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70 Cards in this Set

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According to BEACH data (2003-2004), what percentage of GP encounters involve CVD?
20.5%.
What is the single most common CVD problem?
Hypertension (46% of all CVD problems, 10/100 encounters)
Clustering of risk factors for CVD occur in what populations?
- Certain ethnic groups (Indigenous, Indian).
- Elderly.
- People with diabetes.
- Low SES groups.
List important aspects to assess in the history, physical examination and laboratory tests in prevention of vascular disease.
History:
- Age.
- Gender.
- Family history of CVD.
- Smoking.
- Exercise.
- Diabetes.

Physical examination:
- BMI.
- Waist circumference.
- Blood pressure.
- Proteinuria.

Laboratory tests:
- Fasting lipids.
- Fasting glucose.
- Creatinine.
- Calculate GFR.

DETERMINE ABSOLUTE RISK OF CVD EVENT OVER THE NEXT 5 YEARS.
Investigations in the prevention of vascular disease.
Basic:
- Urine dipstick.
- Fasting lipid fractions.
- E/LFTs etc.

Specific:
- HbA1c in diabetes.
- ABPI.
- ECG, etc.
What are the main aspects of proper management of diabetes?
- Systematic care.
- Glycaemic control.
- BP control.
- Management of all CVD risk factors.
Who should be recommended to make lifestyle changes to reduce blood pressure and total risk?
Anyone with above-optimal blood pressure (>120/80) should be encouraged to make lifestyle changes.
Who should take anti-hypertensive drugs?
The decision to take anti-hypertensive drugs should be based on absolute cardiovascular risk and blood pressure. People at high to very high risk are candidates for drug therapy.
This includes:
- High on cardiovascular risk calculator.
- Target organ damage (left ventricular hypertrophy, atherosclerotic plaques, hypertensive retinopathy, renal function changes).
- Associated clinical conditions (established heart, vascular, cerebrovascular or renal disease).
- Diabetes.
- ATSI.
What is recommended for a patient with medium risk on the cardiovascular risk calculator?
Generally, a 3-6 month trial of lifestyle changes should be tried to reduce BP and risk to acceptable levels and allow some to avoid drug therapy.
Drugs are attempted if the patient appears refractive to this therapy, for whatever reason.
What lifestyle modifications can be done to reduce cardiovascular risk?
- Weight reduction.
- Healthy eating.
- Dietary sodium restriction.
- Physical activity.
- Moderation of alcohol consumption.
- Quitting smoking.
What is the optimal BMI to aim for to reduce cardiovascular risk?
18.5-24.9.
What should the diet comprise of to reduce cardiovascular risk?
A diet rich in fruits, vegetables and low-fat dairy products and with a reduced content of saturated and total fat.
What is the recommended exercise regime to reduce cardiovascular risk?
Engage in at least 30 minutes of moderate intensity physical activity, such as brisk walking, on 5 or more days per week.
What is the recommended alcohol guidelines to reduce cardiovascular risk?
Limit daily consumption to no more than 2 standard drinks per day in men and no more than 1 in women.
What is chlorthalidone?
A thiazide-like diuretic.
What doses are thiazides usually taken for hypertension?
Equivalent to hydrochlorothiazide 12.5-25mg/day. Low enough dose to make side effects unusual.
How is the tolerability of thiazides in comparison with lisinopril?
Adherence to thiazide therapy was better than on ACE inhibitors after 5 years.
How would you prescribe a thiazide?
- Initiate at a low dose and titrate up.
- Doses above an equivalent of hydrochlorothiazide 25mg provide no substantial antihypertensive benefit but increases the risk of metabolic disturbances.
- A BP response to the thiazide is usually evident within 2-4 weeks of initiation.
- Allow at least a month between dose increments.
Should fixed dose combination products containing low-dose thiazide be used for first-line initiation and why?
It should NOT because they make it difficult to titrate dose to effect, or identify the source of adverse effects.
How is reaching BP goals more difficult more diabetic patients?
- Most will require at least 2 anti-hypertensive drugs.
- Compliance may be compromised when patients are receiving medications for other conditions.
- Diabetic patients are just naturally more resistant to BP control for whatever reason.
Why are beta-blockers not recommended for diabetics in BP control?
- May predispose some patients to hypoglycaemia.
- Masks the adrenergic warning signs of hypoglycaemia (tremor and tachycardia).
Are calcium-channel blockers (i.e. amlodipine) recommended as first-line or second-line drugs for BP control in diabetics?
Second-line.
What is the first-line treatment for Type 1 diabetes accompanied by microalbuminuria or proteinuria?
ACE-I delay progression of renal disease.
What might be useful for a Type II diabetic patient with overt nephropathy?
AT-II receptor antagonists might slow the progressive loss of renal function, although results rely heavily on the surrogate endpoint of serum creatinine.
All patients with IHD should have daily 75-150mg aspirin. True or false?
True. Contraindications exist however.
What are the life-threatening but exceedingly rare risks of using daily aspirin?
- Extracranial bleeding.
- Haemorrhagic stroke.
What are the contraindications to daily aspirin use to reduce cardiovascular risk?
- Peptic ulcer disease.
- Aspirin allergy.
- Bleeding disorder.
What are the symptoms of actual aspirin allergy (as opposed to just an intolerance)?
- Rhinorrhoea, bronchospasm and/or laryngospasm.
- Urticaria with or without angioedema.
- Anaphylaxis (e.g. hypotension, swelling, tachypnoea, laryngeal oedema, pruritis).
What alternative can be used in a patient with an aspirin contraindication?
Clopidegrel (more expensive than aspirin, but just as effective).
What are some potential side effects of clopidegrel?
- Skin rash.
- Diarrhoea.
- Thrombotic thrombocytopenic purpura.
When could clopidegrel be added to aspirin?
If the patient is compliant and still has recurrent vascular events while on aspirin alone.

