1
Q
Cardiovascular Dz Prevention
-Recommendations?
A
Look at article**
2
Q
CVD
-Modifiable Risk Factors
A
- Smoking
- Dyslipidemia
- DMT2
- Increased waist to hip ratios
- Physical inactivity
- Poor diet
- HTN
- Psychosocial stress
3
Q
ASCVD Risk Assessment
-What is it?
A
- Estimate a patients initial 10-year ASCVD risk in ages 40-79 yrs old ***
- You can only do LIFETIME risk not 10 year risk outside of the age range
- Low risk (<5%)
- Borderline Risk (5-7.5%)
- Intermediate risk (>/=7.5-20%)
- High risk (>/=20%)
4
Q
ASCVD
-Risk?
A
- Most Potent risk factor for ASCVD over age 50 is diabetes
5
Q
Diabetes T2DM Med Management
-SGLT-2 & GLP-IR
A
- SGLT-2
- Significant reduction in ASCVD events and HF
- “Flozin” meds - GLP-IR Agonists
- Found to significantly reduce ASCVD events w/ T2DM and high risk
- “utide” meds
6
Q
Lipids
-Labs to monitor
A
- Fasting Lipid panel and CMP
- Follow up in 4-12 wks to check adherence and for med changes
- Check yearly once stable
- Check CMP and CK if pt is symptomatic of liver dz or has myalgias
7
Q
Lipid Labs
-Total cholesterol?
A
- Total cholesterol below 200 mg/dl is Optimal; High is above 240 mg/dl
8
Q
Lipid Labs
-LDL-C?
A
- LDL below 100 mg/dl is Optimal; VERY HIGH is above 190 mg/dl
Treat to the LDL
9
Q
Lipid Labs
-HDL?
A
- HDL above 60 is optimal; Very low is below 40
10
Q
Lipid Labs
-Triglycerides
A
- Below 150 is Optimal; Very high is above 500
If Triglycerides come back high, question if patient was fasting**
11
Q
Hypertriglyceridemia
-FIBRATES
A
- Fasting serum Triglyceride level > 400mg/dl
- FIBRATES decrease triglyceride values by 35-50% and increase HDL levels 5-20%
- NO FIBRATES to pt’s with severe hepatic or renal dysfunction
- Complication risk is Increased when used with Statins
- MONITOR LFT’s to detect and prevent liver damage
12
Q
Hypertriglyceridemia
-Complications
A
- HTG is the 3rd most common cause of acute pancreatitis after alcohol and gallstones
- If Triglyceride level is persistently above 886 mg/dl, start drug therapy to lower risk of pancreatitis
13
Q
Hypertriglyceridemia
-Management
A
- Statins
- Bile Acid sequestrants
- Nicotinic acid
- Fibric acids
- Cholesterol absorption inhibitors
14
Q
Hyperlipidemia
-Primary Prevention
A
- Assess risk factors beginning in childhood
- Age <19 w/ familial hypercholesterolemia = START STATIN
- Age 20-39 = estimate lifetime risk and promote healthy lifestyle
- Consider statin in those w/ family hx of premature ASCVD and LDL-C >/= 160
15
Q
Hyperlipidemia
-Treatment Guideline (High Intensity)
A
- Ages 20-75 + LDL-C >/=190 mg/dl = high intensity statin w/out risk assessment
- T2DM >/= 10 yrs, T1DM >/=20 years, renal dz, retinopathy, PVD with ABI <0.9
- High intensity statin w/ aim to lower LDL by 50%
16
Q
Hyperlipidemia
-Treatment Guideline (Moderate Intensity)
A
- Ages 40-75 + T2DM = Moderate intensity statin
- Use risk assessment to see if patient needs high intensity statin
17
Q
Hyperlipidemia
-Treatment Guideline CAD
A
If a patient has known coronary disease, they need to be on a statin.
Treatment guidelines are for patient w/out known coronary artery disease
18
Q
Breakdown of Risk and Treatment
-Borderline Risk
A
- 5-7.5%
- Reduce present modifiable factors
- Discuss moderate intensity statin
- Consider coronary artery calcium score
19
Q
Breakdown of Risk and Treatment
-Intermediate Risk
A
- > 7.5-20%
- Use moderate intensity statin
- Use High intensity statin if Pt has increased Risk factors (Risk stratification w/ CAC if risk is uncertain
*Coronary artery calcium score (CAC)
20
Q
Breakdown of Risk and Treatment
-High Risk
A
- > /= 20%
- Risk discussion to initiate high intensity statin
- Goal to reduce LDL by >/=50%
21
Q
Coronary Artery Calcium Score (CAC)
-CAC scores?
