cardiovascular assessment, Cheat Sheet of Medicine

Download cardiovascular assessment and more Cheat Sheet Medicine in PDF only on Docsity! 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Cardiovascular Assessment History Introduction, How may I help you today? Experiencing any symptoms of cardiovascular disease: chest pain, chest pain on exertion, shortness of breath, tiredness, loss of consciousness, ulcers on legs? Assessment of cardiovascular symptoms: duration, management, effect on work and daily life Experiencing any pain? (SOCRATES = site, onset, character, radiation, associated symptoms, time, exacerbating and alleviating factors, severity) Any other symptoms or concerns? Any constitutional symptoms? (Fever, weight loss, change in mood or appetite) Depending on circumstance —> Five Ps (partner, practices, protection from STI, past history of STI, pregnancy intention) Family History: diseases (heart attacks, high cholesterol, hypertension, kidney disease, diabetes, psychiatric conditions), family members (number, support, stress, bereavement, socio-economic status, aboriginal) Social History: SODDDOM = smoking, alcohol, drugs, diet, daily activities and physical activities, occupation, mood (depression/ anxiety/stress screen) Medical History: surgeries, stents, clotting problems, diabetes, thyroid, hypertension, hyperlipdemia, Drugs History: pharmaceutical medications (duration, compliance, side effects), alternative medications (St. John warts etc.), allergies, immunisations Keeping an eye out for risk factors and causes © EXmodifiable risk factors Modifiable risk factors © Smoking status Blood pressure Serum lipids Waist circumference and body mass index Nutrition Physical activity level Alcohol intake © Einon-modifiable risk factors Non-modifiable risk factors + Age and sex ‘+ EXFamily history of premature CVD Family history First-degree relative aged < 55 years, with a history of cardiovascular disease + Social history, including cultural identity, ethnicity, socio-economic status, and mental health ‘© Eirelated conditions Related conditions + Diabetes + Kidney impairment (microalbumin with or without urinary protein, reducing eGFR) + Fai ial hypercholesterolaemia Evidence of atrial fibrillation on history, examination, electrocardiogram © Diabetes and aged > 60 years * Diabetes with microalbuminuria (> 20 micrograms/min or urine albumin:creatinine ratio > 2.5 mg/mmol males, > 3.5 mg/mmol females) ‘* Moderate or severe chronic kidney disease (proteinuria or estimated glomerular filtration rate < 45 mL/min/1.73 m2) Known familial hypercholesterolaemia © Systolic blood pressure 2 180 mmHg or diastolic > 110 mmHg * Serum total cholesterol > 7.5 mmol/L Secondary causes of hypercholesterolaemia * Hypothyroidism Nephrotic syndrome and chronic kidney disease (CKD) * Cholestatic biliary disease * Diabetes * Anorexia nervosa © Hypopituitarism « Medications - thiazide diuretics, corticosteroids, oral contraceptives, cyclosporin, atypical antipsychotics, anticonvulsants Secondary causes of hypertriglyceridaemia* * Diabetes * Obesity * Alcohol excess © Chronic kidney disease (CKD) * Pregnancy * Gout © Hypopituitarism * Medications - beta blockers, corticosteroids, oral contraceptives, atypical antipsychotics, ciclosporin, HIV or antiretroviral drugs, retinoids Risk Assessment Algorithm Cardiovascular risk assessment tools provide a measure of a patient’s absolute cardiovascular risk. Use the algorithm and the charts on the next pages to calculate absolute risk. Consider the following as part of a comprehensive risk assessment: (PP) Modifiable risk factors Non-modifiable risk factors * Smoking status* * Age" and sex* * Blood pressure” * Family history of premature CVD * Serum lipids* * Social history including cultural identity, ethnicity, socioeconomic status * Waist circumference and BMI and mental health © Nutrition Related Conditions * Physical activity level * Diabetes* * Alcohol intake* * Chronic Kidney Disease (albuminuria + urine protein, eGFR) * Familial hypercholesterolaemia* * Evidence of atrial fibrillation (history, examination, electrocardiogram) v * Aboriginal and Torres Strait Islander adults aged over 74 (CBR) [ v YES * Enter age 74 for adults aged 74+ (CBR) L v Tv v High: greater than 15% risk of CVD Moderate: 10-15% risk of CVD Low: Less than 10% risk of CVD within the next five years (includes. within the next five years (PP) within the next five years (PP) clinically determined high risk) (PP) * Risk parameters that are included in the absolute risk calculator, based on the Framingham Risk Equation (FRE) + Alcohols a risk factor for elevated blood pressure, stroke and cardiomyopathy (see NHMRC Guidelines to reduce health risks from drinking alcohol [2009). 