CiPC 2

strengths of transdermal nicotine

7mg, 14mg, 21mg OTC & Rx (generic)

when to avoid aspirin

: low-dose ASA routine for primary prevention for >70 y/o, low- dose ASA for primary prevention in adults at any age who are at ↑risk of bleeding (III): previous GI bleeding, PUD, thrombocytopenia or coagulopathy, meds that ↑ bleeding, chronic kidney disease.

recommended blood pressure goal for patients with uncomplicated hypertension

<130/80

impaired glucose tolerance (IGT)

A disorder in which blood glucose levels become elevated 140-199 mg/dL

Never smoker

A person who has not smoked tobacco regularly and does not now smoke every day or some days. NHIS defines never smoker as an individual who has not smoked 100 cigarettes (5 packs) in his or her lifetime

Nonsmoker

A person who is currently either a former or never tobacco smoker.

type-2 diabetes

A1C levels of 6.5% or higher on two separate tests indicates diabetes; often associated with obesity and tends to be diagnosed in older people

blood levels to diagnose pre-diabetes

A1C: 5.7-6.4 FPG: 100-125 Oral glucose tolerance: 140-199

blood levels to diagnose diabetes

A1C: >6.5 FPG: >126 Oral glucose tolerance: >200

normal blood levels

A1C: about 5 FPG: 99 or below Oral glucose tolerance: 139 or below

Recommended drugs for chronic kidney disease (CKD)

ACEI or an ARB

leading preventable cause of morbidity and mortality worldwide, responsible for over 6 million deaths annually

Tobacco use

Third- generation e-cigarette

designs allow the user to customize the devices by manipulating features such as batteries, temperature, and dose of nicotine

second generation e-cigs

devices are larger and have rechargeable batteries and/or replaceable cartridges of e-liquid

Class (strength) of recommendation (COR)

indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk.

recommendation if ASCVD risk if >7.5%-<20% *patients 40-75 y/o

initiate moderate intensity statin to reduce LDL by 30-49%

CAC score of >100 or 75th percentile

initiate statin therapy

recommendation if ASCVD risk if >20% *patients 40-75 y/o

initiate statin to reduce LDL by >50%

federal policy on tobacco

smoking ban on commercial flights

where PCE may underestimate risk

some studies have found underestimation of risk (and potential for under-treatment) among individuals with chronic inflammatory conditions (e.g., autoimmune disease, HIV infection or socioeconomic disadvantage)

varenicline dosing

start 1wk before quit date. ↑ gradually to minimize nausea/insomnia Day 1-3: 0.5mgQD day4-7: 0.5mgBID Day 8 to end: 1mg BID.

Orthostatic hypotension

BP ↓ (standing from supine/sitting) SBP ↓ 20mmHg or DBP ↓ >10mmHg within 3 min of standing. ~ dizziness, lightheadedness, fainting, weakness, blurred vision.

secondary prevention if cardiovascular disease

Focus is to treat and reduce impact of existing disease; prevent recurrence of CV disease

systemic review

Focus on specific therapeutic Q. Comprehensive.

easiest way to practice evidence-based medicine is to

use EBM resources that continually search, appraise and summarize the literature for you.

Polacrilex gum(OTC): Nicorette, nicotine gum

Sugar-free gum base w/ buffering agents to enhance buccal absorption of nicotine.

Non-HDL =

TC - HDL

LDL-C is a _________ value

calculated

External review

public comment + final guidelines revised

relapse vs slip

slip is one time and relapse is continuing to smoke

Nicotine solutions (E-juice):

propylene glycol, vegetable glycerin, flavorings, nicotine (0-36mg/ml).

