Week 5 CVS Flashcards
In patients without CVD, lipid testing is suggested in men age ______ and women age _______.
men 40 and up
women 50 and up
Testing can be considered earlier for patients with known traditional CVD risk factors including but not limited to hypertension, family history of premature CVD, chronic kidney disease, diabetes, and smoking.
When reassessing CVD risk in patients not taking lipid-lowering therapy, how often is it suggested to reassess lipid levels?
no more than every 5 years and preferably 10 years, unless risk factors change.
High-intensity statins are recommended when your 10 yr CVD risk score is _____ or higher.
20%
Moderate-intensity statins are recommended when your 10 yr CVD risk score is _____.
10-19%
What are the recommendations when your 10 yr CVD risk score is less than 10%?
Retest lipids in 5 -10 yrs (10 is preferred).
If your patient is on max statin therapy and still needs some help to decrease CVD risk, which meds are recommended?
Ezetimibe or PCSK9 inhibitors.
At what age is it recommended that we stop testing our patients’ lipid levels and assessing risk using a CVD risk calculator?
75 years old.
Statins are not recommended for primary prevention in patients 75+ yrs old.
True or false?
True, but it is still reasonable to so discuss risks vs benefits if your patient’s overall health status is good.
If your patient has a cardiovascular event but is older the age of 75, you should not recommend starting a statin.
True or false?
False. The CFP guideline recommends encouraging your patient to start statin therapy after reviewing risks and benefits.
If your patient is on a statin and tolerating it well, it should not be stopped simply because your patient reaches the age of 75.
True or false?
True.
What should you recommend if your patient cannot tolerate a statin due to non-severe muscle cramps?
Statin therapy > non-statin therapy. Try switching med, lower dose, or alternate daily dosing.
For primary prevention in patients unable to tolerate any
statin use, should you recommend non-statin use?
What about in secondary prevention?
Not in primary prevention.
In secondary prevention, it is suggested in the CFP guideline to explore non-statin meds like ezitimibe, fibrates or PCSK9 inhibitors
When should you repeat lipid testing once your patient starts lipid-lowering therapy?
The CFP guideline recommends against repeat testing, and against cholesterol targets.
What is the big red flag adverse reaction to statins to make sure you counsel your patients on?
Rhabdo! I heard my preceptor counsel about cola-coloured urine and I thought that was a good way to make sure they knew what to watch for.
Some patient teachings when you prescribe a statin?
May cause muscle cramping, low incidence of 5% or less.
Serious possible A/E: rhabdo, may increase your blood glucose and contribute to DMT2, and may cause memory loss or confusion.
Avoid grapefruit juice.
What is Afib and why is it a problem?
Atrial fibrillation (AF) is the irregular and rapid heart rhythm caused by abnormal electrical impulse formation and/or propagation. These impulses make the atria beat irregularly and in a dyssynchronous manner with the ventricles, causing blood pooling and poor systemic circulation
How do you classify Afib based on duration?
(paroxysmal vs persistent vs longstanding, permanent)
Paroxysmal = episodes last longer than 30 seconds but less than 7 days
Persistent = episodes last longer than 7 days but less than 1 year
Longstanding persistent = continuous AF for more than 1 year but rhythm control is still being pursued
Permanent = continuous AF where the decision is made to not pursue sinus rhythm restoration
What is the difference between valvular and non-valvular Afib?
Valvular = AF in the presence of a mechanical valve or moderate-severe mitral stenosis
Non-Valvular = AF in all patients who do not fit the valvular classification
Who most typically gets Afib?
Increased age (12% inover 75)
Male
Caucasian
What does Afib look like on an ECG?
irregular rhythm with no discernible, distinct P waves, lasting at least 30 seconds.
Why does a patient’s AFib become increasingly unlikely to restore (convert to sinus rhythm) the longer it goes on?
The presence of AF leads to structural and electrical re-modelling of the atria that over time, advances the severity from paroxysmal –> persistent –> permanent. Thus, the longer a patient has been in continuous AF, the less likely it is to terminate spontaneously, and harder it is to restore and maintain sinus rhythm.
S&S of AF?
- Palpitations
- Irregular, tachycardic, pounding/fluttering heartbeat
- Fatigue
- Weakness
- Dizziness/Light-headedness
- Dyspnea at rest or on exertion
- Potential angina
- Potential syncope
How do we diagnose Afib?
