Professional Documents
Culture Documents
Key Issues in
Cardiovascular Health
Case # 1
Hyperlipidemia
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
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Screening Recommendations
Screening tests
Total cholesterol and HDL-C
http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
ATP III
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Hyperlipidemia Question
A. 160
B. 130 with option of 100
C. 100
D. 70
E. 100 with option of 70
Hyperlipidemia Answer
Reference
ATP III
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Case # 2
Hypertension
Hypertension
Risk Factors
Race – blacks
Family history
Excess sodium intake
Excess ETOH intake
Obesity and weight gain
Physical inactivity
Dyslipidemia
Complications -increased in risk at BP above 115/75 mmHg
Premature cardiovascular disease – MC risk factor
Ischemic Stroke – MC risk factor
Heart failure
Intracerebral hemorrhage
Chronic kidney disease
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Hypertension
Hypertension
Hypertension Question
According to JNC VIII guidelines, the blood pressure goal for this
patient should be:
A. 140/90
B. 135/85
C. 130/80
D. 120/80
E. 115/75
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Hypertension Answer
Correct answer is A.
Reference
JNC VIII
Case # 3
Atrial Fibrillation
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Atrial Fibrillation
Atrial Fibrillation
Rate control
Resting heart rate of less than 80 bpm at rest and 110 with exercise
Beta blockers and nondihydropyridine calcium channel blockers
Rhythm Control: Cardioversion
Electrical
anticoagulate 3 weeks before 4 weeks after
Pharmacologic
Medication choice depends on cardiac history
Anticoagulation therapy to prevent CVA
CVA risk is 5% per year
CHADS2
Outpatient Bleeding Risk Index
Warfarin is superior to aspirin and clopidogrel in CVA prevention
Goal INR 2-3
Atrial Fibrillation
Risk of Stroke Stratefied by CHADS2 Score
Adjusted Stroke Recommended
Score Rate Risk Level Therapy
0 1.9 Low ASA 81-325 mg
1 2.8 Low
2 4 moderate Warfarin target
3 5.9 moderate INR of 2-3
4 8.5 high
5 12.5 high Warfarin target
6 18.2 high INR of 2-3
•Patients less than 60 years of age with no heart disease – ASA or no therapy
• Therapy options:
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A 65 year old male with past medical history of hypertension and non-
insulin requiring type 2 diabetes presents to your office for routine follow
up. He has no history of tobacco use. His medications include a statin, an
ace-inhibitor, a thiazide diuretic and an aspirin. His blood pressure and
cholesterol are at goal. He states in the past few weeks he has been getting
dyspnic on exertion and he often feels his heart skip a beat. He has no
other medical history.
A. 0
B. 1
C. 2
D. 3
E. 4
References
Gutierrez et al. Atrial Fibrillation: Diagnosis and Treatment. Am Fam Physician. 2011;
83 (1):61-68
Case #4
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Etiology
Causes/risk factors:
CAD (60 to 70 %)
Hypertension
Valvular
Diabetes mellitus
Smoking
Physical inactivity
Obesity
Evaluation
History
Physical Exam:
Peripheral edema
Pulmonary Rales
JVD
Hepatojugular reflex
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Stages of CHF
ACCF/AHA Stages of HF
A: No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary
physical activity.
B: Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during
ordinary activity. Comfortable at rest.
C: Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to
symptoms, even during less-than-ordinary activity. Comfortable only at rest.
D: Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even
while at rest.
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp
Treatment
Stage A:
Control HTN (diuretics, ACE, ARB, B-blockers)
Control Hyperlipidemia (statins)
Stage B:
Control HTN: ACE and B-blocker
Consider cardioverter-defibrillator
Avoid nondihydropyridine calcium channel blockers
Stage C: Symptom Management
Diuretics
Aldosterone receptor antagonists
Combo therapy with isosorbide dinitrate and hydralazine, digoxin,
anticoagulants, and omega-3 polyunsaturated fatty acids
Lifestyle modifications for all stages!