ASK

"Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?" CONCERN, NO JUDGMENTAL TONE.

severe bradycardia

(40-50 bpm), deflate cuff slower to prevent underestimation of BSP & prevent overest DBP.

dosing of transdermal nicotine

--> Light smoker <10cig/day step 2 :14mgx6wks & 3: 7mgx2wks --> Heavy smoker >10/day (step 1:21mgx4wks, 2, 3)

nicotine inhaler dosing

->6 cartridges/day during 1st 3-4 wks: ↑ PRN to MAX 16/day -Generally 1 cartridge every 1-2 hr, duration 3 mo., reduce daily. Cartridge does not have to be used all at once; open cartridge works for 24 hrs. Mouthpiece is reusable; clean regularly.

healthy diet goal to reduce CV event

-DASH dietary pattern -consume diet rich in fruits, vegetables, whole grains, and low fat dairy products with reduced content of saturated and total fats -trans fats should be avoided

orthostatic hypotension

-Significant decrease in BP upon standing from a supine or sitting position -Symptoms: dizziness, lightheadedness, sense of weakness, blurred vision, fainting -Causes: hypoperfusion of the brain due to pooling of blood in the lower extremities when patient stands - hypoperfusion is a reduced amount of blood flow to the brain

Pooled Cohort Equation (PCE)

-Used to predict 10 year risk and lifetime risk -For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the pooled cohort equations (PCE)

Firstline med for tobacco cessation

-bupropion SR, NRT, varenicline -*Varenicline & combination = highest level of efficacy.*

ASCVD --> Identify the appropriate risk assessment actions and considerations for patients whose age is 0-19 years, 20-39 years, and >75years

0-19: change lifestyle to prevent or reduce ASCVD event; or if diagnosed with FH (statin needed) 20-39: estimate risk, lifestyle changes, consider statin if family history or LDL of >160 >75: LDL greater than 70 but less than 190 without diabetes, needs 10year ASCVD to start discussion

nicotine nasal spray dosing

1 dose = 1mg 1 spray each nostril; Start w/ 1-2 doses/hr ↑ PRN to max 5 doses/hr or 40mg QD. At least 8/daily for 1st 6-8 wks. Gradual tapering over additional 4-6 wks.

4 "actions" of treating tobacco dependence

1) assessment → ask whether an individual smokes every day or only on some days 2) advice to quit → provide strong, clear, personalized advice to the smoker to quit all tobacco use as soon as possible, with helpful phrases like, "As your doctor (or healthcare provider), I want you to know that quitting smoking now is the best way for you to improve your health." 3) offer and provide treatment → translates into providing a pharmacotherapy prescrip- tion and actively connecting the patient to behavioral support resources. This can be done with a statement such as, "There are effective treatments to help smokers quit and I can help you identify the best one for you today." 4) follow-up → Close monitoring also demonstrates to patients that the clinician assigns a high priority to tobacco treatment and may encourage patients to sustain their effort to become smoke-free.

appropriate caloric intake to achieve weight loss. When are very-low-calorie diets appropriate?

1. Adults with obesity are also typically prescribed a diet designed to reduce caloric intake by ≥500 kcal/ day from baseline, which often can be attained by limiting *women to 1200 to 1500 kcal/day and men to 1500 to 1800 kcal/day.* 2. A very-low-calorie diet (defined as <800 kcal/day) should be prescribed only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision.

importance of public health

1. Aims to provide maximum benefit for the largest number of people 2. Provide resources that reduce the need for medical intervention and care 3. Education and prevention strategies 4. Increase access to resources for underserved

3 core functions of public health

1. Assessment - systematically collect, analyze, and make available information on healthy communities 2. Policy development - promote the use of a scientific knowledge base in policy and decision making 3. Assurance - ensure provision of services to those in need

how EBM is used in clinical practice to address patient specific questions

1. Combines individual clinical expertise, best external evidence, and patient values and expectations 2. Define clinical question, retrieve pertinent information, evaluate literature, categorize quality of evidence, develop conclusion and recommendation 3. Assess the patient, ask the question, acquire appropriate resources, appraise the evidence, apply the results, act and evaluate

four first-line therapeutic classes of antihypertensive agents

1. Diuretics → good if the patient also has heart failure, high coronary disease risk, diabetes, and good for recurrent stroke prevention 2. ACE inhibitors → pretty much good for HTN + any other compelling indication 3. ARBs → if the patient has CKD or diabetes 4. CCBs → if the patient has high coronary disease risk or diabetes

What are the questions included in the "Heaviness of Smoking Index"?

