What is the risk assessment tool for osteoporosis? What does it measure?
- FRAX score
- Gives 10 year probability of a fracture in the spine, hip, shoulder or wrist for people aged 40–90 years old.
What are the components of the FRAX score?
- Age (40-90)
- Sex
- Weight (kg)
- Height (cm)
- Previous fracture
- Parent fractured hip
- Current smoker
- Glucocorticoids
- Rheumatoid arthritis
- Secondary osteoporosis
- Alcohol >3 units/day
- Femoral neck BMD
How can we incorporate the components of the FRAX score into a general history?
Personal information:
- Age.
- Sex.
- Weight (kg).
- Height (cm).
Past medical history:
- Rheumatoid arthritis.
- Previous fracture.
- Secondary osteoporosis: kidney failure, hyperthyroidism, coeliac disease, kidney failure, T1DM, chronic liver disease, premature menopause.
- Femoral neck BMD from previous DEXA-T scan (g/cm2).
Drug history:
- Glucocorticoids.
- Lithium.
Family history:
- Parental fractured hip.
Social history:
- Smoking.
- Alcohol intake (≥3 alcoholic drinks a day).
What is a T-score? What is a Z-score?
- A T-score shows how much your bone density is higher/lower than the bone density of a healthy 30-year old adult.
- A Z-score compares the condition of your bones with someone of your age/sex/weight/ethnicity.
What are the three different categories of a T-score?
- T–score ≥ –1 = normal bone density, no intervention.
- –2.5 < T–score ≤ –1 = osteopenia, consider medication, lifestyle advice
- T–score ≤ –2.5 = osteoporosis, medication, lifestyle advice.
What is the treatment offered for the three different categories of FRAX scores?
- Low risk (≤10%, reassess 5y):
Lifestyle advice: - More weight-bearing exercise, quitting smoking and limiting alcohol.
- Calcium + vitamin D rich diet, balance exercises.
Home adaptations: - Getting rid of throw rugs, installing grab bars.
- Wearing shoes with good grip.
Intermediate risk (10 < % < 20):
- DEXA scan to measure BMD. If ≤–2.5, treat with bisphosphonate like alendronate 10mg OD or denosumab (RANK-L), teriparatide.
High risk (≥20%):
- T-score >–2.5 modify risk factors and reassess in 2 years.
- T score <–2.5 Tx as above.
How do we assess DVT risk?
Well’s score (probability of developing a DVT)
What are the different components of a Well’s score?
- Active cancer
- Bedridden >3 days or major surgery within 12 weeks
- Calf swelling >3cm compared to the other leg
- Collateral superficial veins present
- Entire leg swollen
- Localised tenderness along the deep venous system
- Pitting oedema in symptomatic leg
- Paralysis, paresis, or recent plaster immobilisation of the lower extremity
- Previously documented DVT
How can we incorporate the different components of a Well’s score into a general history?
History of presenting complaint:
- Paralysis, paresis or recent immobilisation of leg = 1 point.
- Localised tenderness along the deep venous system = 1 point.
- Entire leg swollen = 1 point.
- Calf swelling >3cm compared to other leg (measured 10cm below the tibial tuberosity) = 1 point.
- Pitting oedema, confined to symptomatic leg = 1 point.
- Collateral superficial veins present = 1 point.
Past medical history:
- Bedridden recently >3 days or major surgery within 12 weeks = 1 point.
- Active cancer (treatment or palliation within 6 months) = 1 point.
- Previous DVT = 1 point.
- Alternative Dx to DVT as or more likely = –2 points.
Social history:
- Long-haul flights
- Smoking
- HRT/OCP if appropriate.
- Pregnancy if appropriate.
What do the three categories of Well’s score mean?
Score ≤0 = DVT unlikely, 5% prevalence
Score 1–2 = DVT moderate risk, 17% prevalence
Score ≥3 = DVT likely, 17–53% prevalence
> or equal to 2 – DVT likely (D-dimer and USS)
or equal to 1 – DVT unlikely (D-dimer)
What is the gold standard test for diagnosing a PE?
CTPA
How should we treat a DVT?
- LMWH, e.g. dalteparin
- Oral warfarin and maintain INR 2–3 or a DOAC.
- Compression stockings.
- Treat/seek underlying cause.
- Diet, exercise, smoking cessation.
What are the components of the diabetes risk score?
Non-modifiable risk factors (personal information):
- Age: 50 ≤ age < 60 = 5 points, 60 ≤ age < 70 = 9 points, ≥70 = 13 points.
- Gender: male = 1 point.
- Ethnicity: any other ethnic group other than white European = 6 points.
