Cvd Risk In General Practice - Assessment And Management

Front 1

According to BEACH data (2003-2004), what percentage of GP encounters involve CVD?

Back 1

20.5%.

Front 2

What is the single most common CVD problem?

Back 2

Hypertension (46% of all CVD problems, 10/100 encounters)

Front 3

Clustering of risk factors for CVD occur in what populations?

Back 3

- Certain ethnic groups (Indigenous, Indian).
- Elderly.
- People with diabetes.
- Low SES groups.

Front 4

List important aspects to assess in the history, physical examination and laboratory tests in prevention of vascular disease.

Back 4

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.

Front 5

Investigations in the prevention of vascular disease.

Back 5

Basic:
- Urine dipstick.
- Fasting lipid fractions.
- E/LFTs etc.

Specific:
- HbA1c in diabetes.
- ABPI.
- ECG, etc.

Front 6

What are the main aspects of proper management of diabetes?

Back 6

- Systematic care.
- Glycaemic control.
- BP control.
- Management of all CVD risk factors.

Front 7

Who should be recommended to make lifestyle changes to reduce blood pressure and total risk?

Back 7

Anyone with above-optimal blood pressure (>120/80) should be encouraged to make lifestyle changes.

Front 8

Who should take anti-hypertensive drugs?

Back 8

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.

Front 9

What is recommended for a patient with medium risk on the cardiovascular risk calculator?

Back 9

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.

Front 10

What lifestyle modifications can be done to reduce cardiovascular risk?

Back 10

- Weight reduction.
- Healthy eating.
- Dietary sodium restriction.
- Physical activity.
- Moderation of alcohol consumption.
- Quitting smoking.

Front 11

What is the optimal BMI to aim for to reduce cardiovascular risk?

Back 11

18.5-24.9.

Front 12

What should the diet comprise of to reduce cardiovascular risk?

Back 12

A diet rich in fruits, vegetables and low-fat dairy products and with a reduced content of saturated and total fat.

Front 13

What is the recommended exercise regime to reduce cardiovascular risk?

Back 13

Engage in at least 30 minutes of moderate intensity physical activity, such as brisk walking, on 5 or more days per week.

Front 14

What is the recommended alcohol guidelines to reduce cardiovascular risk?

Back 14

Limit daily consumption to no more than 2 standard drinks per day in men and no more than 1 in women.

Front 15

What is chlorthalidone?

Back 15

A thiazide-like diuretic.

Front 16

What doses are thiazides usually taken for hypertension?

Back 16

Equivalent to hydrochlorothiazide 12.5-25mg/day. Low enough dose to make side effects unusual.

Front 17

How is the tolerability of thiazides in comparison with lisinopril?

Back 17

Adherence to thiazide therapy was better than on ACE inhibitors after 5 years.

Front 18

How would you prescribe a thiazide?

Back 18

- 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.

Front 19

Should fixed dose combination products containing low-dose thiazide be used for first-line initiation and why?

Back 19

It should NOT because they make it difficult to titrate dose to effect, or identify the source of adverse effects.

Front 20

How is reaching BP goals more difficult more diabetic patients?

Back 20

- 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.

Front 21

Why are beta-blockers not recommended for diabetics in BP control?

Back 21

- May predispose some patients to hypoglycaemia.
- Masks the adrenergic warning signs of hypoglycaemia (tremor and tachycardia).

Front 22

Are calcium-channel blockers (i.e. amlodipine) recommended as first-line or second-line drugs for BP control in diabetics?

Back 22

Second-line.

Front 23

What is the first-line treatment for Type 1 diabetes accompanied by microalbuminuria or proteinuria?

Back 23

ACE-I delay progression of renal disease.

Front 24

What might be useful for a Type II diabetic patient with overt nephropathy?

Back 24

AT-II receptor antagonists might slow the progressive loss of renal function, although results rely heavily on the surrogate endpoint of serum creatinine.

Front 25

All patients with IHD should have daily 75-150mg aspirin. True or false?

Back 25

True. Contraindications exist however.

Front 26

What are the life-threatening but exceedingly rare risks of using daily aspirin?

Back 26

- Extracranial bleeding.
- Haemorrhagic stroke.

Front 27

What are the contraindications to daily aspirin use to reduce cardiovascular risk?

Back 27

- Peptic ulcer disease.
- Aspirin allergy.
- Bleeding disorder.

Front 28

What are the symptoms of actual aspirin allergy (as opposed to just an intolerance)?

Back 28

- Rhinorrhoea, bronchospasm and/or laryngospasm.
- Urticaria with or without angioedema.
- Anaphylaxis (e.g. hypotension, swelling, tachypnoea, laryngeal oedema, pruritis).

Front 29

What alternative can be used in a patient with an aspirin contraindication?

Back 29

Clopidegrel (more expensive than aspirin, but just as effective).

Front 30

What are some potential side effects of clopidegrel?

Back 30

- Skin rash.
- Diarrhoea.
- Thrombotic thrombocytopenic purpura.

Front 31

When could clopidegrel be added to aspirin?

Back 31

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).

Front 32

How quickly can one develop tolerance to nitrates?

Back 32

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).

Front 33

How long should a patient on nitrates have a 'rest' period and how frequently to prevent tolerance?

Back 33

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).

Front 34

What are common side effects of using nitrates?

Back 34

- Headache (usually resolves in a few days).
- Postural hypotension (usually resolves in a few days).
- Flushing.
- Syncope.
- Skin irritation (patches).
- Nausea (oral)

Front 35

How can you help minimise the side effects of using nitrates?