1. How many cigs do you smoke? 2. how soon after waking up do you smoke your first cig of the day?

diabetes treatments (w/ or w/o MetS)

1. Lifestyle modification = first line 2. Metformin first line 3. When A1C still ≥7% (if CVD risk factors ADD SGLT-2 inhibitor or GLP-1 receptor agonist)

the general concept of measuring blood pressure by sphygmomanometry

1. Listening to blood flow through brachial artery 2. Systolic BP when first sounds appear, diastolic BP when sounds go away/silence

technique for assessing a patient for orthostatic hypotension

1. Measure BP with the patient in supine position 2. Have patient stand and measure BP one minute after standing and three minutes after standing 3. A decrease in systolic BP of >20 mmHg or decrease in diastolic BP of >10 mmHg upon standing is consistent with a diagnosis of orthostatic hypotension

health literacy and relationship to medication use, including the role of the pharmacist

1. Medication use instructions/information can be complicated 2. Role of pharmacist is to communicate these clearly with patient and make sure they understand

ten essential services of public health

1. Monitor Health (Assessment) 2. Diagnose and Investigate (Assessment) 3. Inform, Educate & Empower (Assessment) 4. Mobilize Community Partnerships (Assessment) 5. Develop Policies (Policy) 6. Enforce Laws (Policy) 7. Link to and/or Provide Care (Assurance) 8. Assure a Competent Workforce (Assurance) 9. Evaluate (Assurance) 10. System Management & Research (Assurance)

Searching for Clinical Practice Guidelines

1. National Guideline Clearinghouse 2. clinical ket --> guidelines 3. Pub Med but limit article type to "Guideline" 4. US Preventative Services Task Force (USPSTF) Recommendations 5.

5 dietary recommendations for patients at risk for ASCVD

1. Plant-based and Mediterranean diets, along with increased fruit, nut, vegetable, legume, and lean vege- table or animal protein (preferably fish) consumption, with the inherent soluble and insoluble vegetable fiber, 2. Trans and saturated fats have been associated with a higher risk of total and cause-specific death → so decrease the trans and saturated fat intake 3. Dietary sodium reduction was found to reduce BP and cardiovascular events in the DASH trial and in TOHP (Trials of Hypertension Prevention) 4. Intake of several food products has been shown to be potentially harmful or increase risk of ASCVD. Sugar- sweetened and artificially sweetened beverages have been correlated with increasing the development of T2DM and with ASCVD risk, with a 20% increase in the frequency of diabetes mellitus with 1 daily serving of these sweetened beverages 5. Intake of trans fat has been shown to be harmful and increase risk of ASCVD. Trans fat was associated with higher all-cause mortality rate

2 specific situations where lifestyle interventions alone may be recommended for elevated blood pressure/hypertension

1. Pre-diabetes → weight loss 2. non pharmacological intervention is the preferred therapy for adults with elevated BP and an appropriate first-line therapy for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of <10% (reassess in 3-6 months)

Role of PH in Healthcare:

1. Provide resources to ↓need for medical intervention & care. 2. Education & prevention strategies. 3. Increase access to resources for underserved.

State what artery is used to take a patient's pulse and describe its location

1. Radial artery 2. Base of thumb, near wrist bone

regularly irregular vs irregularly irregular

1. Regularly irregular - recurring pattern to the pulses 2. Irregularly irregular - no discernible pattern to irregularity

2 pharmacologic anti-diabetic classes recommended as add-on Rx, that have demonstrated a reduction in CVD events in patients with type-2 diabetes

1. SGLT-2 inhibitor (eg. empagliflozin, canagliflozin) 2. GLP-1 receptor agonist (eg. liraglutide, semiglutide)

nicotine pharmacotherapy is not recommended for

1. Smokeless tobacco users 2. Individuals who smokes <10 cigs/day 3. Adolescents (requires prescriptions)

how would you now counsel a patient who is interested in using e-cigarettes for smoking cessation?

1. Switch completely to e-cigarettes. Avoid dual use of both combustible tobacco products and e-cigarettes. 2. The eventual goal is cessation of e-cigarettes as well as combustible cigarettes, because of uncertainty about e-cigarettes' long-term health risks. After stopping combustible tobacco, plan to taper off e-cigarettes. 3. Heed safety instructions. Choose products with child-proof packaging to minimize the risk of nicotine poisoning of children. Follow instructions for device maintenance, battery recharging, and storage to minimize the risk of explosion. 4. Avoid using e-cigarettes around children.

