Cardiovascular part 1 System Notes

Hyperlipidemia Treatment

• The ACC guidelines divide hyperlipidemia treatment into:

  • Primary prevention: Treating patients without established atherosclerotic cardiovascular disease (ASCVD) to prevent its development.

  • Secondary prevention: Prescribing statins to patients with known ASCVD to prevent future cardiovascular events.

Primary Prevention

• ACC guidelines stratify patients into treatment groups based on:

  • Lipid panel results.

  • Comorbidities.

  • ASCVD risk, estimated using an ASCVD risk calculator that factors in age, blood pressure, lab results, and smoking history to estimate the percentage risk of cardiovascular death over ten years.

• First-line treatment involves HMG CoA reductase inhibitors (statins).

  • Statins are classified by LDL reduction intensity: low, moderate, or high.

Primary Prevention Treatment Groups:

1. Patients aged 20-75 with LDL ≥ 190 mg/dL:

   • Should receive a high-intensity statin, regardless of ASCVD risk score.

   • High-intensity statins include high-dose rosuvastatin (Crestor) and atorvastatin (Lipitor).

2. Patients aged 40-75 with diabetes mellitus:

   • Should start on at least a moderate-intensity statin.

   • ASCVD risk score calculation is not needed due to inherently higher cardiovascular risk.

3. Adults aged 40-75 with LDL between 70-189 mg/dL and ASCVD risk score ≥ 7.5%:

   • Adults without diabetes, but with elevated ASCVD risk.

   • Require at least a moderate-intensity statin.

USPSTF Guidelines:

• Recommends statins for primary prevention in adults aged 40-75 with at least one ASCVD risk factor and an ASCVD risk score of \geq 10 % .

• The exam will specify which guidelines (ACC or USPSTF) to follow.

Secondary Prevention

• Involves prescribing high-intensity statins to patients with known ASCVD to prevent future cardiovascular events.

Levels of Prevention

• Primary: Preventing the initial onset of disease.

• Secondary: Detecting and treating disease early to prevent progression.

• Tertiary: Reducing the impact of established disease.

• The cholesterol guidelines terminology differs from these basic principles, especially regarding secondary versus tertiary prevention.

Elevated Triglycerides

• Fibroids are typically used first to treat super elevated triglycerides.

• Patients with triglyceride levels > 500 mg/dL are at increased risk for acute pancreatitis, especially with alcohol consumption.

• Assessment findings in acute necrotizing pancreatitis:

  • Cullen's sign: Periumbilical bruising.

  • Grey Turner's sign: Flank bruising.

  • Refer to the emergency department immediately upon seeing above signs.

Hypertension

• Focus on ACC/AHA guidelines which push for stricter blood pressure control to reduce long-term complications.

JNC 8 Guidelines

• Defines hypertension as a blood pressure of \geq 140/90 mmHg or greater.

• The goal is \geq 150/90 mmHg in those > 60 years with no underlying diabetes or chronic kidney disease.

ACC/AHA Guidelines Stages:

• Elevated: Systolic between 120-129 and diastolic < 80.

• Stage 1: Systolic 130-139 or diastolic 80-89.

• Stage 2: Systolic \geq 140 or diastolic \geq 90 .

• Always classify based on the higher stage if readings fall into different categories.

• Diagnosis requires the average of at least two separate readings on at least two separate occasions.

Treatment

• Stage 1 Hypertension:

  • No ASCVD history and no major cardiovascular risk factors: Lifestyle modifications, reassess in 3-6 months.

  • ASCVD risk \geq 10 %: Lifestyle modifications and pharmacological therapy are indicated.

• Stage 2 Hypertension: Requires medications and lifestyle modifications from the start.

First-Line Drug Classes:

• ACE inhibitors.

• ARBs.

• Calcium channel blockers.

• Thiazide diuretics.

• The best initial choice depends on the patient's medical history.

  • ACE inhibitors or ARBs are preferred for patients with diabetes or chronic kidney disease due to their kidney-protective effects.

  • Thiazide diuretics may be considered for patients with osteoporosis as they stimulate osteoblasts and help retain calcium.

Side Effects and Monitoring

• ACE Inhibitors:

  • Angioedema and cough (ACE acronym: A stands for Angioedema and Cough). Angioedema requires immediate discontinuation and emergency care. Cough can lead to switching to an ARB.

  • Monitor kidney function and potassium levels.

• Calcium Channel Blockers:

  • DHPs (e.g., amlodipine): The suffix is 'pine.'

  • Non-DHPs (e.g., verapamil, diltiazem).

  • Side effects: Ankle edema and headache.

  • Contraindicated in patients with GERD as they relax the lower esophageal sphincter.

  • Non-DHPs should be avoided in patients with heart failure with reduced ejection fraction due to the risk of bradycardia and reduced cardiac output.

• Thiazide Diuretics:

  • Known to increase uric acid, glucose, and triglycerides (HCT acronym: Hyperglycemia, Crystals, and Triglycerides).

  • Avoid in patients with related comorbidities.

• Goal blood pressure on medication: \leq 130/80 mmHg.

• Follow-up: Reassess in one month after starting or adjusting medication; then every 3-6 months if stable.

• Monitor for target organ damage: Retinopathy, chronic kidney disease, cardiovascular complications.

• Preferred medications during pregnancy (NLM mnemonic: New Little Mama): Nifedipine, labetalol, and methyldopa.

• ACE inhibitors and ARBs are contraindicated during pregnancy.

Metabolic Syndrome

• A group of conditions increasing the risk of diabetes and cardiovascular disease.

• Defined by the National Cholesterol Education Program Adult Treatment Panel III (ATP III): Meeting three out of five criteria:

  1. Abdominal obesity.

  2. Elevated triglycerides.

  3. Decreased HDL (good cholesterol).

  4. Elevated blood pressure.

  5. Elevated fasting glucose.

• First-line treatment: Lifestyle modifications and weight reduction.

Abdominal Aortic Aneurysm (AAA)

• Dilation or enlargement of the abdominal aorta, associated with hypertension.

• USPSTF recommends a one-time screening with abdominal ultrasound in men aged 65-75 who have ever smoked.

• Most cases are asymptomatic; potential for rupture if enlarged.

• Symptoms of rupture: Acute tearing abdominal or back pain, low blood pressure, pulsatile abdominal mass. Immediate EMS transport is required due to high fatality rates.

Pulsus Paradoxus

• A decrease >10 mmHg in systolic blood pressure during inspiration.

• Indicates a serious condition, such as cardiac tamponade or status asthmatics.