- Relative with diabetes (ask in family history): yes = 5 points.
Modifiable risk factors (past medical history):
- Waist measurement: 90 ≤ cm < 100 = 4 points, 100 ≤ cm < 110 = 6 points, ≥110cm = 9 points.
- Height and weight measurement for BMI: 25 ≤ kg/m2 < 30 = 3 points, 30 ≤ kg/m2 < 35 = 5 points, ≥35kg/m2 = 8 points.
HTN: yes = 5 points.
What are the 4 categories of the diabetes risk score and what do they mean?
- Low risk = 0 – 6 points, 1 in 100 risk.
- Increased risk = 7 – 15 points, 1 in 35 risk.
- Moderate risk = 16 – 24 points, 1 in 10 risk.
- High risk = 25 – 47 points, 1 in 4 risk.
What is the lifestyle advice we can give to someone for the diabetes risk score?
- Regular meals/portion size
- Decrease fat/sugar/salt
- Moderate alcohol.
- Exercise 150mins/week
- Weight loss.
What are the signs of diabetes?
5Ts:
- Toilet (polyuria).
- Thirsty (polydipsia).
- Tiredness (more than usual).
- Thrush (genital itching secondary to infection).
- Thinner (unintentional weight loss).
What does the CHA2DS2VaSc score assess?
Stroke risk in AF
What are the different components of the CHA2DS2VaSc score?
- Congestive heart failure (PMH) = 1 point.
- HTN (PMH) = 1 point.
- Age (personal information) – 65 ≤ age < 75 = 1 point. ≥75 = 2 points.
- Diabetes (PMH) = 1 point.
- Stroke/TIA (PMH) = 2 points.
- Vascular disease (PMH) = 1 point.
- Sex category female (personal information) = 1 point.
What are the different categories of the CHA2DS2VaSc score and what do they mean? What happens if they are already on an anticoagulant?
- Score 0 = no anticoagulation required.
- Score 1 = consider anticoagulation with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban), maybe aspirin.
- Score 2 or more = anticoagulation required with vitamin K antagonist like warfarin within therapeutic range (INR 2–3) or a DOAC (rivaroxaban, apixaban).
- If already on anticoagulant:
Manage modifiable risk factors for bleeding (HAS BLED – uncontrolled HTN, renal/liver disease, labile INR, using NSAIDs/antiplatelets, alcohol consumption).
What is the general lifestyle advice, warfarin advice, and DOAC advice that we can offer to those with an increased CHA2DS2VaSc score?
General lifestyle advice:
- Avoid alcohol.
- Smoking cessation.
- Healthy diet.
- Exercise.
Warfarin advice:
- Needs INR check.
- Teratogenic.
- Can interfere with other medications.
- Increased bleeding risk.
- Diet control.
- Can be reversed with vitamin K.
DOACs advice:
- Non-reversible.
- Increased bleeding risk.
- Expensive.
- C/I in renal impairment/Hx of GI bleed.
What does the Q-RISK3 score measure? When is it only valid?
- Calculates the patient’s risk of developing an
MI or stroke over the next 10 years. - Only valid if the patient does not already have
a diagnosis of coronary heart disease (inc.
angina/MI), stroke or TIA
What are the different components of a Q-RISK3 score?
Personal information:
- Age.
- Sex.
- Ethnicity.
- BMI (height cm, weight kg).
Past medical history (C.A.R.D.S M.E.M.):
- CKD (stage 3/4/5).
- Atrial fibrillation.
- Rheumatoid arthritis.
- Diabetic status.
- Systemic lupus erythematosus (SLE).
- Migraines.
- Erectile dysfunction.
- Severe mental illness
Drug history:
- Antihypertensives (blood pressure medication).
- Atypical antipsychotics.
- Steroids.
Family history:
- Angina/heart attack in first degree relative <60 years old.
Social history:
- Smoking status.
Direct measurements:
- Cholesterol/HDL ratio
- Systolic blood pressure (mmHg).
What are the 3 different categories of the Q-RISK3 score and what do they mean?
<10% = low risk.
10–20% = moderate risk.
>20% = high risk.
What is the management plan for the different types of Q-RISK3 score?
Management <10%:
- Advise that risk is low but further reductions in risk can often still be achieved.
- Offer advice on relevant lifestyle factors that can be improved:
- Stop smoking.
- Exercise.
- Diet change/weight loss.
- Disease control/medication adherence.
Management >10%:
- Offer advice on any relevant lifestyle factors to reduce risk.
- Consider reviewing any relevant comorbidities that may not be optimally controlled.
- Discuss the benefits and risks of taking a lipid modification therapy.
