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Secondary Prevention of Heart Disease Flashcards

1
Q

What is primordial prevention?

A

Preventing the development of risk factors that lead to a disease.

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2
Q

What is primary prevention?

A

Risk factors present, trying to prevent development of disease

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3
Q

What is secondary prevention?

A

Someone has had their first cardiac event. Secondary prevention is to prevent further development of disease

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4
Q

What is tertiary prevention?

A

Disease has progressed despite efforts and now it’s just just about managing symptoms and improving quality of life.

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5
Q

Secondary prevention is needed for patients with confirmed CAD or vascular equivalent. What are the vascular equivalents? (name 4)

A

These are vascular equivalents to CAD that warrant secondary prevention:

  1. Stroke
  2. TIA (transient ischemic attack/ministroke)
  3. cerebrovascular disease
  4. peripheral vascular disease
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6
Q

What is the main goal of secondary prevention for plaques? What are the 2 interventions?

A

Prevent plaque rupture and plaque progression.

This is done pharmacologically and through lifestyle change

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7
Q

Guideline classifications are set up as I, IIa, IIb, or III. What do these mean?

A

I - should do it
IIa - reasonable
IIb - might be considered
III - don’t do it

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8
Q

Guideline classifications have different level of evidence organized as A, B, and C. What do these mean?

A

A - several randomized trials
B - observational studies, case reports
C - expert opinion (about half of all guidelines are rated C)

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9
Q

The 2011 CAD secondary prevention guidelines suggest 3 things for pharmacologic intervention. What are they?

A
  1. Anti-platelets
  2. Beta-blockers
  3. RAAS (renin-angiotensin-aldosterone system) inhibitors
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10
Q

What are the two pathways focused on for oral anti-platelet therapy given for CAD secondary prevention?

A

Thromboxane synthetase inhibitors (aspirin) and P2Y12 antagonists (clopidogrel, prasugrel, ticagralor)

“Dual anti-platelet therapy”

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11
Q

True or False: Antiplatelets significantly reduce cardiac and cerebral events like MIs, strokes, and others.

A

True

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12
Q

How much aspirin is recommended for all CAD patients in the Class I anti platelet guidelines?

A

75-162mg daily (generally 81mg in USA is baseline)

100-325 for post-bypass surgery patients
75-235 for post-stroke patients
75-235 for symptomatic peripheral artery disease patients
75-81 for patients on warfarin

clopidogrel can be added or used to replace in various circumstances.

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13
Q

What do beta-blockers do for secondary prevention? (4 things)

A
  1. reduces HR
  2. reduces contractility
  3. reduces conduction velocity
  4. reduces systemic blood pressure
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14
Q

True or false: beta-blockers reduce mortality and MI

A

True

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15
Q

What is the Class I (should do) beta-blocker guideline?

A

Beta-blockers in all with LVSD (ejection fraction less than 40%) and heart failure symptoms or MI/ACS in the prior 3 years.

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16
Q

What is the Class IIa (reasonable) beta-blocker guideline?

A
  • Beta blockers in all with LVSD (ejection fraction less than 40%) even in the absence of heart failure symptoms.
  • Beta blockers in all with any history of MI/ACS
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17
Q

What do RAAS blockades do for secondary prevention? (4 things)

A
  1. vasodilation
  2. natriuresis
  3. decreased sympathetic activity
  4. reduces cardiac remodeling
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18
Q

What are the 3 pathways that RAAS blockades inhibit?

A
  1. ACE inhibitor
  2. ARB
  3. Aldosterone antagonist

Combining these together provides the best effect

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19
Q

True or false: RAAS inhibition reduces mortality among post-MI patients, especially diabetics and LVSD

A

True

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20
Q

What are Class I RAAS inhibition guidelines?

A

ACE Inhibitors given to all with LVSD (ejection fraction 5.0 mEq/L)

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21
Q

Which RAAS inhibitor has side effect of dry cough?

A

Ace inhibitors. Replace with ARB

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22
Q

What 2 things should you be careful of for aldosterone antagonists?

A

Avoid in renal dysfunction or significant hyperkalemia (>5.0 mEq/L).

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23
Q

What 5 things are suggested by the 2011 CAD secondary prevention guidelines for pharmacologic/lifestyle?

A
  1. Blood pressure control
  2. Lipid management
  3. Diabetes management
  4. Depression screening and treatment
  5. Smoking cessation
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24
Q

True or false: Increasing systolic and diastolic BP increases mortality

25
Q

BP levels below what level are sufficient to prevent cardiac events?

26
Q

The ACCORD studies compared moderate (controlling to 140/90) to severe (controlling to 120/80) control of hypertension to see if it impacted outcomes of patients. What was the finding?

A

No significant difference with exception of non-fatal stroke.

The group with increased therapy had increase side effects but no significant benefit.

27
Q

What 6 things are recommended to control BP?

A
  1. Lifestyle (reduced sat fat/sodium w/ DASH diet)
  2. RAAS inhibitors (ACEIs, ARBs)
  3. Beta-blockers
  4. Diuretics
  5. Calcium channel blockers
  6. Direct vasodilators

(typically 1-3 of these drugs are used at once)

28
Q

What are the 2014 Class I blood pressure control guidelines based on age?

