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Secondary Prevention of Heart Disease Flashcards

(58 cards)

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1
Q

What is primordial prevention?

A

Preventing the development of risk factors that lead to a disease.

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2
Q

What is primary prevention?

A

Risk factors present, trying to prevent development of disease

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3
Q

What is secondary prevention?

A

Someone has had their first cardiac event. Secondary prevention is to prevent further development of disease

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4
Q

What is tertiary prevention?

A

Disease has progressed despite efforts and now it’s just just about managing symptoms and improving quality of life.

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5
Q

Secondary prevention is needed for patients with confirmed CAD or vascular equivalent. What are the vascular equivalents? (name 4)

A

These are vascular equivalents to CAD that warrant secondary prevention:

  1. Stroke
  2. TIA (transient ischemic attack/ministroke)
  3. cerebrovascular disease
  4. peripheral vascular disease
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6
Q

What is the main goal of secondary prevention for plaques? What are the 2 interventions?

A

Prevent plaque rupture and plaque progression.

This is done pharmacologically and through lifestyle change

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7
Q

Guideline classifications are set up as I, IIa, IIb, or III. What do these mean?

A

I - should do it
IIa - reasonable
IIb - might be considered
III - don’t do it

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8
Q

Guideline classifications have different level of evidence organized as A, B, and C. What do these mean?

A

A - several randomized trials
B - observational studies, case reports
C - expert opinion (about half of all guidelines are rated C)

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9
Q

The 2011 CAD secondary prevention guidelines suggest 3 things for pharmacologic intervention. What are they?

A
  1. Anti-platelets
  2. Beta-blockers
  3. RAAS (renin-angiotensin-aldosterone system) inhibitors
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10
Q

What are the two pathways focused on for oral anti-platelet therapy given for CAD secondary prevention?

A

Thromboxane synthetase inhibitors (aspirin) and P2Y12 antagonists (clopidogrel, prasugrel, ticagralor)

“Dual anti-platelet therapy”

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11
Q

True or False: Antiplatelets significantly reduce cardiac and cerebral events like MIs, strokes, and others.

A

True

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12
Q

How much aspirin is recommended for all CAD patients in the Class I anti platelet guidelines?

A

75-162mg daily (generally 81mg in USA is baseline)

100-325 for post-bypass surgery patients
75-235 for post-stroke patients
75-235 for symptomatic peripheral artery disease patients
75-81 for patients on warfarin

clopidogrel can be added or used to replace in various circumstances.

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13
Q

What do beta-blockers do for secondary prevention? (4 things)

A
  1. reduces HR
  2. reduces contractility
  3. reduces conduction velocity
  4. reduces systemic blood pressure
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14
Q

True or false: beta-blockers reduce mortality and MI

A

True

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15
Q

What is the Class I (should do) beta-blocker guideline?

A

Beta-blockers in all with LVSD (ejection fraction less than 40%) and heart failure symptoms or MI/ACS in the prior 3 years.

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16
Q

What is the Class IIa (reasonable) beta-blocker guideline?

A
  • Beta blockers in all with LVSD (ejection fraction less than 40%) even in the absence of heart failure symptoms.
  • Beta blockers in all with any history of MI/ACS
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17
Q

What do RAAS blockades do for secondary prevention? (4 things)

A
  1. vasodilation
  2. natriuresis
  3. decreased sympathetic activity
  4. reduces cardiac remodeling
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18
Q

What are the 3 pathways that RAAS blockades inhibit?

A
  1. ACE inhibitor
  2. ARB
  3. Aldosterone antagonist

Combining these together provides the best effect

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19
Q

True or false: RAAS inhibition reduces mortality among post-MI patients, especially diabetics and LVSD

A

True

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20
Q

What are Class I RAAS inhibition guidelines?

A

ACE Inhibitors given to all with LVSD (ejection fraction 5.0 mEq/L)

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21
Q

Which RAAS inhibitor has side effect of dry cough?

A

Ace inhibitors. Replace with ARB

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22
Q

What 2 things should you be careful of for aldosterone antagonists?

A

Avoid in renal dysfunction or significant hyperkalemia (>5.0 mEq/L).

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23
Q

What 5 things are suggested by the 2011 CAD secondary prevention guidelines for pharmacologic/lifestyle?