Criteria for metabolic syndrome

1. Visceral Obesity (Waist >35 inches (women) or >40 inches (men)) 2. High triglycerides >150 mg/dL 3. Low HDL cholesterol <50 mg/dL (women) or <40 mg/dL (men) 4. Increased blood pressure >130/85 (or Rx) 5. Insulin Resistance (Elevated fasting blood glucose > 100 mg/dL)

non-pharmacologic interventions for prevention and treatment of hypertension

1. Weight Loss 2. Healthy Diet 3. Reduced intake of dietary sodium 4. Enhanced intake of dietary potassium 5. Physical activity 6. Moderate alcohol intake target blood pressure should generally be <130/80 mm Hg.

6 specific medical conditions that qualify as an "ASCVD event

1. acute coronary syndromes 2. MI 3. stable or unstable angina 4. arterial revascularization 5. stroke, transient ischemic attack 6. peripheral arterial disease of atherosclerotic origin), as well as heart failure and atrial fibrillation.

physical activity goal to reduce CV event

1. aerobic=90-150min/week 2. dynamic resistance= 90-150 min/week (6 exercises, 3 sets/exercise, 10 repetitions/set) 3. isometric resistance= 4 x 2 min (hand grip), 3 sessions per week for 8-10 weeks -atleast 150 min minute moderate intensity exercise per week or 75 min vigorous exercise per week

3 nonpharmacological behavior interventions for tobacco dependence

1. cognitive behavior training (instructions, modeling, rehearsal, feedback) 2. motivational training (goal-oriented) 3. incentives (cash or vouchers)

what to document after taking BP

1. date 2. time 3. 2 pt identifiers (name & DOB) 4. HR & rhythmBP 5. which arm 6. pt position 7. cuff size

2019 ACC/AHA primary prevention of CVD top 10 take home messages

1. healthy lifestyle 2. team based care 3. ASCVD risk assessment 4. heart healthy diet and manage weight 5. lifestyle changes, metformin, SGLT-2 inhibitors, GLP-1 antagonist 6. at least 150m/week moderate exercise or 75 min vigorous exercise 7. tobacco use should be assessed 8. aspirin for primary prevention patients 8. statin for statin benefit groups 9. HTN goal of <130/80

4 basic techniques of physical exams:

1. inspection (seeing or visualizing) 2. palpation (touching) 3. percussion (striking/tapping; stud in wall to hang frame) 4. auscultation (listening; like with a stethoscope).

1st line treatments for pre-diabetes (w/ or w/o MetS)

1. lifestyle modification = weight loss 2. Metformin (#4) mainly (If obese (BMI ≥35)If female w/ Hx of gestational diabetesIf <60y (especially in combination with one of the above)) 3. Metabolic surgery or other drugs. (lifestyle>metformin)

treatments/options for smokers not ready to quit

1. motivational interviewing 2. prescribe and/or offer medications and encourage to reduce amount of smoking 3. discuss the use of non-combustible tobacco if not interested in medications 4. advise patient to adopt smoke free home and car policy

community-based behavioral support resources available to help smokers quit

1. telephone Quitline 2. smokefree.gov 3. becomeanex.org

Tertiary Search versus Evidence Based Medicine Search

1. tertiary Search = Lexicomp® &Micromedex® 2. Evidence Based Medicine Search = Cochrane Library, PubMed Clinical Queries, TRIP (Turning Research Into Practice) Database

top disease states caused or worsened by tobacco use

1. worsening of CVD through its sympathomimetic properties 2. increases the risk of coronary heart disease (CHD) 3. increased risk of heart failure, as well as both atrial and ventricular arrhythmias

only ____ of individuals born with FH know they have it and are diagnosed today.

