Macros

*AFIB macro​​

  • Trials reporting anticoagulant benefits have been done in patients with clinically significant Afib, either symptomatic AF or AF long enough to be recorded on multiple ECGs, and have not taken into account the burden of the Afib or use of AA drugs, ablation or surgery.

  • Brief episodes of device detected sub-clinical/silent atrial fibrillation [SCAF] , ranging from 6minutes- 24 hours,  appear to be associated with a stroke risk, but SCAF is thought to be potentially different c/w clinical AFib in terms of its character and possibly a relatively lower risk of stroke

  • Initially, it was thought that the stroke risk was the same irrespective of burden, but we now believe that increased burden correlates with increased risk. and that lower burden correlates with lower risk, and that burden should be factored into our assessment of treatment. Further complicating this, is our belief that symptoms and short-term monitorring are not a reliable way to assess burden

  • “Silent atrial fibrillation has been identified.  Data is emerging that the burden on Afib maybe important in determining the risk. For  durations between 6 minutes and 24 hours there is no clear evidence yet as to the specific threshold burden that supports anticoagulation . Trials are ongoing.  Until evidence exists decisions are  individualized. After some discussion. it was recommended that…”

**maybe consider a  high CHADSVASC score and significant underlying structural heart as potential soft indicators or at least for more frequent monitoring. 

Low stroke risk: CHADS 0 regardless of burden

High stroke risk: CHADS 3 regardless of burden

CHF macro

This patient has significant LV dysfunction  (EF<40%) with symptoms and for which appropriate cardioprotective meds include consideration of maximally tolerated doses of ARNI (ideally to replace ACE-I or ARB agent for those with persistent symptoms), beta blocker, MRA (mineralocorticoid receptor antagonist), and ivabradine if NSR>70bpm and EF<35%. ICD may be considered if EF<30-35% despite optimal medical Rx. CRT may be considered if EF<35% and QRS>130msec (LBBB>RBBB). Control of sleep apnea (which is frequently present) is essential.

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SECONDARY PREVENTION

 

*Vascular macro

Lets aim for a BP< 140/90, a lipid target 50% less than baseline (or LDL<1.8-2.0) with statin, consider ACE-I or ARB therapy as well as antiplatelet therapy for cardioprotection, employ exercise, healthy diet and optimize cardio fitness level. Lets consider an intensive systolic BP target <120mmHg in cases where the patient is a 'high risk >50 yr old'  (presents with SBP 130-180 and have one of either a FRS> 15% (DM excluded), LVH, Age>75, vascular disease (stroke excluded), or mild-moderate non diabetic kidney disease [<1g/l proteinurea, eGFR 20-60]). 

 

*Vascular diabetic macro

This patient has vascular disease and is diabetic. Lets aim for a BP< 130/80, a lipid target 50% less than baseline (or LDL<1.8-2.0) with statin, consider ACE-I or ARB therapy as well as antiplatelet therapy for cardioprotection, employ exercise and a healthy diet, optimize cardio fitness level and strongly consider the use of a SGLT2 inhibitor such as empagliflozin for glucose control (if not contraindicated).

*ACS vascular macro

Lets aim for a BP< 140/90 **, a lipid target 50% less than baseline (or LDL<1.8-2.0..even down to 1.4) with maximally tolerated statin and possibly ezetrol, consider maximum dose ACE-I or ARB therapy as well as antiplatelet therapy (dual for a minimum of 1 year post event) for cardioprotection, employ exercise, healthy diet and optimize cardio fitness level. **Lets consider an intensive systolic BP target <120mmHg in cases where the patient is a 'high risk >50 yr old'  (presents with SBP 130-180 and have one of either a FRS> 15% (DM excluded), LVH, Age>75, vascular disease (stroke excluded), or mild-moderate non diabetic kidney disease [<1g/l proteinurea, eGFR 20-60]). 