ECG (Sensitivity > 92% and Specificity > 90%) is the gold standard
Holter monitor
Echocardiogram (
o Assess for structural concerns related to valvular AF such as mitral valve stenosis
What are the 3 main pillars of management plan for AF?
1) lifestyle - managing modifiable risk factors & comorbidities
2) anticoagulation for stroke/systemic embolism prevention
3) rate/rhythm control
What bloodwork needs to be done prior to starting a DOAC?
ALT, AST, GGT, bilirubin (as per BC Guidelines)
CBC, CrCl (apparently do not use GFR)
T/F most patients with AF will require and benefit from OAC therapy
True!
An oral anticoagulant is NOT recommended in what group with AF?
OAC is not recommended for NVAF patients < 65 years with none of the CHADS2 risk factors because the risk of stroke is very low in this group
A patient has valvular AF and a mechanical valve. Do you start them on a DOAC or warfarin?
Warfarin only!
***Direct oral anticoagulants (DOACs) are contraindicated in patients with valvular AF
A patient has valvular AF and moderate/severe mitral stenosis. Do you start them on a DOAC or warfarin?
Warfarin only!
A patient has nonvalvular AF and is 65 years or older. What do you do?
Start a DOAC
**For patients with NVAF, use the CCS Algorithm (CHADS-65) to determine the optimal antithrombotic therapy.
A patient has nonvalvular AF and is 60 years old. They have HTN. What do you do?
DOAC
- Although they are younger than 65, they have one of the CHADS risk factors so they should be started on an anticoagulant
Name the 4 CHADS risk factors
1) Prior stroke or TIA
2) HTN
3) Heart failure
4) DM
**Regardless of age, if anyone has nonvalvular AF and any of these risk factors, they are recommended to start on a DOAC
A patient with CAD or PAD should be started on what therapy?
Antiplatelet!
**Note – the antiplatelet therapy is provided primarily for the management of concomitant vascular disease and not as a stroke preventative therapy per se
Why do we choose DOACs over warfarin when we can?
DOACs are preferred over warfarin in NVAF because pooled data from randomized trials have shown that the risks of stroke/ systemic embolism, intracranial bleed and all-cause mortality are significantly reduced with DOAC compared with warfarin
T/F A patient has Afib but no symptoms. They don’t require anticoagulation.
FALLLLSSEEEEEEE
Absence of symptoms (e.g., in subclinical AF) does not change management (according to BC guidelines).
According to the CCS pocket guide: We suggest that it is reasonable to prescribe OAC for patients with AF who are aged ≥65 years or with a CHADS2
score ≥1 who have episodes
of subclinical AF lasting >24 continuous hours
Your patient is newly diagnosed with valvular AF. They state their symptoms have been present for a couple of months.
T/F you should refer them for immediate cardioversion.
NO! Risk of throwing clot
OAC for a minimum of 3 weeks is needed BEFORE planned cardioversion in the following patients:
- Valvular AF
- NVAF episode duration < 12 hour and recent (< 6 months) stroke or transient ischemic attack (TIA)
- NVAF episode duration 12 – 48 hours and CHADS2 score > 2
- NVAF episode duration > 48 hours
You patient was cardioverted in hospital 2 weeks ago. You notice they’re still on a anticoagulant. You can stop it…right?
NO!
OAC for a minimum of 4 weeks is needed AFTER cardioversion and then long-term anticoagulation should be managed according to CHADS-65
Your patient is a frail 98 year old and tends to fall a few times per year. T/F: falls are a contraindication for anticoagulation and you should stop their DOAC or warfarin.
FALSE
It is estimated that patients with AF taking warfarin have to fall more than 295 times in 1 year for the risks of warfarin to outweigh its benefits. Fall risk alone should therefore not be a reason to withhold anticoagulation
In the outpatient setting, choosing rate vs rhythm control is dependent on what factors?
1) type of AF (paroxysmal vs persistent),
2) duration of AF,
3) LV function
4) patient symptoms and preferences.
In what situations is rhythm control preffered over rate control for AF?