10%

1st-line anti-HTN for "Uncomplicated HTN":

10mmHg/5mmHg ↓ BP: Thiazide diuretics, ACE-I Angiotensin receptor blockers (ARBs) Calcium channel blockers

onset for nasal nicotine

11-13 min.

dose of nicotine gum

2mg if after 30 min of waking up, 4mg if within 30min wk1-6: 1Q1-2H Wk7-9: 1Q2-4H wk10-12: Q4-8H, max 24 max 24 pieces per day

when is low dose aspirin good to recommend

2nd prevention and consider for primary prevention with high ASCVD risk. role in primary prevention: Low-dose ASA Qday (IIb): 40-70 y/o at higher ASCVD risk, low bleeding risk.

how long do systemic reviews take?

6-18 months

normal pulse rate for resting adults

60-100 bpm

How much moderate-to-vigorous physical activity is needed for benefits for ASCVD risks to start to accrue?

Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

stage 1 hypertension

BP 130-139 OR 80-89 mm Hg

auscultatory gap

BP sounds begin and then disappear then begin again and continue until diastolic BP is reached Avoided by measuring POP and listening for at least 10 mmHg after sounds disappear *Result of a auscultatory gap could lead to an overestimation of the patient's diastolic bp*

treatment of patients with FH

Although lifestyle and diet are important factors to staying heart healthy, for individuals with FH, that is not enough statins are first line

Tobacco (or nicotine) dependence:

An individual's perception of the need to smoke characterized by difficulty reducing and/or refraining from smoking for extended periods of time, continued use despite knowledge of harm, and, for most daily smokers, nicotine withdrawal symptoms that develop when chronic exposure to nicotine in tobacco products ends.

5 A's of tobacco Transtheoretical model of change

Ask-advise-assess-assist-arrange

Evidence based medicine A's

Assess → Ask (PICOT) → Acquire (relevant) → Appraise (eval) → Apply (benefit vs. harm) → Act (monitor)

PD of nicotine

CNS (pleasure, arousal, ↑ task performance, anxiety relief) Appetite suppression, ↑metabolic rate, skeletal m. relax.

role/utility of the 10-y ASCVD Risk Score (by PCE) in a primary prevention patient with hypertension

Can allow for a clinician-patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals

Maintenance of quitting tobacco

Changed a while ago (tobacco free for 6 months) Ongoing relapse prevention is needed. Goal: tobacco free for life

systematic reviews and meta-analyses using appropriate search methods

Cochrane Library, PubMed clinical queries, Trip database

benefit of combination approaches to smoking cessation

Combination therapy with bupropion and nicotine patch is more effective than bupropion alone or NRT alone Counseling and medications are both effective, but the combination of counseling and medication is more effective than either alone. Varenicline and combination therapy approaches demonstrate the highest level of efficacy

Contemplation of quitting tobacco

Considering change, but not yet (for 30 days) Patients considering to take steps *within 6 months*, aware of the need to quit, but struggling with ambivalence.

how to take an apical pulse

Count the number of cardiac cycles per minute while listening to heart sounds with the diaphragm of the stethoscope at apex of heart

1st generation ENDS

Disposable: cig shaped, battery plus cartridge with atomizer, not rechargeable

Individual skills & ability

EDU, socioeconomic, personal & community resources, social support, culture, experience

First-line meds for select CD risk factors

Elevated BP/Hypertension Hyperlipidemia T2DM & pre-DM

why measuring/interpreting pulses and blood pressures are important skills for pharmacists

Enables pharmacists to monitor patient response to drug therapy, develop therapy plans, understand patient medical records, communicate with other healthcare professionals

patient population for which long-term risk assessment (30-year or lifetime risk) can be considered appropriate.

For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be considered

how frequently ASCVD risk should be assessed in adult patients who are free from ASCVD

For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years

characteristics of metabolic syndrome

HAVE TO HAVE ≥ 3 TO HAVE METABOLIC SYNDROME: 1. VISCERAL OBESITY waist circumference > 35 in (women) or > 40 in (men): (Top of iliac crest, exhale, snug)a. WC: for physical assessment technique to ID those at higher ASCVD risk 2. Insulin resistance: elevated fasting glucose ≥100mg/dL 3. HTN: ≥130/85 (or Rx) 4. high TG: >150mg/dL 5. low HDL-cholesterol: <50mg/dL (women) or <40mg/dL (men)

lipid profile high risk

HDL <35mg/dL LDL 160-289 mg/dl TG 200-499mg/dL TC >240 mg/dL

Causes of orthostatic hypotension

HTN med, impaired venous return, hypovolemia, cardiac insufficiency, autonomic dysfx (age, DM).

