrombo-embolism
vi) Vascular disease (MI/angina/CABG/PCI/claudication/A or VTE/thoracic, abdominal or lower vascular surgery)
vii) Age 65-74
viii) Sex category (Female)
What is the HASBLED score?
Score for bleeding risk
Combined with CHADSVASc to know whether to anticoagulate
What does HASBLED take into account?
i) HTN (uncontrolled or >160 systolic)
ii) Abnormal liver function
iii) Abnormal renal function
iv) Alcohol (greater or equal to 8 units/wk)
v) Stroke (particularly lacunar)
vi) Bleeding (history of or propensity to)
vii) Labile INRs
viii) Elderly (>65)
ix) Drugs (antiplatelets or NSAIDs)
What is the ABCD2 score?
The risk of stroke after having a TIA
What does ABCD2 take into account?
Age >60 BP > or equal to 140/90 Clinical features of TIA i) Unilateral weakness = 2 ii) Speak disturbance without weakness = 1 iii) Other symptoms = 0 Duration of symptoms i) <10 mins = 0 ii) 10-59 mins = 1 iii) > or equal to 60 mins = 2 Diabetes Hx
What is the Well’s score?
Probability of DVT
What does the Well’s score take into account?
Current/previous cancer treatment within 6 months
Bedridden >3days or major surgery within 4wks
Previous DVT
Symptoms
i) Calf swelling >3cm compared to other leg (measure 10cm below tibial tuberosity)
ii) Collateral (non varicose) superficial veins present
iii) Entire leg swollen
iv) Localised tenderness along deep venous system
v) Pitting oedema confined to symptomatic leg
vi) Paralysis, paresis or recent plaster immobilisation of lower extremity
Alternative diagnosis to DVT more likely
i) -2 points
What advice should be given to someone with a high Qrisk or diabetes risk?
Diet - regular meals, portion sizes, low sat fats, salt and
sugar, wholegrain, fruit+veg x5, 2x oily fish
Exercise - 150 mins of moderate intensity aerobic/week or in keeping with national guidelines - increase HR/RR; muscle strengthening exercise
Weight loss
Reduce alcohol consumption (14/wk ie 6 pints) (offer support)
Smoking cessation (offer support)
What medical treatments can be offered to someone with a high Qrisk?
Statin - atorvastatin 20mg for those who have >10% risk (80mg if established CVD)
What medical interventions can be offered to someone with a high diabetes risk?
Metformin - ie 500mg and increase as tolerated
Monitor HbA1c
What advice and medical treatment would you give to someone with a high FRAX score?
Smoking cessation Alcohol reduction Weight bearing exercise Ensure any comorbidities are managed Adequate dietary calcium Adequate vitamin D (supplementation?) Bisphosphonates ?HRT
How do you interpret CHADSVASc scores?
0 (male) or 1 (female) - no anticoagulation therapy
1 (male) - oral anticoagulant considered
2+ - oral anticoagulant recommended
Anticoagulants are vitamin K antagonist ie warfarin or NOAC ie rivaroxaban, apixaban
How do you interpret the ABCD2 score?
0-3 = 2 day stroke risk is 1%, hospital obs might not be necessary without other indication ie new AF
4-5 = 4%, hospital obs justified in most situations
6-7 = 8.1% hospital obs justified
- risk also increases as time progresses post TIA ie score of 7 = 22% risk at 90 days post
How do you investigate someone with a high ABCD2 score?
?Hospitalisation
FBC, U+E, fasting glucose, lipids
ECG + CT/MRI head + carotid imaging/CT angiography (in 48hrs)
How do you manage someone with a high ABCD2 score?
Antithrombotic therapy - atherothrombotic TIA = aspirin or clopidogrel; cardioembolic TIA = anticoagualte ie warfarin/NOAC
HTN control - ACE-I/ARB/diuretic - to <140/90
Carotid endarterectomy
Statin
Diabetes control
Smoking and alcohol cessation
Exercise
How do you investigate and treat someone with a high Well’s score?
0 = low risk, 1-2 = moderate, >3 = high risk
For people likely to have a DVT - proximal leg vein USS in <4hrs
For people unlikely to have DVT - D-dimer testing, if positive, refer to USS <4hrs
Dalteparin (LMWH)
Warfarin or rivaroxaban - INR (2-3)
Engage in regular walking, leg elevation and to delay long-haul aeroplane travel 2wks