A
  1. Blood pressure control
  2. Lipid management
  3. Diabetes management
  4. Depression screening and treatment
  5. Smoking cessation
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24
Q

True or false: Increasing systolic and diastolic BP increases mortality

25
BP levels below what level are sufficient to prevent cardiac events?
140/90
26
The ACCORD studies compared moderate (controlling to 140/90) to severe (controlling to 120/80) control of hypertension to see if it impacted outcomes of patients. What was the finding?
No significant difference with exception of non-fatal stroke. The group with increased therapy had increase side effects but no significant benefit.
27
What 6 things are recommended to control BP?
1. Lifestyle (reduced sat fat/sodium w/ DASH diet) 2. RAAS inhibitors (ACEIs, ARBs) 3. Beta-blockers 4. Diuretics 5. Calcium channel blockers 6. Direct vasodilators (typically 1-3 of these drugs are used at once)
28
What are the 2014 Class I blood pressure control guidelines based on age?
Age less than 60yo: BP less than 140/90 | Age greater or equal 60yo: BP less than 150/90
29
What did the SPRINT trial show?
SPRINT trial was even bigger and more recent than the ACCORD trial and it showed efficacy in controlling BP down to 120/80. Prof said this probably won't be tested on but the guidelines may change soon due to this.
30
True or false: Elevated cholesterol leads to CAD
True
31
True or false: Increased LDL and decreased HDL leads to CAD
True
32
True or false: High dose statins are most efficacious in reducing cardiac events
True. (e.g. simvastatin). If you're stuck on an island with only one medication and you have CAD, it should be a high dose statin.
33
In addition to controlling LDL, statins seem to do what other positive thing?
Anti-inflammation. Helps stabilize plaques.
34
What are 3 non-statin lipid treatments that also reduce LDL? Do these have any effect for reducing coronary events?
Bile-acid binding agents, niacin, fibrates. However, they are not shown to have any efficacy in reducing coronary events. LDL drops but doesn't translate to benefit in reducing coronary events.
35
What are the 2013 Class I Lipid guidelines? 6 things
1. Statins in all CAD patients 2. No need to titrate to particular LDL 3. No indication for non-statin lipid-lowering therapies (except potentially ezetimibe) 4. Not proven in HF NYHA Class 3/4 or hemodialysis patients 5. Myopathy/myalgias in 5-15%. unclear relationship-perhaps misattribution 6. New-onset DM in 0.1-0.3%, rhabdo in 0.01%, hemorrhagic CVA in 0.01%.
36
What is the mortality risk difference between a diabetic patient without prior MI and a non diabetic patient with a prior MI?
They are about the same. This means that diabetes confers about the same mortality risk as a prior MI.
37
Does glycemic control reduce MI risk?
No. Glycemic lower agents don't effect cardiac disease and may even cause harm.
38
What is the Class I diabetes guideline (should do it)?
Lifestyle modifications and coordination with the patient's primary care physician should occur
39
What is the Class IIa diabetes guideline (reasonable)?
Metformin should be a first-line pharmacologic therapy
40
What is the Class IIb diabetes guideline (might be considered)?
HbA1c
41
True or False: Depression is associated with worse cardiac outcomes
True. Perhaps because depression is an inflammatory condition. Also, depressed patients may be more prone to certain behaviors:don't take their medicines, don't exercise, and smoke.
42
Does treating depression improve the risk of cardiac events?
No.
43
What are the Class IIa depression guidelines?
Assessment of depression is reasonable
44
What are the Class IIb depression guidelines?
Treatment for depression does not appear to improve cardiac outcomes, but is beneficial for overall mental health
45
What is the Class I smoking guideline?
Stop smoking
46
What do the 2011 CAD Secondary Prevention Guidelines say about Lifestyle? (2 things)
1. Weight management | 2. Physical activity
47
Obesity is defined both by ___ and ____
BMI, waist size
48
BMI 25-29.9
overweight
49
BMI 30-39.9
Obese
50
BMI 40 or greater
extremely obese
51
Does obesity directly facilitate cardiac disease?
No. It's thought that obesity causes other things which are risk factors for cardiac disease. - central obesity - high BP - high triglycerides - low HDL-cholesterol - Insulin resistance Many of these can be reversed by losing weight
52
What are the 3 ways to lose weight?
1. Diet (caloric restriction is key. macronutrient composition less important. nutrition counseling essential. physical activity useful adjunct) 2. Meds - aren't that effective (only FDA approved medication - orilstat, sibutramine is dangerous) 3. Bariatric surgery (effective, reserved for BMI >40 or >35 with co-morbidities)
53
What is the key way to lose weight through diet?
Caloric restriction. Exercise is thought to help but you still have to calorie restrict.
54
What is the class I weight control guideline?
Goal BMI is 18.5-24.9. Goal waist circumference is
55
True or false: Physical activity reduces cardiac events
True. And also, the fitter you are, the more you are able to tolerate coming CAD.
56
What is the class I physical activity guideline?
Moderate to high-intensity exercise for 30-60 minutes/day. At least 5 and ideally 7 days a week.
57
What are the 2011 CAD secondary prevention guidelines for "other"? (2 things)
1. Cardiac rehabilitation (patient education. paid for by any insurance) 2. Influenza vaccination (healthier patients have lower events and higher tolerance)
58
How effective is cardiac rehabilitation (patient education)?
Very effective! only 20% of these patients get cardiac events. So profoundly helpful.

Cardiovascular (22 decks)

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