The risk of major bleeds increases further with combination therapy (doubled GI bleed risk).
How quickly can one develop tolerance to nitrates?
Tolerance can develop within 24 hours of continuous or frequent exposure by any route.

Ensure patients have a nitrate free period of 10-12 hours per day during a period when symptoms are less likely (i.e. during sleep).
How long should a patient on nitrates have a 'rest' period and how frequently to prevent tolerance?
Ensure patients have a nitrate free period of 10-12 hours per day during a period when symptoms are less likely (i.e. during sleep).
What are common side effects of using nitrates?
- Headache (usually resolves in a few days).
- Postural hypotension (usually resolves in a few days).
- Flushing.
- Syncope.
- Skin irritation (patches).
- Nausea (oral)
How can you help minimise the side effects of using nitrates?
Slow upward titration of the dose, or reducing the dose.

Take oral nitrates with food.

Change application sites for patches to minimise skin irritation.
What is the compliance rate of oral nitrates 2-3 times a day in stable angina patients?
50%.
What is the compliance rate of oral nitrates once a day in stable angina patients?
90%.
How is isosorbide mononitrate?
One daily at same time every day (formulation allows for nitrate free period).
How is glyceryl trinitrate?
Apply morning or evening and remove patch for a 10-12 hour nitrate-free interval.
How is isosorbide dinitrate taken?
Up to 3 times a day with 10-12 hours nitrate free interval between two doses. (e.g. 8am, 12pm, 3pm).
What are predictors of medication non-compliance?
- Age (>75 years).
- Depression.
- Dementia.
- Social isolation or deprivation.
- Recent MI or other vascular event.
- Multiple medications.
- Poor education on meds.
- Treatment does not control symptoms.
- Intolerable side effects (i.e. beta blockers).
- Poor attitude to taking meds.
- Lack of insight into benefits.
- Missed appointments.
How do you identify and regularly monitor patients for non-compliance?
- Identify those at risk early.
- Asking how many meds were missed during the previous week.
- Check for poor responses to dose increments.
- Following up missed appointments.
What strategies can help improve compliance?
- Simplify dosing regime.
- Minimise number of medications: use drug classes that treat multiple conditions if possible for patients with more than one conditon.
- Time the doses with patient's routine (e.g. meals).
- Organise follow-up appointment within 2 weeks for an early review of compliance.
- Contact those who miss appointments.
- Regular reviews.
- Increase education by conveying risks and benefits.
- Acknowledge patient's efforts with compliance.
- Monitor treatment effects.
GPs can help their patients with ischaemic heart disease
to manage the many healthcare services they require by
using....
An enhanced primary care (EPC) plan.
Patients having difficulty taking their medicines for
ischaemic heart disease may benefit from...
A Home Medicines Review (HMR) where a pharmacist provides advice to the GP on the medicines issues of the patient being reviewed.
Primary hyperlipidaemia can be divided into what?
- Hypercholesterolaemia.
- Hypertriglyceridaemia.
- Combined hyperlipidaemia.
Secondary hyperlipidaemia can be due to...
Diabetes, excess alcohol intake and adverse drug effects.
Cholesterol screening every 5 years is recommended for what patients?
- 45+ years in the general population.
- 20+ years in those with a first-degree relative with premature CHD (Males<55, Females<65).
Cholesterol screening should be how frequent for high risk individuals or those with established CHD?
Yearly.
According to the PBS, how long must the patient try dietary therapy before they can get subsidised statins?
6 weeks. Fasting lipids must be checked after completion of dietary therapy.
A patient with CHD qualifies for a PBS statin if total cholesterol level is above...
4mmol/L.
A patient with diabetes, familial hypercholesterolaemia, family history of CHD, or hypertension qualifies for a PBS statin if total cholesterol level is above...
6.5mmol/L

