CVDRA

Question 1

When to screen gen population for cardiovascular risk (no sx or known risk factors)

Answer 1

Men - 45yo - 74yo
Women - 55yo - 74yo

Question 2

When to screen Māori, Pacific or South-Asian for cardiovascular risk

Answer 2

Men - 30yo - 74yo
Women - 40yo - 74yo

Question 3

When to screen people with personal or family risk factors for cardiovascular risk

Answer 3

Men - 35yo - 74yo
Women - 45yo - 74yo

Question 4

When to screen people with diabetes (type 1 or 2) for cardiovascular risk

Answer 4

From diagnosis

Question 5

When to screen people with severe mental illness for cardiovascular risk

Answer 5

From 25yo

Question 6

What counts as severe mental illness for CVDRA early screening

Answer 6

Schizophrenia
Depression
Bipolar
Schizoaffective disorder
Addiction

Question 7

Family risk factors for CVD

Answer 7

Hospitalisation or death from MI or stroke < 50 years in a first-degree relative
Diabetes in a first-degree relative
Familial hypercholesterolaemia

Question 8

Patients with ________ (what conditions etc.) are at high risk of CVD and do not require screening but do require aggressive risk management

Answer 8

Prior cardiovascular event e.g. angina, CABG, MI, PCI, PVD, stroke, TIA
Familial hypercholesterolaemia
CHF
Diabetes with eGFR < 45
Stage 4 CKD (eGFR <30)
Asymptomatic carotid (plaque on carotid USS) or coronary disease (coronary artery calcium score >400 or plaque on CT angiography)

Question 9

Modifiable risk factors for CVD

Answer 9

Smoking
BP
Alcohol
Nutrition
BMI > 30, or waist circumference >102 cm in men or >88 cm in women
Physical activity level
HbA1c 41 to 49

Question 10

Non modifiable risk factors for CVD

Answer 10

Age and sex
Known CVD, asymptomatic carotid disease or cardiac disease, or at high risk of developing diabetes
Family history of CVD younger than 50 years
Genetic lipid disorder
eGFR < 60
AF
Diabetes
Gestational diabetes
Māori, Pasifika, or South Asian
HIV
Systemic lupus erythematosus (SLE)
Serious mental illness

Question 11

Cut offs for low, intermediate and high CVD risk

Answer 11

Low <5%
Intermediate 5-15%
High >15%

Question 12

General recommendations for management of low risk CVD

Answer 12

Medication not recommended (harm likely to exceed benefit)

Question 13

General recommendations for management of intermediate risk CVD

Answer 13

Benefits & risks of BP and lipid lowering meds should be discussed and initiation of treatment considered

Question 14

General recommendations for management of high risk CVD

Answer 14

BP and lipid lowering meds recommended
Consider aspirin for primary prevention of CVD if <70yo

Question 15

If a patient has elevated BP, every 10 mmHg reduction in SBP = _____ relative reduction in CVD events

Answer 15

20%

Question 16

Benefits of lowering BP greatest if ________ rather than those with highest BP

Answer 16

Multiple risk factors

Question 17

Home BP readings are generally ______ lower than clinic-based measurements

Answer 17

5 – 10 mmHg

Question 17

Home BP monitoring should be considered when…

Answer 17

White-coat hypertension is suspected
Marked variation between clinic measurements or between clinic and home
Medicine-induced hypotension is suspected
The patient is not responding to treatment, i.e. resistant hypertension is suspected

Question 18

Advise patients performing home-based blood pressure monitoring to

Answer 18

Take BP after sitting for five minutes
Record two consecutive measurements, one minute apart
Take morning measurements before breakfast and before taking any medicines
Take evening measurements before going to bed and after taking medicines
Record obvious reasons for variations, e.g. illness, caffeine, smoking or recent exercise

Question 19

A home BP level can be calculated using…

Answer 19

Average of their home measurements

Question 20

Risk based approach to managing BP

Answer 20

Risk <5% = lifestyle modifications if BP ≥ 130/80. Medicines not recommended.
Risk 5-15% = discuss benefits and harms of medication if BP persistently ≥ 140/90
Risk ≥15% = medication strongly recommended if BP persistently ≥ 130/80
≥ 160/100 with any level of CVD risk = medication recommended

Question 21

Lifestyle interventions for reducing BP

Answer 21

Reducing salt intake
Regular exercise of moderate intensity (e.g. 30min walk per day)
Alcohol intake within guidelines

Question 22

Reducing salt intake can result in clinically significant reductions in BP in _________ (timeframe). The ideal daily intake of salt is thought to be _______.