CV Risk Factors

Hypertension, age (men: >45, women>55), race (white, AA, etc), Low HDL, smoking, family hx of premature ASCVD (primary relative, men<55, women<65), obesity, physical inactivity, south Asian ancestry

Traditional risk factors

Hypertension, age, race, low HDL, smoking (HARLS)

Action of quitting tobacco

In the process of changing (within < 6 mo. since quit).

How do comorbidities guide therapeutic selection of antihypertensive Rx?

It allows us to select a medication that would help BOTH their hypertension and their comorbidities. It is basically a two for one.

NO calculators for

LDL>190 or secondary preventions

transdermal nicotine

Longer [conc] 1-4 hours Peak at 3-12 hrs Steady amount: less fluctuation; Delivery: 24 hours

Critical appraisal

Meta-analysis, Systemic reviews Critically appraised lit, evidence-based practice guidelines

first-line pharmacologic agent recommended for patients with confirmed diagnosis of type-2 diabetes

Metformin is first line therapy

appropriate information to document after measuring a patient's pulse and blood pressure

Name, DOB, date and time, pulse rate and rhythm, measured BP, arm used, cuff size, patient position

Precontemplation of quitting tobacco

Not thinking about change soon (50-60%) 6 months ahead into the future Not ready/unwilling/unable (unconcerned or discouraged) Goal: move to contemplation stage. leave decision up to pt, strongly advise to quit, provide info, ask non-invasive Qs,

Explain why the PCE is not appropriate to use in patients with familial hypercholesterolemia

Patients with familial hypercholesterolemia are at significant risk of having an early ASCVD event, and the use of risk calculators is not applicable to these patients.

Recognize the role of the pharmacist regarding social determinants of health

Pharmacists are present in medically underserved areas and are generally most accessible healthcare provider

PICO(T)-

Pt/problem, Intervention, Compare, Outcome, Type/time

four vital signs

Pulse, blood pressure, respirations, temperature

ADVISE

QUIT "Occasional is still harmful." "it's the most important thing you can do for your health. I have training to help to quit"

ASSIST

QUIT ATTEMPT (good listener)

ASSESS

READINESS to make a quit attempt. Not ready: enhance motivation (5 R's)

Preparation of quitting tobacco

READY TO QUIT IN NEXT 30 DAYS (10-15%) GOAL: ACHIEVE CESSATION -set a quit date -develop coping strategies

Experimental studies

Randomized controlled trials

the two components of taking a pulse

Rate and rhythm

5 R's—method of increasing MOTIVATION for Transtheoretical model of change

Relevance, Risks, Rewards, Roadblocks, Repetition

regularity of a normal pulse

Rhythmic beating, evenly spaced

Stage 2 hypertension

SBP >140 OR DBP of >90

Cascade screening

Screening of all 1st degree relatives, Identified FH cases provide additional relatives to be screened

Clinical Practice Guidelines

Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options

variables that are included in the PCE calculator

Sex Age Race total cholesterol HDL Systolic BP diabetic? smoker? HTN treatment?

importance of early diagnosis of Familial Hyperlipidemia

Start screening between the ages of 9 -11, All individuals should be screened by age 20 In families with positive history of FH or premature CHD, screening begins age 2 yr → Each child of a person with FH has a 50% chance of inheriting the disorder so it is essential to screen parents, siblings and children of a person diagnosed with FH to find others who may have inherited the gene

Total cholesterol

This is a sum of your blood's cholesterol content.

Low-density lipoprotein (LDL) cholesterol.

This is called the "bad" cholesterol. Too much of it in your blood causes the buildup of fatty deposits (plaques) in your arteries (atherosclerosis), which reduces blood flow. These plaques sometimes rupture and can lead to a heart attack or stroke.