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CHF Question
CHF Answer
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Case #5
Physical examination:
Cool skin
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Screening:
The USPSTF recommends against routine screening for peripheral
arterial disease [Grade D]
American Diabetes Association – diabetics over age 50
ACC/AHA – high risk population screening
Treatment
Lifestyle modifications – smoking cessation
Medication
Statins
ASA (75-325mg) or Plavix 75mg
Cilostazol
Pentoxifyline
Ramipril
Surgery for lifestyle limiting claudication
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Case #6
Screening:
USPSTF & AHA/ASA do not recommend screening for general
population and asymptomatic patients
Joint guidelines say screening “may be considered” for asx patients
with known atherosclerotic disease
Treatment:
Reduction of risk factors for atherosclerosis
Goal BP <140/90 mmHg
Goal LDL <100 or optional <70 with a statin
Antiplatelet drugs
ASA 75-325mg daily
Carotid endarterectomy
Carotid stenting
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CAD Question
A 64-year-old man presents for a routine wellness examination. His blood pressure
and cholesterol level are within normal limits, and he has no history of tobacco use
or heart disease. He is fearful of having a stroke and questions you if he should be
screened for carotid artery stenosis.
A. Asymptomatic men older than 60 years should be screened once for carotid
artery stenosis.
B. Men older than 65 should be screened annually for carotid artery stenosis.
C. Men should be screened for carotid artery stenosis every five years after 70 years
of age.
D. Screening for asymptomatic carotid artery stenosis in the general adult
population is not recommended.
E. The benefits of screening asymptomatic adults for carotid artery stenosis
outweigh the potential harms of further testing and treatment.
CAD Answer
Reference
U.S. Preventive Services Task Force. Screening for carotid artery
stenosis: U.S. Preventive Services Task Force recommendation
statement [published correction appears in Ann Intern Med.
2008;148(3):248]. Ann Intern Med. 2007;147(12):854–859.
Wolff T, Guirguis-Blake J, Miller T, Gillespie M,
Harris R. Screening for carotid artery stenosis: an update of the
evidence for the U.S. Preventive Services Task Force. Ann Intern
Med. 2007;147(12):860–870.
Case # 7
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Screening
Blood pressure:
Annually [USPSTF A]
Lipids:
Every 5 years through age 75 [USPSTF A]
Screening interval is uncertain
Age to stop not established
Aspirin use:
(81mg) for prevention of CHD age 45-79 [USPSTF A]
AAA
USPSTF:
Men 65-75 who have ever smoked - [USPSTF B]
Men 65-75 who have never smoked – [USPSTF C]
Screening women –[USPSTF D]
References
Hyperlipidemia
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to
Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. Circulation. 2014;129:S1-S45; originally
published online November 12, 2013
American College of Cardiology Cardiosource. Journal Scan Summary
of 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to
Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol 2013;Nov 12
Then and Now: ATP III vs. IV. Grundy, Scott. December 18, 2013.
Cardiosource.org. Accessed August 3, 2014.
PAD
Diagnosis and Treatment of Peripheral Arterial Disease. Hennion, D and
Siano, K at Tripler Army Medical Center, Honolulu, Hawaii. Am Fam
Physician. 2013 Sep 1;88(5):306-310.
References
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References
Atrial Fibrillation
Overview of Atrial Fibrillation. Up To Date. Accessed 8/3/2014.
Gutierrez et al.Atrial Fibrillation: Diagnosis and Treatment. Am Fam Physician.
2011; 83 (1):61-68
Practice Guidelines: Updated Guidelines on Management of Atrial Fibrillation
from the ACCF/AHA/HRS. Lambert, Mara. Am Fam Physician. 2011. 84 (11):
1304-1306
AHA/ASA Publish Advisory on Oral Antithrombotics for Stroke Prevention in
Non-valvular Atrial Fibrillation. Am Fam Physician. 2013 May 15;87(10):732-733
Congestive Heart Failure
Diagnosis and Evaluation of Heart Failure. King, Michael, MD, Kingery, Joe, DO, Casey,
Baretta MD. Am Fam Physician. 2012 Jun 15;85(12):1161-1168.
ACCF and AHA Release Guidelines on the Management of Heart Failure. Am Fam
Physician. 2014 Aug 1;90(3):186-189
2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American
College of Cardiology Foundation/American Heart Assocaition Task Force on Practice
Guidelines. Circulation. 2013;128:e240-e327. Accessed Online 7/28/2015.
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