Answer 22

~4 weeks
3 g

Question 23

Frequent alcohol consumption may increase SBP by ________

Answer 23

5 – 10 mmHg

Question 24

Regular exercise of moderate intensity, e.g. walking for 30min/day, can reduce SBP by ________ mmHg and diastolic by ______ mmHg

Answer 24

SBP 4 – 10 DBP 3 – 8

Question 25

Alcohol recommended intake

Answer 25

Women: 2 std drinks/day; ≤ 10 std drinks/ week; ≥ 2 alcohol free days/week Men: 3 std drinks/day; ≤ 15 std drinks/week; ≥ 2 alcohol free days/week

Question 26

A standard drink is approximately how much beer/wine

Answer 26

330 mL of 4% beer 100 mL of 12.5% wine

Question 27

Meta-analyses of RCTs show that every 1 mmol/L reduction in LDL from statin treatment =______reduction in the relative risk of major CVD events over five years

Answer 27

~25%

Question 28

Who to treat with statins regardless of their CVD risk

Answer 28

TC:HDL ≥ 8 Familial hyperlipidaemia Triglycerides ≥ 11 mmol/L

Question 29

Which part of lipids is used when calculating CVD risk and which is used as a target once treatment started

Answer 29

TC:HDL is used when calculating CVD risk and to guide treatment decisions. Once treatment started, LDL levels are used to inform decisions about the intensity of lipid-lowering medicines.

Question 30

Most effective dietary approach to lowering LDL while continuing to maintain/improve HDL is _________

Answer 30

Substitute saturated fats with mono- and polyunsaturated dietary fats.

Question 31

Lipid management recommendations for CVRA <5% (low risk)

Answer 31

Lifestyle interventions recommended Lipid-lowering medicines are not recommended

Question 32

Lipid management recommendations for CVRA 5-15% (intermediate risk)

Answer 32

Benefits of treatment likely outweigh adverse effects. Discuss benefits/harms of statins and encourage dietary changes. If statins started, aim reduction in LDL ≥ 40%

Question 33

Lipid management recommendations for CVRA >15% (high risk)

Answer 33

Statins strongly recommended + dietary changes. LDL target of < 1.8mmol/L

Question 34

1st line treatment to lower lipids

Answer 34

Statins Atorvastatin generally used first line in NZ

Question 35

Blood test monitoring after starting lipids

Answer 35

Check lipids (non-fasting) every 6-12 months until target reached, then annually LFTs not routinely required.

Question 36

When to consider rosuvastatin in primary prevention

Answer 36

Maori/Pasifika peoples at risk of CVD High CVD risk not meeting LDL target (<1.8) with max tolerated dose of atorvastatin/simvastatin

Question 37

When to consider rosuvastatin in secondary prevention

Answer 37

If meets SA critera after treatment with max tolerated dose of atorvastatin/simvastatin: Familial hypercholesterolemia not meeting LDL <1.8 Known CVD and not meeting LDL <1.4 Recurrent major cardiovascular event (MI, ischaemic stroke, coronary revascularisation, hospitalisation for unstable angina) in the last 2 years and LDL not <1.0

Question 38

Is statin intolerance common?

Answer 38

Most people tolerate statins well and serious adverse effects are rare Statin intolerance (esp myalgia) is over-diagnosed

Question 39

Is there evidence of link between statins and cognitive impairment

Answer 39

No

Question 40

What to do if adverse effects occur when starting statin?

Answer 40

Stop statin until sx resolves (e.g. 2-3 weeks) then re-start and monitor for return of sx. If symptoms recur consider lowering the dose, alternate day dosing or switching to an alternative statin (rosuvastatin generally better tolerated)

Question 41

Statins can have serious interactions with other medicines; be aware of the interaction between simvastatin and ________ which can result in rhabdomyolysis

Answer 41

Potent CYP3A4 inhibitors e.g. erythromycin, clarithromycin, azole antifungals and ciclosporin

Question 42

When would you check CK in a patient on statins?

Answer 42

Only check CK if muscle pain, tenderness or weakness which could indicate myopathy

Question 43

What to do if muscle pain & no rise in CK while on statin

Answer 43

Consider reducing the dose or discontinuing the statin but also consider re-challenging once symptoms subside

Question 44

What to do if CK rise 3–10x above normal with symptoms while on statin

Answer 44

Reduce the dose or discontinue the statin and monitor symptoms and CK weekly

Question 45

What to do if CK rise > 10x above normal with symptoms while on statin

Answer 45

Discontinue the statin immediately

Question 46

When to worry about abnormal LFTs secondary to statin and what to do about it

Answer 46

Transaminases >3x upper limit → stop statin. Once LFT normalised consider re-trialing at lower dose or switching statin.

Question 47

When to consider aspirin for primary prevention

Answer 47

< 70yo if five-year CVD risk is ≥ 15% Asymptomatic carotid/coronary disease or plaque

Question 48

When to consider aspirin for secondary prevention

Answer 48

Aspirin is recommended in all patients with established CVD for secondary prevention

Question 49

If established CVD and needing aspirin but at high risk of GI bleed what should you do

Answer 49

Consider PPI

Question 50

Aspirin contraindications

Answer 50

Active peptic ulceration, uncontrolled BP and other major bleeding risks Aspirin hypersensitivity/intolerance Severe hepatic or renal impairment

Question 51

CVRA follow up = _______ review for people at high risk or intermediate risk managed with medication

Answer 51

Annual

Question 52

CVRA follow up timing if not on medication

Answer 52

< 3% - 10 years 3 - 9% - 5 years 10 - 14% - 2 years ≥ 15% - 1 year

Question 53

CVRA follow up if severe mental illness

Answer 53

CVDRA every 2 years (or annually if ≥ 15%)