Risk Assessments

Question 1

What does the QRISK score assess and what are its parameters?

Answer 1

Risk of having heart attack/stroke over next ten years

Personal information:

• Age
• Sex
• Ethnicity
• BMI
• Postcode

PMH (CARD):

• CKD (stage 4/5)
• AF
• RA
• Diabetic status

Drug Hx:
- Existing HTN treatment

Family Hx:
- Angina/heart attack in 1st degree relative <60

Social Hx:
- Smoking status

Direct measurements:

• Cholesterol/HDL ratio
• Systolic BP

Question 2

What advice would you give to:

1) a patient with a low QRISK score
2) a patient with a moderate-high QRISK score

Answer 2

1) advise that although risk is low, further reductions can often still be achieved
offer advice for relevant lifestyle factors:
- smoking
- exercise
- diet change
- weight loss
- disease control and adherence to medications

2) offer advice on relevant lifestyle factors to reduce risk (see above)
consider reviewing relevant co-morbidities that may not be optimally treated
discuss benefits vs risks of taking lipid modification therapy

Question 3

What does the CHA2DS2-Vasc score assess and what are its parameters?

Answer 3

Risk of stroke in AF patients

Congestive heart failure (+1)
HTN (+1)
Age - 65-74 (+1), >75 (+2)
Diabetes (+1)
Stroke/TIA history (+2) 
Sex (female = +1)
Vascular disease (+1)

Question 4

What advice is recommended for patients with a:

1) low CHA2DS2-Vasc score
2) moderate CHA2DS2-Vasc score
3) high CHA2DS2-Vasc score

Answer 4

1) no anticoagulant therapy
2) oral anticoagulant should be considered; lifestyle advice
3) oral anticoagulant recommended; lifestyle advice

For those already on anticoagulant:

• manage modifiable RF (HAS-BLED score, HTN, use of NSAIDs, alcohol consumption)
• those on warfarin - assess anticoag control
• those on apixaban, etc. - monitor the drug

General lifestyle advice:

• avoid alcohol
• smoking cessation
• healthy diet
• exercise
• warfarin:
• daily INR, teratogenic, inc. bleeding risk, diet control, reversible w/ Vit K
• NOACs
• non-reversible, inc. bleeding risk, expensive, contraindicated w/ renal impairment and history of GI bleed

Question 5

What does the FRAX score assess and what are its parameters?

Answer 5

Risk assessment tool for estimating ten year risk of osteoporotic fractures in untreated patients

GRAB PASSS

Glucocorticoids
RA
Age
BMD

Previous + parental fracture 
Alcohol intake 
Size - weight and height 
Smoking 
Sex

Question 6

What does it mean when a patient’s T-score is:

1) -1 and above
2) between -1 and -2.5
3) -2.5 and below

Answer 6

1) normal non density, no medication required
2) osteopenia - should consider medication when certain RF present
3) osteoporosis - should consider osteoporosis medication eg bisphosphonates

Question 7

What does the ABCD2 score assess and what are its parameters?

Answer 7

Risk of stroke after TIA

Age - >60 (+1)
BP - >140/90 (+1)
Clinical features (max 2) 
- unilateral weakness (+2)
- speech difficulty w/o weakness (+1)
Duration (max 2)
- >60 mins (+2)
- 10-59 mins (+1)
- < 10 mins (+0) 
Diabetes (+1)

Question 8

What interventions/advice can be offered if a patient’s ABCD2 score is high?

Answer 8

Medication

• antiplatelets (aspirin, clopidogrel)
• statins

Lifestyle

• diet (lower fats and cholesterol)
• exercise
• smoking cessation
• adherence to medication
  
  • diabetes control
  • blood pressure control

Question 9

What does the WELLS score assess and what are its parameters?

Answer 9

Probability of developing a DVT

• paralysis, weakness or recent immobilisation of lower limb
• localised tenderness
• entire leg swollen
• calf swelling 3cm larger than asymptomatic side
• pitting oedema confined to symptomatic leg
• collateral superficial veins
• active cancer
• recently bed ridden >3 days or major surgeries
• previous DVT
• long haul flight
• ask for HRT or oral contraceptive pill if appropriate
• smoking

Question 10

What interventions/advice can be offered if a patient’s WELLS score is high?

Answer 10

Medication

• LMWH
• anticoagulant

Lifestyle

• Diet?
• exercise
• smoking cessation

Question 11

What factors affect diabetes risk?

Answer 11

• age (<49, 50-59, 60-69, >70)
• gender (male)
• ethnicity (other ethnic group than white)
• family Hx of disease
• waist measurement (>35.5 inches)
• BMI (25 or more)
• HTN

Question 12

Lifestyle advice to manage diabetes risk?

Answer 12

• regular meals
• controlled portion sizes
• decrease fats
• limit sugar
• decrease salt
• moderate alcohol
• exercise - 150 mins/week

Consider relevant groups and organisations for support
Improve patient education regarding diet, exercise etc.
Reduce weight if overweight
Recognising 5 Ts of diabetes (Toilet, Thirsty, Tired, Thinner, Thrush)

Question 13

Risk factors for asthma exacerbation?

Answer 13

• check time of day
• pets
• travel
• housing - damp?
• work
• hay fever
• smoking - including passive
• obesity
• inner-city environment

Question 14

Risk factors for COPD?

Answer 14

• cigarette smoke
• occupational dust and chemical inhalation
• recurrent lung infections
• environmental smoke
• air pollution
• genetics
• socio-economic state
• ageing populations

Question 15

What does the HAS-BLED score assess and what are its parameters?

Answer 15

Risk of major bleeding for patients on anticoagulation therapy

• HTN
• renal disease
• liver disease
• stroke Hx
• previous major bleeds or predisposition to bleeding
• labile INR
• age >65
• medication usage predisposing to bleeding
• alcohol use >8 drinks/week