Cardio- Lecture 1

Front 1

Three types of CVD

Back 1

coronary artery disease (CAD)
peripheral vascular disease (PVD)
other

Front 2

CAD and PVD together are called:

Back 2

atherosclerotic CVD (ASCVD)

Front 3

CAD + PVD are predominantly caused by:

Back 3

ATHEROSCLEROSIS

Front 4

what are examples of CAD?

Back 4

MI, angina

Front 5

what are examples of PVD?

Back 5

ischemic stroke (CVA); abdominal aortic aneurysm (AAA); peripheral arterial disease (PAD); renal artery stenosis
(brain, kidney, aorta)

Front 6

what are "other" types of CVD?

Back 6

non-ischemic stroke arrhythmias; deep vein thrombosis; valve disorder

Front 7

what is Atherosclerosis or hardening of the arteries:

Back 7

-Accumulation of lipids and fibrous tissue within arteries fibrous plaque growth
-occlusion of arterial lumen
-narrows blood flow
-+/- plaque rupture (can be lodged in vessels)
-Reduced perfusion in Coronary/Peripheral Vessels

Front 8

CAD defined as:

Back 8

heart / vessel diseases that result from atherosclerosis and related changes in coronary perfusion

Front 9

examples of CAD:

Back 9

-Stable angina (angina pectoris)
-Ischemic heart disease (IHD)
-Evidence of clinically significant myocardial ischemia (asymptomatic)
-Myocardial Infarction (MI) (heart attack)
-Acute Coronary Syndrome (ACS) or unstable angina
-Coronary artery procedures* (coronary stent, angioplasty, or coronary artery bypass graft [CABG])

Front 10

PVD defined as:

Back 10

non-coronary vessel diseases that most commonly result from atherosclerosis and related changes in perfusion to peripheral vessels (e.g., carotid artery/brain; renal artery/kidney; etc.).

Front 11

examples of PVD

Back 11

Cerebrovascular - ischemic stroke (CVA); transient ischemic attack (TIA); symptomatic carotid disease
Kidney - renal artery stenosis
Aorta – abdominal aortic aneurysm (AAA)
GastrointestinaI – mesenteric artery disease (bowel infarction)
Peripheral arterial disease (PAD) - intermittent claudication

Front 12

"other" CVD defined:

Back 12

General category of vascular diseases NOT related to atherosclerosis (not involving CAD or PVD)

Front 13

examples of "other"

Back 13

Heart failure
Arrhythmias
Non-ischemic strokes
Thromboembolic disorders
Heart valve defects

Front 14

4 assessments of CVD (adult)

Back 14

1.) Is this primary or secondary prevention?

2.) How many MAJOR CVD risk factors are present?
- Which are modifiable?
- Is Metabolic Syndrome present?

3.) Does patient qualify as CAD risk equivalent?
-If yes, why?

4.) If indicated*, what is patient’s estimated 10-year
CAD risk?

* ≥ 2 major RF, age 20-79, primary prevention (no CAD), not CAD risk equivalent

Front 15

Primary prevention:

Back 15

aims to modify or eliminate risk factors that can reduce risk of initial CVD conditions/events
in persons without established CVD

NOTE: Data shows that majority of CVD cases are “known and modifiable”

Front 16

Secondary prevention:

Back 16

aims to modify or eliminate risk factors that can reduce risk of additional or recurrent CVD conditions/events
in persons with established CVD due to known events or conditions (e.g. had MI, stroke, CABG)

NOTE: data shows that past MI poses 4-6 fold increase risk of another MI or death

Front 17

broad treatment goal

Back 17

reduce risk of CVD morbidity and mortality

Front 18

specific treatment goal

Back 18

reduce or eliminate specific, modifiable CVD risk factors

Front 19

in primary CVD prevention:

Back 19

Risk factor management can prevent or slow the development of CVD and related complications

Front 20

in secondary CVD prevention:

Back 20

Aggressive, comprehensive risk factor management in persons with existing CVD can improve patient survival, quality of life, and rate of recurrent events/ interventional procedures

Front 21

cardiovascular risk factors

Back 21

- any condition (or surrogate marker) statistically related to risk of developing cardiovascular disease (CVD)

Lack of risk factors won’t guarantee protection from CVD
Focus on major, independent risk factors

Front 22

CVD risk factor categories

how many risk factors:

Back 22

Nine-
Each factor alone proven to increase CVD risk
Combination of risk factors = additive in CVD predictive power

Front 23

CVD risk factor categories

predisposing risk factors

Back 23

Increase CVD risk but unclear causality (dependent on something else?)
e.g., prothrombotic factors or inflammatory indicators
small LDL size; homocysteine; lipoprotein(a); fibrinogen; C-reactive protein
** emerging risk factors **

Front 24

CVD risk factor categories

conditional risk factors

Back 24

May worsen the MAJOR independent risk factors
E.g. psychosocial factors (i.e., type A; stress; cocaine abuse)

Front 25

Nine major risk factors:

Back 25

1.Age >55 years for males; >65 years for female
2.Family History of premature CVD
= Major CVD event/sudden death in 1st degree (sibling; offspring; parent) female relative at age <65 yrs or 1st degree male at relative <55 yrs
3.Dyslipidemia
4.Hypertension (BP > 140/90 mmHg or being treated)
5.Diabetes Mellitus (DM)
6.Cigarette Smoking (any within the last month)
7.Obesity (Body Mass Index [BMI] ≥30 kg/m2)
8.Physical Inactivity (not active ≥30 min. most days of week)
9.Microalbuminuria or Estimated Glomerular Filtration rate (GFR) <60 mL/min – these are indicators of CKD!