A

Age less than 60yo: BP less than 140/90

Age greater or equal 60yo: BP less than 150/90

29
Q

What did the SPRINT trial show?

A

SPRINT trial was even bigger and more recent than the ACCORD trial and it showed efficacy in controlling BP down to 120/80.

Prof said this probably won’t be tested on but the guidelines may change soon due to this.

30
Q

True or false: Elevated cholesterol leads to CAD

31
Q

True or false: Increased LDL and decreased HDL leads to CAD

32
Q

True or false: High dose statins are most efficacious in reducing cardiac events

A

True. (e.g. simvastatin). If you’re stuck on an island with only one medication and you have CAD, it should be a high dose statin.

33
Q

In addition to controlling LDL, statins seem to do what other positive thing?

A

Anti-inflammation. Helps stabilize plaques.

34
Q

What are 3 non-statin lipid treatments that also reduce LDL? Do these have any effect for reducing coronary events?

A

Bile-acid binding agents, niacin, fibrates. However, they are not shown to have any efficacy in reducing coronary events. LDL drops but doesn’t translate to benefit in reducing coronary events.

35
Q

What are the 2013 Class I Lipid guidelines? 6 things

A
  1. Statins in all CAD patients
  2. No need to titrate to particular LDL
  3. No indication for non-statin lipid-lowering therapies (except potentially ezetimibe)
  4. Not proven in HF NYHA Class 3/4 or hemodialysis patients
  5. Myopathy/myalgias in 5-15%. unclear relationship-perhaps misattribution
  6. New-onset DM in 0.1-0.3%, rhabdo in 0.01%, hemorrhagic CVA in 0.01%.
36
Q

What is the mortality risk difference between a diabetic patient without prior MI and a non diabetic patient with a prior MI?

A

They are about the same. This means that diabetes confers about the same mortality risk as a prior MI.

37
Q

Does glycemic control reduce MI risk?

A

No. Glycemic lower agents don’t effect cardiac disease and may even cause harm.

38
Q

What is the Class I diabetes guideline (should do it)?

A

Lifestyle modifications and coordination with the patient’s primary care physician should occur

39
Q

What is the Class IIa diabetes guideline (reasonable)?

A

Metformin should be a first-line pharmacologic therapy

40
Q

What is the Class IIb diabetes guideline (might be considered)?

41
Q

True or False: Depression is associated with worse cardiac outcomes

A

True.

Perhaps because depression is an inflammatory condition. Also, depressed patients may be more prone to certain behaviors:don’t take their medicines, don’t exercise, and smoke.

42
Q

Does treating depression improve the risk of cardiac events?

43
Q

What are the Class IIa depression guidelines?

A

Assessment of depression is reasonable

44
Q

What are the Class IIb depression guidelines?

A

Treatment for depression does not appear to improve cardiac outcomes, but is beneficial for overall mental health

45
Q

What is the Class I smoking guideline?

A

Stop smoking

46
Q

What do the 2011 CAD Secondary Prevention Guidelines say about Lifestyle? (2 things)

A
  1. Weight management

2. Physical activity

47
Q

Obesity is defined both by ___ and ____

A

BMI, waist size

48
Q

BMI 25-29.9

A

overweight

49
Q

BMI 30-39.9

50
Q

BMI 40 or greater

A

extremely obese

51
Q

Does obesity directly facilitate cardiac disease?

A

No. It’s thought that obesity causes other things which are risk factors for cardiac disease.

  • central obesity
  • high BP
  • high triglycerides
  • low HDL-cholesterol
  • Insulin resistance

Many of these can be reversed by losing weight

52
Q

What are the 3 ways to lose weight?

A
  1. Diet (caloric restriction is key. macronutrient composition less important. nutrition counseling essential. physical activity useful adjunct)
  2. Meds - aren’t that effective (only FDA approved medication - orilstat, sibutramine is dangerous)
  3. Bariatric surgery (effective, reserved for BMI >40 or >35 with co-morbidities)
53
Q

What is the key way to lose weight through diet?

A

Caloric restriction. Exercise is thought to help but you still have to calorie restrict.

54
Q

What is the class I weight control guideline?

A

Goal BMI is 18.5-24.9. Goal waist circumference is

55
Q

True or false: Physical activity reduces cardiac events

A

True. And also, the fitter you are, the more you are able to tolerate coming CAD.

56
Q

What is the class I physical activity guideline?

A

Moderate to high-intensity exercise for 30-60 minutes/day. At least 5 and ideally 7 days a week.

57
Q

What are the 2011 CAD secondary prevention guidelines for “other”? (2 things)

A
  1. Cardiac rehabilitation (patient education. paid for by any insurance)
  2. Influenza vaccination (healthier patients have lower events and higher tolerance)
58
Q

How effective is cardiac rehabilitation (patient education)?

A

Very effective! only 20% of these patients get cardiac events. So profoundly helpful.

Cardiovascular (22 decks)

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