4 Refer to National Heart Foundation of Australia's information sheet Familal Hypercholesterolaemia: Information for doctors. BMI: body mass index. eGFR: estimated glomerular fitration rate. Goals depending on where they fall on the scale Risk management summary table Use the table below to develop a management plan for your patients. CVD risk a a) HIGH RISK [irons sustained specific - advice and support Sy regarding diet and een] physical activity. eee kr tee i Prone ed Sporonriate aves, TEC charmacotherapy for Po smoking cessation. Advice given simultaneously with BP and lipid lowering drug treatment. Pharmacotherapy Treat simultaneously with lipid lowering and BP lowering unless contraindicated or clinically inappropriate. Aspirin not routinely recommended. Consider withdrawal of therapy for people who make profound lifestyle changes. Targets BP: <140/90 mmHg in people mmHg if micro or macro albuminuria (UACR > 2.5 mg/mmol in men and >3.5 mg/mmol in women). Ny [e)2) ==): \ 9 =| Appropriate, specific advice and support RISK regarding diet and physical activity. ere Ra) . at aa Appropriate advice, Pe support and Pea) | Pharmacotherapy for ann smoking cessation. Lifestyle advice given in preference to drug therapy. Not routinely recommended. Consider BP lowering and/ or lipid lowering in addition to lifestyle advice if 3-6 months of lifestyle intervention does not reduce risk or: * Specific population where the i k Consider withdrawal of therapy for people who make profound lifestyle changes. Lifestyle: ‘Smoking cessation (if smoker); consume diet rich in vegetables and fruit, low in salt and saturated and trans fats; at least 30 mins physical activity LOW RISK [aiaschood advice regarding diet and physical activity. (rene hn) se ea Petts tay Neen) Appropriate advice, support and pharmacotherapy for smoking cessation. Not routinely recommended. Consider BP lowering therapy in addition to specific lifestyle advice if BP persistently 160/100 mmHg, Consider withdrawal of therapy for people who make profound lifestyle changes. ‘on most or preferably every day of the week; limit alcohol intake. Colada lal ere until sufficient improvement or maximum tolerated dose achieved. ‘Adjust medication as required. Review of absolute risk according to clinical context. eee until sufficient improvement or maximum tolerated dose achieved. Adjust medication as required. Revi every eee until sufficient improvement or maximum tolerated dose achieved. Adjust medication as required. ey yer Blood test results within 5 years can be used. ‘A&TSI: Aboriginal and Torres Strait Islander peoples; BP: blood pressure; CKD: Chronic Kidney Disease; CVD: cardiovascular disease; DBP: diastolic blood pressure; FRE: Framingham Risk Equation; HDL-C: high density lipoprotein cholesterol; LDL-C: low density lipoprotein cholesterol; SBP: systolic blood pressure; TC: total cholesterol; TG: Triglycerides; UACR: urinary albumin:creatinine ratio. Lipid lowering therapy In general Consider treatable secondary causes of raised blood lipids before commencing drug therapy (PP) v In adults aged over 74 years, use clinical judgement to consider benefits and risks of treatment, co-morbidities and values before initiating therapy (PP) For those intolerant to statins For raised triglycerides Side effects and dosages  Drug Class Agents Effects (% change) Side Effects HMG CoA reductase inhibitors Lovastatin Pravastatin {LDL (18-55),t HDL (5-15) | Triglycerides (7-30) Myopathy, increased liver enzymes Cholesterol absorption | Ezetimibe { LDL( 14-18), * HDL (1-3) | Headache, GI distress inhibitor {Triglyceride (2) Nicotinic Acid {LDL (15-30), * HDL (15-35) | Flushing, Hyperglycemia, | Triglyceride (20-50) Hyperuricemia, Gl distress, hepatotoxicity Fibric Acids Gemfibrozil {LDL (5-20), tHDL (10-20) Dyspepsia, gallstones, Fenofibrate | Triglyceride (20-50) myopathy Bile Acid sequestrants Cholestyramine {LDL ? HDL No change in triglycerides Gl distress, constipation, decreased absorption of other drugs Intensity Definition Dosage Low Daily dose lowers LDL-C Simvastatin 10 mg by <30%, on average — Pravastatin 10-20 mg Lovastatin 20 mg Fluvastatin 20-40 mg Pitavastatin 1 mg Moderate Daily dose lowers LDL-C Atorvastatin 10-20 mg by approximately 30% Rosuvastatin 5-10 mg to <50%, on average Simvastatin 20-40 mg Pravastatin 40-80 mg Lovastatin 40 mg Fluvastatin XL 80 mg Fluvastatin 40 mg bid Pitavastatin 2-4 mg High Daily dose lowers LDL-C Atorvastatin 40-80 mg by approximately 250%, | Rosuvastatin 20-40 mg On average