1) recently diagnosed AF (within 1 year)
2) Highly symptomatic or significant QOL impairment
3) Multiple recurrences
4) Difficulty to achieve rate control
5) Arrythmia-induced cardiomyopathy
FYI: In those patients with recently diagnosed AF (within 1 year), an initial strategy of rhythm control is preferred as the first treatment strategy because it is associated with reduced cardiovascular death and reduced rates of stroke.11 However, antiarrhythmic drugs have not been associated with a beneficial effect on mortality and many have significant adverse effects.
In those patients with established AF (duration > 1 year), RCTs have shown no significant difference in cardiovascular outcomes between patients treated with a strategy with rate control vs rhythm control.
Longterm rate control: Titrate rate-controlling agents to achieve a target heart rate of ≤ ______ bpm at rest.
100
How do you choose rate control agents in relation to the person’s LVF?
If you start some rate control agent and have inadequate symptoms or heart rate control, what might be the next steps?
LVEF 40% or less: bisoprolol, carvedilol, or metoprolol
LVEF >40%: beta blocker, diltiazem or verapamil
May need to add digoxin or another agent (but this is again dependent on the LVEF….see the handy dandy algorithms in the BC Guidline for AF)
T/F the purpose of long-term rhythm control is to eliminate ALL AF episodes.
False - The focus of rhythm control is on symptom relief, improving functional capacity and quality of life, and reducing health care utilization, and not necessarily the elimination of all AF episodes
T/F we should consult a specialist if considering rhythm control
True
In what kind of AF patient might it be appropriate to have a “pill in pocket” method for treatment? What is this?
For symptomatic AF episodes (e.g. ≥2hrs) occurring less than monthly,
flecainide or propafenone can be taken intermittently (PRN) or as a
booster dose as an outpatient (pill-in-the-pocket).
Generally used in paroxysmal Afib
According to CCS pocket guide, appropriate candidates are:
1) symptomatic patients with sustained AF episodes (e.g. ≥2 hours) that
occur less frequently than monthly
2) absence of severe or disabling symptoms during an AF episode (e.g.
fainting, severe chest pain, or breathlessness)
3) ability to comply with instructions, and proper medication use
**The first time a patient does it has to be closely supervised in the hospital to monitor for AEs
What guidance should you give your patient with AF regarding alcohol and tobacco use?
Limit to 2 standard drinks/week (or none!)
Abstinence from tobacco
According to the BC guidelines, what is the BP target for someone with AF?
130/80 at rest and 200/100 at peak exercise.
What exercise recommendations will you give your patient with Afib?
BC guidelines:
200 or more minutes of moderate intensity aerobic exercise (30mins x 3-5 days)
Resistance exercise 2-3 days/week
Flexibility exercises at least 10 minutes per day x 2 days/week in those >65yrs old
**Rx files says to AVOID INTENSE EXERCISE
What is the SAF score?
Severity of AF
OUtlines symptoms and effect on QOL
Rated class 0-4
Tell me again how we define paroxysmal AF?
Continuous AF episode lasting longer than 30 seconds but terminating within 7 days of onset
Tell me again how we define persistent AF?
Continuous AF episode lasting longer than 7 days but less than 1 year.
Differentiate “longstanding persistent AF” and “permanent AF”
Both are continuous AF >1 year
In longstanding persistent, rhythm control management is still being pursued. In permanent, have stopped persuing sinus rhythm.
Risk factors for AF
Advancing age
* Male sex
* Hypertension
* HF with reduced ejection fraction
* Valvular heart disease
* Overt thyroid disease
* Obstructive sleep apnea
* Obesity
* Excessive alcohol intake
* Congenital heart disease (e.g. early
repair of atrial septal defect)
What are some triggers for AF episodes?
- Stimulants
- Alcohol
- Sleep deprivation
- Emotional Stress
- Physical Exertion
- Sleep/Nocturnal
- Digestive
What are some reversible causes of Af?
- surgery
- Acute cardiac pathology
- Acute pulmonary pathology
- Acute infection
- Thyrotoxicosis
- Alcohol
- Pharmacologic agents (e.g. Ibrutinib)
- Supraventricular tachycardia
- Ventricular pacing
What is the weight loss target for someone with AF?
Target a weight loss of ≥10% to a
BMI of less than 27 kg/m2
.
What other treatments beyond pharmacologic rate/rhythm control and cardioversion might be used for AF?
pacemaker implantation and AVJ Ablation