Front 26

which of the nine risk factors are non modifiable?

Back 26

age and family history

Front 27

What are risk equivalent conditions ?

Back 27

DM and CKD (chronic kidney disease)

Front 28

what is metabolic syndrome

Back 28

Constellation of interrelated “metabolic” risk factors

This “Death Quartet” affects 47 million Americans

Front 29

does metabolic increase risk of CVD?

Back 29

Imparts high risk for CVD and for Diabetes (DM)
~2-fold increase in relative risk for atherosclerotic CVD events
~ 5 fold increase in relative risk of developing Type 2 DM

Front 30

what appears to be the underlying cause of metabolic syndrome?

Back 30

appears to be insulin resistance (due to overweight/obesity, physical inactivity and genetic factors)

Front 31

management of metabolic syndrome?

Back 31

Weight loss
increased physical activity
Monitor/control blood glucose, cholesterol, blood pressure

Front 32

you know metabolic syndrome is present if 3 of the following are present:

Back 32

-Large Waist Circumference
Men ≥ 40 inches; Women ≥ 35 inches
-Elevated Triglycerides (TG)
≥150mg/dL or TG treated with drug therapy
-Elevated Blood Pressure (BP)
≥130 mmHg Systolic BP; ≥ 85 mmHg Diastolic BP; or BP treated with drug therapy
-Elevated Fasting Blood Glucose (FBG)
≥ 100mg/dL OR FBG treated with drug therapy
-Reduced HDL-Cholesterol
Men <40mg/dL; Women <50 mg/dL; or -HDL treated with drug therapy

Front 33

Here is rationale behind “coronary equivalent” (CAD risk equivalent) status:

Back 33

Atherosclerosis in 1 arterial tree region predicts atherosclerosis in other regions.
Atherosclerosis in peripheral vessels (PVD) is powerful predictor of Atherosclerosis in coronary vessels (CAD), and vice versa

Front 34

qualifications for CAD risk equivalent status.
A or B
A: Patient with a CAD equivalent medical condition

Back 34

1.)Diabetes Mellitus (DM) – either Type 1 or 2
2.) Significant Chronic kidney disease (CKD)
3.) Peripheral Vascular Disease (PVD) - atherosclerotic
Peripheral Arterial Disease (PAD)
Carotid Artery Disease - CVA, TIA, >50% carotid stenosis
Aorta Disease (AAA-Abdominal Aorta Aneurysm)
Renal artery stenosis

Front 35

qualifications for CAD risk equivalent status.
A or B

B: Patients with estimated 10-year CAD risk > 20%

Back 35

Framingham score tool that estimates 10-year risk of hard CAD

Front 36

rates of survival from CVD worse if a patient has DM and MI vs non-DM and MI

Back 36

true

Front 37

Framingham tool for 10 year CAD risk

benefits:

Back 37

For patients 20-79 years old with
- at least 2 major CVD risk factors
- no known CVD (primary prev.)
- No CAD risk equivalent status
Quantifies individual patient risk of 10-year “hard CAD”
Demonstrates impact of modifying risk factors

Front 38

Framingham tool for 10 year CAD risk

limitations:

Back 38

FALSELY low risk assessment if
age < 20 or >79
CVD (secondary prev.)
DM (CAD risk equiv)
PVD (CAD risk equiv)
CKD (CAD risk equiv)
Assesses “hard CAD” risk
Excludes risk assessment of PVD (e.g. stroke)/ heart failure
May be unjustifiably reassuring to patients with significant risk factor burden.

Front 39

summarizing CVD risk

high risk:

Back 39

-Secondary CVD prevention (has CAD and/or PVD)
-Primary CVD prevention and CAD risk equivalence from 10-year CAD risk >20%, DM and/or CKD
-Some patients may qualify as Very high risk
E.g., Secondary prevention (has CAD and/or PVD) plus multiple major CVD risk factors especially DM, CKD

Front 40

summarizing CVD risk

moderate risk:

Back 40

Primary prevention, no CAD risk equivalence AND at least 2 Major CVD risk factors (10-year CAD risk 10-20%)

Front 41

summarizing CVD risk

low risk:

Back 41

Primary prevention, no CAD risk equivalence) AND 0-1 Major CVD risk factor (10-year CAD risk < 10%)

Front 42

information to assess CVD risk

patient medication profile:

Back 42

Identify drugs that may be used for CVD
CAUTION: Many cardiovascular drugs/drug classes have multiple indications for use, including some non-CVD treatments

Front 43

information to assess CVD risk

patient history/interview:

Back 43

Age, Gender, Heredity
Physical activity, stress level
Adherence (to reduce CV risk)
To prescribed medications
To recommended therapeutic lifestyle changes

Front 44

case 1- Mike:

Back 44

see slides

Front 45

case 2- suzie

Back 45

see slides