A
- Score of 0
- Can avoid statins and recheck CAC in 5-10 yrs. (Make sure pt doesn’t smoke) - Score 1-100
- Reasonable to initiate moderate intensity statin - Score >100
- >75th percentile; Use a statin at any age
22
Q
Coronary Artery Calcium Score (CAC)
-More Info
A
- A score of ZERO does not imply zero risk
- ALWAYS incorporate w/ other known risk factors
- Doesn’t replace a stress test
23
Q
Primary Prevention of ASCVD
-Aspirin Use?
A
- Consider low dose aspirin (75-100mg daily) for
- 40-70 yr old adults who have higher risk for ASCVD but NO increased risk of bleeding
24
Q
Primary Prevention
-Weight Control
A
- Obesity BMI >/= 30
- Overweight BMI 25-29.9
- Both Obesity and overweight increase risk for ASCVD, HF, A fib, compared to normal weight - Meaningful weight loss is considered >/= 5% of initial weight
- 5-10% loss can result in improvement in BP, lipids, glucose and can delay T2DM
- Document DMI and waist circumference during each visit.
25
Primary Prevention
| -Physical activity recommendation
1. 150 min/wk of moderate intensity
2. 75 min of vigorous-intensity exercise
- 50% of patients are considered sedentary
Moderate activity = brisk walking, biking, dancing, yoga, swimming recreationally
Vigorous activity = Jogging/running, biking >10 mph, tennis, swimming laps
26
HTN
| -Non-modifiable (Relative) Risk Factors
1. CKD
2. Family Hx
3. Increased Age
4. Low socioeconomic status
5. Male
6. Obstructive Sleep apnea
7. Psychosocial stress
27
HTN
| -Risk Factors
1. Obesity
2. Metabolic Syndrome
3. High dietary Fat
4. Smoking
5. Stress
6. Genetic
28
HTN Can be a Risk Factor for?
1. CVA
2. MI, HF
3. Aneurysms
4. PAD
5. Cognitive dysfunction
6. Dementia
7. Nephropathy (renal Failure)
8. Retinopathy
29
Secondary HTN
| -Causes
1. #1 Cause of Secondary HTN is RENOVASCULAR DZ (Renal artery stenosis)
30
Secondary HTN
| -Common Causes
1. Obstructive sleep apnea
2. Renal parenchymal dz
3. Primary aldosteronas
4. Renal artery stenosis
31
Secondary HTN
| -Uncommon Causes
1. Pheochromocytoma
2. Cushing’s dz
3. Hyperparathyroidism
4. Aortic coarctation
32
HTN
| -Medication and Substances that increase BP
1. Alcohol
2. Amphetamines
3. Antidepressants (SNRI’s NOT SSRI’s)
4. Herbal supplements (St. John’s wart
5. Oral contraceptives
6. NSAIDS
7. Cocaine, meth
8. Systemic steroids
33
True Resistant HTN
| -Definition
1. Pt is on max doses of all meds + a spironolactone
34
HTN
| -Initial Treatment Non-Black
1. Non-Black patient + or - DM:
| - Start Diuretic, CC or ACE/ARB
35
HTN
| -Initial Treatment Black Patients
1. Start Thiazides-like diuretics or a CCB
| 2. Add an ACE-I/ARB later if they have DM
36
HTN
| -Initial Treatment w/ HFrEF, or CAD
1. BB
2. ACE/ARB
3. Amlodipine
37
HTN
| -Most likely Initial Treatment
1. Thiazide diuretic (HCTZ
2. CCB’s
3. ACE-I or ARB’s
Start with one of these and MAX the dose then add a second one if needed
38
HTN
| -Follow up
1. See patient every 3-6 months
| 2. Yearly if BP is under control
39
HTN
| -BP treatment goal?
<130/80 **
40
Apparent Resistant HTN
| -Definition
Uncontrolled clinic BP despite being prescribed 3 or more anti-HTN meds or require prescriptions of four or more drug to control BP
41
True Resistant HTN
| -Definition
1. Uncontrolled clinic BP w/ med adherence
AND
2. Uncontrolled BP confirmed by 24-hr ambulatory BP monitoring
42
Pseudo-resistant HTN
Poorly-controlled HTN that appears resistant but is actually other factors:
1. Inaccurate Cuff size (Small = high; Large = low)
2. Poor adherence to meds
3. Suboptimal med therapy
4. Poor adherence to lifestyle and dietary approaches
5. White coat HTN
43
Refractory HTN
1. Uncontrolled on maximal medical therapy
-Defined as 5 or more medications including Chlorthalidone and MRA
—Spironolactone
44
HTN
| -When to Refer
1. Uncontrolled on 3 full doses or maximum tolerance
2. Secondary causes
3. Autonomic failure w/ or tho static hypotension but HTN when supine
6030 Primary Care Test 2 Complete ☑️
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