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Three states of CV disease
- coronary artery disease (coronary heart disease)
- cerebrovascular disease (stroke)
- peripheral artery disease
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2 most important risk factors for myocardial infarction
lipids and smoking
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fish oil
- 1. typical dietary intake <1gram/day
- 2. we are carrying better and fish oil isn't having a positive effect
- 3. if you are neglecting treatment fish oil will work
- 4. eat a diet with 1-2 servings of oily fish per week or 1 gram daily fish oil supplement (200-800mg EPA + DHA).
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5 CHD risk equivalents
- 1. diabetes
- 2. stroke/transient ischemic attack (TIA)
- 3. peripheral artery disease (PAD)
- 4. abdominal aortic aneurysm (AAA)
- 5. calculated 10-year framingham risk for CHD of > 20%
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ATP II risk calculations, 5 major risk factors
- 1. cigarette smoking
- 2. age (men > 45yo; women >55 yo)
- 3. hypertension (BP > 140/90 or on antihypertensive medication)
- 4. low HDL (<40mg/dl
- - HDL > 60 mg/dl counts as a"negative" risk factor
- 5. family history of premature CHD
- - CHD in male 1st degree relative < 55 yo
- - CHD in female 1st degree relative < 65 yo
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what is the JNC 7 guideline to initiate therapy with 2 agents for high blood pressure
BP > 20/10
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4 LDL risk factors and goals
- 1. CHD + risk factors - optional < 70mg/dl
- 2. CHD or CHD risk equivalent (10-year risk >20%) - < 100mg/dl
- 3. multiple (2+) risk factors (10year risk < 20%) - < 130mg/dl
- 4. 0-1 risk factor - < 160 mg/dl
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BP targets
- general CAD prevention - <140/90
- LVD - <120/80
- the rest - 130/80
- stable angina
- UA/NSTEMI
- STEMI
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When should you recommend someone start taking aspirin for primary prevention of cardiovascular disease?
Benefit outweighs risk only when risk of CV event begins to exceed 5-10% in 10 years
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aspirin for primary prevention of stroke and MI in men and women
- MEN
- 32% reduction in MI
- No effect on stroke
- WOMEN
- 17% reduction in stroke
- No effect on MI
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effects of aspirin therapy for primary prevention of MI and stroke among men and women with diabetes
Aspirin significantly reduced the risk of MI in men by 43%, no benefit seen in women with diabetes
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when should aspirin be used for primary prevention of CV event with diabetes
- Men >50 y/o + additional CHD risk factors (smoking, HTN, dyslipidemia, family history of premature CHD, albuminuria)
- Women >60 y/o + additional CHD risk factor
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secondary prevention of CV event
Combination of statin + ASA in secondary prevention may yield up to a 50% reduction in CV events
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chads2 scores
- C - heart failure - 1pt
- H - hypertension - 1pt
- A - age > 75 years - 1pt
- D - diabetes - 1pt
- S - prior TIA or stroke - 2 pts
predicts risk of stroke in patients with A-fib and determines degree of anticoagulation
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recommendations for anticoagulation on CHADS2 scores
- Score = 0 (Low risk)
- Aspirin
- Score = 1-2 (Moderate risk)
- Aspirin or warfarin
- Score = 3+ (High risk)
- Warfarin
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Primary prevention
- avoid or delay the development of disease
- Most public health promotion activities focus on primary preventative measures
- immunizations
- seat belts
- counseling on healthy lifestyle
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Secondary Prevention
- reduce recurrent events/prevent mortality in patients with disease
- Interventions are to prevent the progression of disease and the emergence of symptoms
- lifestyle
- beta-blocker
- eye exam for diabetes
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Relative Risk
- Ratio of likelihood of a disease developing
- Tells you nothing about actual risk
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Absolute Risk
Probability of developing the disease in a finite period (ie within the next 10 years)
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Folic acid – Primary prevention
- Pregnancy
- Supplementation in pregnancy reduces neural tube defects
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Folic acid – Secondary prevention
4 mg/day for women with previous child with neural tube defect
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Vitamin D – dosing recommendations
- Breast-fed infants should be supplemented with 400 IU daily
- RDA for children and adults (1 y/o+) = 600 IU daily
- Adults >70 = 800 IU
- Patients with known osteoporosis or previous fracture = 800 IU daily
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Calcium
- Recommended for risk of osteoporosis
- recommend calcium citrate
- RDA 1000-1300 mg/day
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Vitamin B12
In elderly, gastric atrophy and hypochlorhydra (low stomach acid secretion) result in less gastric acid and less absorption of vitamin B12
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Multivitamins
Generally not beneficial for most adults who eat a balanced diet and get regular sun exposure or consume vitamin D-fortified dairy products
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Selenium
Increased risk of diabetes in selenium group
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Dietary fiber
RDA: 25 grams for women, 30 grams for men
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Alcohol
Meta analysis found no benefit above 0.5 portion/day
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Primary Prevention of Diabetes
who should be screened
- early detection BMI > 25 +
- 1. overweight
- 2. over 45
- 3. inactive
- 4. first relative with DM
- 5. baby weighing over 9 lbs
- 6. HTN
- 7. HDL <35 TG > 250
- 8. History of vascular disease
- 9. previous test showed glucose tolerance
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Secondary Prevention with Diabetes
- Glucose control
- HbA1c <7%
- Lipid control
- LDL <100mg/dL
- Hypertension
- BP <130/80 mmHg
- Eye exams
- Foot exams
- Kidney function monitoring
- Immunizations
- Flu, pneumococcal
- Dental exams
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