4. Cardiovascular risk estimation & Management of Cardiovascular Risk Factors Flashcards
Why has CHD mortality declined?
Reduced disease incidence:
- Primary prevention for at-risk people: Hypertension, lipid disorders, diabetes, weight management
- Healthier lifestyle
Improved disease management:
- Earlier treatment of acute events
- More effective treatment of acute events
- Secondary prevention
Disparities
Socio-economic:
- Those who are most deprived have a 2-4 fold greater risk of CVD death in middle-age compared with those least deprived
Ethnicity:
- Maori are 2x likely to die from CVD & 1.5x likely to be hospitalised from CVD
Comorbidity:
- CVD risk is increased at an earlier age in those who experience serious mental health illnesses & have 1.5x higher chance of having a CV event
Cardiovascular risk
- Genetic & environmental factors interact to create “intermediary” risk factors
- Environmental factors include socioeconomic, socio-cultural aspects, income, education, housing
- Primary prevention achieved through education & public policy
- Secondary prevention & high risk intervention directed at individuals with either manifest clinical disease or high absolute risk profiles
Risk factors
Non-modifable:
- Age
- (Male) gender
- Family history
- Diabetes
- Familial hyperlipidaemia
- Clinical coronary, cerebrovascular, per vasc disease
Modifiable:
- Cigarette smoking
- Physical activity
- Obesity
- Dietary (western, high SF)
- Psychosocial
- Socioeconomic
- HYPERTENSION
- HYPERCHOLESTEROLAEMIA (high LDL, low HDL cholesterol)
Risk estimation - Assessment of CVD risk
Risk is estimated using:
- Prior CVD event
- Congestive heart failure
- Familial hypercholesteroaemia
- Patients with chronic kidney disease
- Diabetes with overt nephropathy or other renal disease
PREDICT age range is 30-74 years
Risk management - Shared treatment decisions
Take into account:
- Individual’s 5 year combined CVD risk
- Recommendations based on benefit, harms & cost effectiveness
- Individuals clinical state, age, cormorbidities, frailty & life expectancy
- Personal preferences for treatment
Hypertension guideline
Patients should aim for:
- 140/85 if 5 yr risk < 15%
- 130/80 if 5 year risk > 15%
Prevalence
- ~40% of men & women have raised blood pressure
- Patients who are normotensive at age 55 have a 90% lifetime risk for developing hypertension
Aetiology
- 95% of hypertensives have essential hypertension
- 2-5% have hypertension secondary to other causes
If secondary hypertension … treat the primary cause
Consequence of hypertension
- Stroke
- Coronary artery disease
- Left ventricular hypertrophy
- Heart failure
- Peripheral vascular disease
- Renal disease
- Retinopathy
Hypertension: Non-drug treatment
- DASH eating plan
- Reduce sodium intake
- Physical activity
- Moderation of alcohol consumption
Hypertension: Drug treatments
- ACE inhibitors OR ARBs
- CCBs
- Diuretics
- Alpha-blockers OR spironolactone OR beta-blockers
- Centrally acting agents, vasodilators
Treatment resistant hypertension - Causes (exclusions)
“Failure to reach target BP in patients who are adhering to full doses of an appropriate 2-drug regimen that includes a diuretic”
- Exclude secondary hypertension
- Check BP measurement techniques
- Check for non-adherence, inadequate doses or inappropriate combinations
- Consider drug induced: NSAIDs/COX-2, sympathomimetics, OCP, corticosteroids, cyclosporin, tacrolimus, EPO, cocaine, amphetamines, illicit drugs
- Consider OTC medicines
- Check for volume overload, excess sodium intake, volume retention from kidney disease, obesity, excess alcohol intake
Dyslipidaemia - hypercholesterolaemia
Risk factor for coronary heart disease
Classification of lipidaemia
Primary - genetic
Secondary - acquired
- Diabetes
- Hypothyroidism
- Renal failure
- Obesity
- Ethanol
- Drugs
