Vascular and metabolic disease Flashcards
What are the most important risk factors for CVD?
Smoking, diabetes, hypertension, dyslipidaemia, obesity, poor diet, physical inactivity
Who should have a CVD risk assessment?
Patients aged
> 45 - 74 years
> 35 years AND Indigenous
WITHOUT established CVD
AND not clinically determined to be at high risk
What scenarios are patient’s automatically at high risk of CVD?
- Diabetes and > 60 years old
- Diabetes with microalbuminuria
- CKD stage 3b or worse
- Familial hypercholesterolaemia
- Previous BP reading > 180 / 110
- Serum total cholesterol > 7.5mmol/L
- ATSI patient 75 years and older
How often should CVD risk assessments be performed?
Every 2 years
When do we start screening for hypertension?
From the age of 18 years old - BP checks recommended every 2 years
When should BP readings be interpreted in the context of absolute CVD risk?
Adults > 45 years
ATSI > 35 years
What should be done for a patient with hypertension and low CVD risk?
Lifestyle advice and education
If sBP 140-159 - review after 2 months of lifestyle modification
If BP persistently > 160/100 - offer anti-hypertensives
Repeat BP minimum every 2 years
Who has a low CVD risk ?
Absolute CVD risk of < 5%
< 5% chance of developing CVD in the next 5 years
Who has a moderate CVD risk?
Absolute CVD risk of 5-10%
- 5-10% chance of developing CVD in the next 5 years
Who is of high CVD risk?
Patients with a high CVD risk are those with either:
1) Absolute CVD risk > 15% (i.e. 15% chance of developing CVD in the next 5 years)
2) Patients with clinically determined high risk (not explored here)
What should be done for a patient with hypertension and moderate CVD risk?
Intensive lifestyle advice
‘Consider’ starting anti-hypertensives if SBP 140-159 or DPB 90-99
Offer anti-hypertensive if > 160/100
Repeat BP 6-12 months
What should be done for a patient with hypertension and high CVD risk?
Intensive lifestyle advice
Offer anti-hypertensives
What is the BP target for a patient with hypertension and high CVD risk, who DOES NOT have diabetes, CKD or existing CVD?
< 140/90
What is the BP target for a patient who has hypertension AND diabetes WITHOUT albuminuria?
< 140/90 (Heart Foundation)
< 130/80 (Red Book)
What are the definitions of microalbuminuria?
Males - spot urine ACR > 2.5mg/mmol
Females - spot urine ACR > 3.5mg/mmol
What is the BP target for a patient with hypertension AND chronic kidney disease (i.e. a GFR reduction or albuminuria)
< 130/80
- aiming towards 120/80
What treatment should be offered to a patient with LOW CVD risk and an LDL level of 3.2?
Lifestyle advice only
How often should you repeat lipid testing for a patient with dyslipidaemia and low CVD risk?
Every 5 years
What lipid levels would prompt you to consider that dyslipidaemia may be due to familial hypercholesterolaemia?
LDL > 4
Total cholesterol > 7.5
What should be done in a patient with moderate (5-10%) CVD risk AND a dyslipidaemia
Intensive lifestyle advice
Consider starting lipid lowering medication if
- not reaching target after 6 months
- family history premature CVD
- ATSI / Islander
How often should you repeat lipid testing in a patient with dyslipidaemia and moderate CVD risk?
Every 2 years
What should be done if a patient with high CVD risk, or established CVD presents with dyslipidaemia
Start lipid lowering therapy
Intensive lifestyle advice
How often should you repeat lipids in a patient with established CVD or with a high CVD risk?
Every 12 months (unless doses to lipid lowering meds are changed)
True or false
All adults 40 years and over (and ATSI 18 years and older) without obvious comorbidities elevating them to high risk, are at intermediate risk of diabetes.
True
What are the components of the AUSDRISK screen for type 2 diabetes?
Point based scoring system looking at
- Age
- Sex
- ATSI/Islander/Maori
- Where you were born - Australia / Asia etc
- Family history of diabetes
- Previously detected high BSL?
- Blood pressure meds?
- Smoker?
- Daily fruit / veg?
- Exercise - 2.5 hours per week?
- Waist measurement
What patients are considered high-risk for developing diabetes?
> 40 years old AND overweight or obese
AUSDRISK > 12
Patients with impaired glucose tolerance test or impaired fasting glucose
Established CVD
Women who have had GDM
High risk race (Indian, Pacific Islanders)
Women with PCOS
Patients on anti-psychotics
What diabetic screening should be offered to patients less than 40 years of age?
None, unless clinically indicated
What diabetic screening should be offered to patients at intermediate risk of developing diabetes?
AUSDRISK assessment, every 3 years
What diabetic screening should be offered to patients at high risk of developing diabetes?