OR

Total cholesterol > 5.5mmol/L with a HDL < 1mmol/L.
A 35-75 yo male or a postmenopausal woman up to 75 years of age qualifies for a PBS statin if total cholesterol level is above...
6.5mmol/L

or a triglyceride level of >4mmol/L.
A patient with no other significant risk factors qualifies for a PBS statin if total cholesterol level is above...
9mmol/L


or triglyceride level is 8mmol/L.
What relationship does cholesterol levels have for stroke risk?
High cholesterol - increased risk of ischaemic stroke.

Low levels of cholesterol - increased risk of haemorrhagic stroke.

That's why there's no real benefit (or harm) in giving statins to patients with history of TIAs or stroke.

There is a benefit if a history of CHD or elevated serum cholesterol exists.
What are the current LDL cholesterol, total cholesterol, HDL and triglyeride targets recommended for individuals with established CHD or are at high risk?
- LDL cholesterol <2.5 mmol/L.
- Total cholesterol <4.0 mmol/L
- HDL >1.0 mmol/L, and
- Triglycerides <2.0 mmol/L.
What are currently the two most frequently prescribed statins in Australia?
- Atorvastatin 20mg.
- Simvastatin 20mg.
What are the side effects of using statins?
- Muscle aches and pains.
- Elevated creatinine kinase.
- Hepatotoxicity (3% experience dose-dependent elevations of ALT and AST).
- Rhabdomyolysis (0.04-2% of users but death is rare).
When should the statin be ceased in terms of myopathy?
If the patient has symptoms and a creatinine kinase 4 times the upper limit.
Who SHOULDN'T take statins (contraindications)?
- Severe liver disease.
- Chronic hepatitis.
- Heavy alcohol consumption.
What drug is recommended for hypercholesterolaemia and what needs to be monitored?
Statin.

Monitor:
- LFT.
- Creatinine Kinase.
- Lipid levels.
What drugs are recommended for hypercholesterolaemia if statins have an inadequate response?
Resin or ezetimibe.
What drug is recommended for hypertriglyceridaemia and what needs to be monitored?
Fibrates (or fish oils).

Monitor:
- LFT.
- Creatinine kinase.
- Lipid levels.
What drug treatment options are available for combined hyperlipidaemia?
Use either:
- Statin + Fish oil

OR

- Statin + Fibrate.
How does ezetimibe work?
Ezetimibe works by decreasing the absorption of cholesterol from the small intestine.
What role does fibrates play (what hyperlipidaemias are they used for)?
They have a role in combined hyperlipidaemia and predominant triglyceridaemia.
What do fibrates do to the lipid profile?
Lowers triglycerides and raises HDL.
Bile acid binding resins have what predominant side effect?
Gastrointestinal disturbances. But it lowers LDL and raises HDL.
What are fish oils rich in that are important in combating lipidaemia?
Omega 3 polyunsaturated fatty acids.
What do statins do for CRP levels?
Reduces it.