Back 35

Slow upward titration of the dose, or reducing the dose.

Take oral nitrates with food.

Change application sites for patches to minimise skin irritation.

Front 36

What is the compliance rate of oral nitrates 2-3 times a day in stable angina patients?

Back 36

50%.

Front 37

What is the compliance rate of oral nitrates once a day in stable angina patients?

Back 37

90%.

Front 38

How is isosorbide mononitrate?

Back 38

One daily at same time every day (formulation allows for nitrate free period).

Front 39

How is glyceryl trinitrate?

Back 39

Apply morning or evening and remove patch for a 10-12 hour nitrate-free interval.

Front 40

How is isosorbide dinitrate taken?

Back 40

Up to 3 times a day with 10-12 hours nitrate free interval between two doses. (e.g. 8am, 12pm, 3pm).

Front 41

What are predictors of medication non-compliance?

Back 41

- 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.

Front 42

How do you identify and regularly monitor patients for non-compliance?

Back 42

- 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.

Front 43

What strategies can help improve compliance?

Back 43

- 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.

Front 44

GPs can help their patients with ischaemic heart disease
to manage the many healthcare services they require by
using....

Back 44

An enhanced primary care (EPC) plan.

Front 45

Patients having difficulty taking their medicines for
ischaemic heart disease may benefit from...

Back 45

A Home Medicines Review (HMR) where a pharmacist provides advice to the GP on the medicines issues of the patient being reviewed.

Front 46

Primary hyperlipidaemia can be divided into what?

Back 46

- Hypercholesterolaemia.
- Hypertriglyceridaemia.
- Combined hyperlipidaemia.

Front 47

Secondary hyperlipidaemia can be due to...

Back 47

Diabetes, excess alcohol intake and adverse drug effects.

Front 48

Cholesterol screening every 5 years is recommended for what patients?

Back 48

- 45+ years in the general population.
- 20+ years in those with a first-degree relative with premature CHD (Males<55, Females<65).

Front 49

Cholesterol screening should be how frequent for high risk individuals or those with established CHD?

Back 49

Yearly.

Front 50

According to the PBS, how long must the patient try dietary therapy before they can get subsidised statins?

Back 50

6 weeks. Fasting lipids must be checked after completion of dietary therapy.

Front 51

A patient with CHD qualifies for a PBS statin if total cholesterol level is above...

Back 51

4mmol/L.

Front 52

A patient with diabetes, familial hypercholesterolaemia, family history of CHD, or hypertension qualifies for a PBS statin if total cholesterol level is above...

Back 52

6.5mmol/L

OR

Total cholesterol > 5.5mmol/L with a HDL < 1mmol/L.

Front 53

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...

Back 53

6.5mmol/L

or a triglyceride level of >4mmol/L.

Front 54

A patient with no other significant risk factors qualifies for a PBS statin if total cholesterol level is above...

Back 54

9mmol/L


or triglyceride level is 8mmol/L.

Front 55

What relationship does cholesterol levels have for stroke risk?

Back 55

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.

Front 56

What are the current LDL cholesterol, total cholesterol, HDL and triglyeride targets recommended for individuals with established CHD or are at high risk?

Back 56

- LDL cholesterol <2.5 mmol/L.
- Total cholesterol <4.0 mmol/L
- HDL >1.0 mmol/L, and
- Triglycerides <2.0 mmol/L.

Front 57

What are currently the two most frequently prescribed statins in Australia?

Back 57

- Atorvastatin 20mg.
- Simvastatin 20mg.

Front 58

What are the side effects of using statins?

Back 58

- 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).

Front 59

When should the statin be ceased in terms of myopathy?

Back 59

If the patient has symptoms and a creatinine kinase 4 times the upper limit.

Front 60

Who SHOULDN'T take statins (contraindications)?

Back 60

- Severe liver disease.
- Chronic hepatitis.
- Heavy alcohol consumption.

Front 61

What drug is recommended for hypercholesterolaemia and what needs to be monitored?

Back 61

Statin.

Monitor:
- LFT.
- Creatinine Kinase.
- Lipid levels.

Front 62

What drugs are recommended for hypercholesterolaemia if statins have an inadequate response?

Back 62

Resin or ezetimibe.

Front 63

What drug is recommended for hypertriglyceridaemia and what needs to be monitored?

Back 63

Fibrates (or fish oils).

Monitor:
- LFT.
- Creatinine kinase.
- Lipid levels.

Front 64

What drug treatment options are available for combined hyperlipidaemia?

Back 64

Use either:
- Statin + Fish oil

OR

- Statin + Fibrate.

Front 65

How does ezetimibe work?

Back 65

Ezetimibe works by decreasing the absorption of cholesterol from the small intestine.

Front 66

What role does fibrates play (what hyperlipidaemias are they used for)?

Back 66

They have a role in combined hyperlipidaemia and predominant triglyceridaemia.

Front 67

What do fibrates do to the lipid profile?

Back 67

Lowers triglycerides and raises HDL.

Front 68

Bile acid binding resins have what predominant side effect?

Back 68

Gastrointestinal disturbances. But it lowers LDL and raises HDL.

Front 69

What are fish oils rich in that are important in combating lipidaemia?

Back 69

Omega 3 polyunsaturated fatty acids.

Front 70

What do statins do for CRP levels?

Back 70

Reduces it.