Fasting BSL
HBa1C
How often should patients, with high risk of diabetes, be screened with a fasting BSL and HbA1c?
In general, high risk patients should be screened every three years.
Except for patients with impaired glucose tolerance or impaired fasting glucose - should be screened yearly.
How is diabetes diagnosed?
Fasting BSL > 7mmol/L OR
HbA1C > 6.5% OR
2 hour, post OGTT > 11.1mmol/L
In the absence of unequivocal symptomatic hyperglycemia, the diagnosis must be confirmed on a different day by repeat measurement, repeating the same test for confirmation.
If the patient has symptomatic hyperglycaemia, then one measurement is enough
What is the definition of impaired fasting glucose?
Definition: Fasting BSL between 5.5–6.9 mmol/L
What can be done for a patient with impaired fasting glucose?
Screen for diabetes yearly with a HbA1c or OGTT
Provide intensive lifestyle advice
What is the significance of impaired fasting glucose?
It is a prediabetic condition.
Without lifestyle modification, diabetes may develop.
It is a component metabolic syndrome.
What is metabolic syndrome?
Elevated waist circumference (values vary for gender and ethnicity)
Elevated triglyceride levels ≥1.7 mmol/L
Reduced HDL-C
<1.0 mmol/L in men
<1.3 mmol/L in women
Hypertension (>130/85)
Elevated fasting glucose - BSL 5.5–6.9 mmol/L
What is the significance of metabolic syndrome?
The MetSy identifies patients at an increased risk of CVD, diabetes and CKD.
It provides an estimate of relative risk.
Patients with MetSy are 2-3 times more likely to develop CVD, CKD or diabetes compared to similar patients who do not have MetSy.
How do you manage metabolic syndrome
Intensive lifestyle modification.
Consider medications to control BP and dyslipidaemia.
Yearly screening for diabetes.
When should you start checking lipids in the general population?
Adults > 45 years
ATSI > 35 years
What is the target LDL level for primary prevention?
< 2 mmol/L
What is the target HDL level for primary prevention?
> 1 mmol/L
What is the target TG level for primary prevention?
<2 mmol/L
What is the target total cholesterol for primary prevention?
< 4 mmol/L
What is impaired glucose tolerance?
Two-hour plasma glucose between 7.8
and 11.0 mmol/L
Who is at high absolute risk of stroke?
High CVD risk
Patients with previous stroke
Patients with previous TIA
Patients with AF and CHADSVASC = 2 or more
What is the ABCD2 score?
Risk assessment tool
Predicts stroke risk after a TIA withing 2 days and 90 days.
What are the components of the ABCD2 score?
Age > 60 (1 point) BP >140/90 (1 point) Clinical features - unilateral weakness (2 point) - speech impairment without weakness (1 point) Duration > 60 minutes (2 points) 10-59 minutes (1 point) Diabetes (1 point)
A 65 year old diabetic tells you that she had unilateral arm weakness, lasting 60 minutes 2 days ago. What do you do?
Send to hospital.
TIA suspected and has an ABCD2 score of 4 or greater.
She is at high risk (4% 2 day risk and ~ 8% 90 day risk) of developing a stroke, and will need a workup.
A 51 year old male with no comorbidities presents following an episode of slurred speech lasting 15 minutes yesterday. After taking a careful history, you find that this is the first episode, he is normotensive, he does not have AF and his neuro exam is normal. You suspect a TIA. What is his ABCD2 score and what does this mean?
ABCD2 = 2
Low risk
2 day stroke risk is 1%
90 day stroke risk is 3%
Could, in theory, be managed as outpatient with urgent CT scan, aspirin and risk factor reduction.
Which patients are at high risk of developing CKD?
Smokers Obese Family history of kidney failure Diabetes Hypertension ATSI >30 years Established CVD or PVD History of AKI Chronic opioid users Chronic NSAID users
How do you screen patients for CKD?
BP
Urine ACR
Perform every 2 years for high risk patients, and yearly in hypertensives or diabetics.
What ACR ratio constitutes macroalbuminuria
Males > 25 mg/mmol
Females > 35 mg/mmol
What is the definition of stage 1 CKD?
eGFR >90 mL/min/1.73 m2 AND microalbuminuria, proteinuria or haematuria with the presence of structural or pathological abnormalities.
What is the definition of stage 2 CKD?
eGFR 60–89 mL/min/1.73 m2 AND microalbuminuria, proteinuria or haematuria with the presence of structural or pathological abnormalities
What is the definition of stage 3a CKD?
eGFR 45–59 mL/min/1.73 m2
What is the definition of stage 3b CKD?
eGFR 30–44 mL/min/1.73 m2
What is the definition of stage 4 CKD?
eGFR 15–29 mL/min/1.73 m2
What is the definition of stage 5 CKD?
eGFR <15 mL/min/1.73 m2 (or on dialysis)
