VASCULAR DISEASE – as a whole

Consider vascular risk as a whole rather than simply cardio-vascular disease

1. Secondary prevention - High risk - Hx of angina, DM, TIA, stroke, PVD
2. Primary prevention
3. Microalbuminuria
4. Atrial Fibrillation
5. Palpitations
6.Chest Pain

1. Secondary Prevention

a. Aspirin

•	Diabetics: males > 30, females later
•	If on aspirin and have a subsequent event, stop and change to clopidogrel as in one third of people cyclo-oxygenase cannot be inhibited. You cannot predict who, therefore switch.
•	If GI upset, use clopidogrel rather than aspirin (probably cheaper than aspirin + PPI)
•	Combine aspirin and clopidogrel for 3 months after episode of unstable angina
•	Consider referral to TIA clinic (RVH) for speedy dopplers/ echo

b. Beta Blocker

•	All with History of MI should be on a B Blocker

c. Anti-hypertensives/ ACE/ ACEII

•	In diabetics, aim for BP < 130/84
•	Consider Angiotensin II receptor antagonists rather than ACE Inhibitors
•	This follows LIFE study which showed losartan (cozaar) to be more effective than atenolol - 25% reduction in stroke, no change in MI
•	Also RENAL study with irbesartan (aprovel)
•	(HOPE study questioned the effects of ACE Inhibitors on BP as it excluded people with uncontrolled BP)
•	Could try aprovel first line rather than diuretic as may benefit kidneys
•	If BP not improving, change to co-aprovel (includes thiazide diuretic)

d. Statins

•	HEART PROTECTION STUDY - treating high risk people with statins reduces the risk of MI and stroke by a third, even in patients with low or normal cholesterol levels
•	CV risk more important than cholesterol level itself
•	Risk tables have limitations
		Primary prevention only
		Only predict CHD risk not TIA/ stroke
		15%/ 30% levels are for economics only
•	Aggressive treatment costly but ultimately may save
•	Ideally, cholesterol, should be < 3.5
•	e.g. Start even a diabetic over 30 on a statin if > 3.5
•	Continue up to 82/83 years of age
•	Which statin: studies on pravastatin 40mg, simvastatin 40mg. Use this study dose
•	Little evidence for atorvastatin 20mg (Greece study - only 342 patients)
•	Recheck lipids in 3 months
•	Look for 1mmol reduction - if not - change to atorvastatin
•	Does not need regular checking, but may need to monitor for side effects
•	If muscle stiffness, check CK/ LFTs
•	In general statins are very safe drugs
•	In considering why someone had an event, if cholesterol < 3.5, consider other factors
•	If > 3.5, start statin

2. Primary Prevention

a. Aspirin

•	No great evidence for use in primary prevention
•	Could consider if strong family history or smoker

b. Anti-hypertensives

•	As per usual

c. Statins

•	Risk tables under-estimate people we should be treating (as predict cardio-vascular rather than vascular disease)
•	Use 15% risk over the next 10 years rather than 30% when considering treatment
•	WOSCOPS (primary prevention trial with pravastatin) - reduced MI
•	Consider total cholesterol/ HDL ratio rather than cholesterol alone
•	HDL protective - FRAMINGHAM study
•	If > 5:1 start a statin - don’t worry - can’t be too aggressive!
•	In healthy people with no risk factors and total < 6.5 - don’t need to treat

3. Microalbinuria  (6-10% of people with Diabetes)

•	Detect in order to delay renal failure
•	Measure with a random quantitative assay of protein/ creatinine ratio
•	i.e. How much protein per unit of creatinine 
•	Normal level is 2 micrograms/ mmol of creatinine
•	If > 2, repeat as could be infection - leaky kidneys
•	If still > 2, need to know exact level
•	If > 75 micrograms/ mmol - do 24 hour collection

•	If protein < 1g/ 24 hours and creatinine < 150

	In Type 1 DM - start ACE inhibitor
	(MICROHOPE study - no evidence in type 2 DM …….)

	In Type 2 DM - start Angiotensin receptor antagonist (e.g. losartan)
	RENAL study- stopped and causes regression of microalbinuria, and so less renal 	failure

•	Recheck micro albumin in 3 months - if increased consider adding the other (ACE or Angiotensin receptor antagonist  - i.e. would be on both ACE and Ang. R. A.)

•	If creatinine > 150 and have microalbuminuria, refer for USS/ follow up

4. New Atrial Fibrillation

•	If rapid pulse in the surgery, 50mg atenolol today and tomorrow, then review at 48 hours. If not reverted, refer.
•	If AF for longer than 48 hours, start warfarin
•	Should be seen within 6 weeks for echo prior to DC cardio version
•	Consider B Blocker depending on age/ rate, rather than digoxin, as more likely to convert to sinus rhythm. Use for 3 months

5. Palpitations

•	Holter monitor preferred - need to know if PAF present - because of warfarin issue
•	ECG in all - exclude HOCM
•	Check TFTs in all
•	Young - probably don’t need referred - very common
•	Elderly and symptomatic - refer for monitor

6. Chest Pain

•	ECG in surgery/ troponin if available
•	Consider RVH chest pain clinic - seen in 2 days
•	If the history sounds cardiac, start aspirin, B Blocker (+/- GTN spray)
•	Refer for treadmill
•	If negative, and history doubtful, stop aspirin and B Blocker
•	If negative and history suspicious of CHD, continue treatment and observe progress. They are probably at low risk
•	Remember treadmill may not always correlate well to angiogram findings
•	Women are less good than men at treadmills (in general!)