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PRIMARY PREVENTION

LIPIDS

INTERMEDIATE RISK MACRO re; 

Current CCS guidelines support that we aim for a 50% reduction in lipid numbers (or LDL<1.8-2.0) with statin therapy given that this patient appears to be an 'intermediate risk' patient and has :

  • baseline lipids are increased (LDL> 3.5, or nonHDL>4.3, or apoB>1.2) or

  • Man> 50/ Woman > 60 with one additional risk factor , such as:

    • smoking,

    • low HDL (<1.0 in men, 1.3 in women),  

    • dysglycemia

    • obesity(waist:hip > 0.85 in women, >0.9 in men),

    • hypertension

  • CAC > 100

  • Lp(a)> 300mg/dl

 

THE HOPE 3 PATIENT

Some patients may be considered for fixed dose crestor 10mg daily, irrespective of baseline LDL, if they are thought to be an 'intermediate risk' type patient

  • Man> 55 or Woman > 65**

  • with one additional risk factor , such as:

    • smoking,

    • low HDL (<1.0 in men, 1.3 in women),  

    • dysglycemia

    • obesity(waist:hip > 0.85 in women, >0.9 in men),

    • renal disease

    • premature family Hx

  •  or Woman > 60 with two of those risk factors

 

https://clinicaltrials.gov/show/NCT00468923

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Statin Indicated macro

Lets use a statin to to lower lipids (LDL< 2.0, or nonHDL<2.6, or apoB<0.8) given the presence of  a 'statin indicated condition', namely, as described below

  • documented vascular disease,

  • AAA (>3.0), 

  • chronic kidney disease, in a 50 yr old (eGFR< 60 or MAU> 3 of at least 3months),

    • excluding dialysis

  • genetic hyperlipidemia/ LDL>5.0, or

  • is a 'high risk diabetic' (>40 yrs old, or  >30yrs old with 15 yrs DM, or microvascular problems). 

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*ASA USPTF macro

Lets consider ASA 81mg daily to reduce the incidence of MI, strokes and colorectal cancer given the patient is a 50-69 yr old with an intermediate cardiovascular risk. 

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*BLOOD PRESSURE

 Not sprint

This patient should have  a target <140/90 [<135/85 AOBP]

*BP Sprint macro (unexpected lower BP benefit)  DOES NOT APPLY TO DIABETICS

This patient appears to meet the SPRINT study entry criteria; namely, >50 yrs old with a baseline SBP >130 and considered to be 'high risk' due to having 1 of the following:  

  • a FRS> 15% (excluding DM and prior CVA),

  • LVH

  • olderAge>75,

  • vascular disease (stroke excluded), or

  • mild-moderate nonDM chronic Kidney disease (<1g/l proteinurea, eGFR 20-60). 

In this case, lets consider an intensive systolic AOBP target <120/90 mmHg.  Sprint guidelines 

They excluded: DM, CHF, strokes, Proteinurea>1.0

There are some cautions: with

  • 'frail 80 yr old with low DBP< 70mmHg' who may be more likely to have side effects/coronary hypoperfusion.

    • there is a J shaped curve re: very low DBP may be bad ​

  • in general 'real world data' may show more side effects

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SUBPOPULATIONS

*DIABETIC macro

Lets aim for a BP< 130/80, a lipid target 50% less than baseline (or LDL<2.0) with statin (if patient is early DM>40 yrs old

or15 yr DM>30 yrs old) , employ exercise, healthy diet and optimize cardio fitness level.  ASA is not routinely recommended for primary prevention in diabetes in the absence of a specific indication.  The use of ACE-I or ARB for vascular protection my be indicated in many ( age < 55 plus micro/macrovascular disease or age ≥55 yrs plus another risk factor ...even in the absence of hypertension).  View Diabetes.ca periodically.

RENAL Macro

This patient has chronic renal disease given eGFR< 60 and/or MAU> 3. Consider ACE-I or ARB for renal protection aiming to keep a low BP (<130/80 for DM, <120/-- for Sprint type patient, <140/90 in others). Consider a  low Lipid target (LDL<2.0, or nonHDL< 2.6, or apoB< 0.8) with statin therapy.  Beware 'SADMAN' (sulfonurea, ACE-I, Diuretic, Metformin, ARB, NSAID, SGLT2 inhibitor) and contrast agents in these patients.

MENOPAUSE macro

Certain menopausal patients appear to benefit from HRT. The USPTF does not presently support its use in asymptomatic patients due to concerns of potential risks of breast cancer and vascular events/thrombosis. However, studies suggest that this risk may be small for those patients who initiate treatment during the early postmenopausal period (1st 10 years, age<60) and that the potential benefits (less vascular events, diabetes, osteoporosis, etc) in these groups may prevail. Studies also suggest lower risks with bio identical HRT compared with Prem-Pro. 

 

© 2017 VitalityCardiology

David Freedman Medicine Professional Corporation

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