High-density lipoprotein (HDL) cholesterol

This is called the "good" cholesterol because it helps carry away LDL cholesterol, thus keeping arteries open and your blood flowing more freely.

Triglycerides

Triglycerides are a type of fat in the blood. When you eat, your body converts calories it doesn't need into triglycerides, which are stored in fat cells. High triglyceride levels are associated with several factors, including being overweight, eating too many sweets or drinking too much alcohol, smoking, being sedentary, or having diabetes with elevated blood sugar levels.

enhanced intake of dietary potassium goal to reduce CV event

aim for 3500-5000mg/day, preferably by diet rich in potassium

Former smoker

a person who does not currently smoke tobacco but has smoked at least 100 cigarettes in his or her lifetime. Because relapse to smoking occurs frequently after quitting, long-term abstinence is often operationally defined as 6 months of abstinence. Abstinence from smoking for at least 7 days in a row is the criterion often required in clinical studies for an individual to be considered a former smoker in the short-term.

Current smoker

a person who reports currently smoking tobacco every day (i.e., daily smoker) or on some days (nondaily smoker). NHIS also requires a current smoker to have smoked at least 100 cigarettes (5 packs) in his or her lifetime

Personal health literacy

ability to find, understand, use info and services to inform health-related decisions and actions.

Dyslipidemia

abnormal amount of lipids (e.g. triglycerides, cholesterol and/or fat phospholipids) in the blood.

Hypertension

abnormally high blood pressure

moderate intensity statins

all statins available in moderate doses

Impaired fasting glucose (IFG)

an intermediate stage between normal glucose homeostasis and diabetes. 100-125 mg/dL

ASCVD

atherosclerotic cardiovascular disease

primary prevention of cardiovascular disease

avoidance of disease happening, goal is to reduce cardiovascular event

Risk enhancing factors

basically lifestyle factors that can increase your risk of having a CV event. These are things such as stress, smoking, poor diet, physical inactivity, obesity, HTN, dyslipidemia, family history

Electronic cigarettes (e-cigarettes)

battery-operated devices that heat a liquid containing nicotine, pro- pylene glycol, and/or vegetable glycerin and flavorant chemicals to generate an aerosol that the user inhales. Because e-cigarettes do not burn tobacco, they do not produce tobacco smoke.

Bell of stethoscope

beLL = Low pitched sounds; larger, flat side isdiaphragm for high pitched sounds

benefits of CAC score

beneficial because plaque inside the arteries of your heart can grow and restrict blood flow to the muscles of the heart Higher the score the higher the chance of cardiovascular event/heart disease A score of 100 to 300 means moderate plaque deposits. It's associated with a relatively high risk of heart attack or other heart disease over the next three to five years. Score of over 300 can indicate sign of heart attack risk

weight loss goal to reduce CV event

best goal is ideal body weight but aim for at least 1mg reduction in body weight in most adults who are overweight. expect about 1 mm Hg for every 1kg reduction in weight

MOA of varenicline

binds w/ high affinity & selectively at α4β2 neuronal nicotinic ACh receptors, stimulates low-level agonist activity. Competitively inhibits nicotine binding

Resistant hypertension

blood pressure that remains above goal in spite of the concurrent use of 3 antihypertensive agents of different classes; does not respond well to aggressive medical treatment

counseling for nicotine gum

chew very slowly, stop chewing at 1st sign of taste, park gum between cheek & gum, resume chewing when taste fades. Taste returns: park gum. Repeat until nicotine gone.

Inhalers and nasal spray not recommended for patients with

chronic lung disease

ENDS rechargeable

cig-shaped, rechargeable. Contains element to regulate inhalations.

Social determinants of health (SDH)

circumstances; Create social & physical environments that promote good health for all. Economic stability, social & community, neighborhood & environment, health care, education.

Articulation of recommendation

clearly stated and actionable. (Benefit > risk)

Metabolic syndrome

cluster of conditions that occur together, increasing your risk of heart disease, stroke and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Increased ASCVD risk is seen with metabolic syndrome

Observational studies

cohort studies, longitudinal studies Case series, retrospective studies, chart/record reviews

Conflicts of interest:

commercial, institutional, professional, intellectual conflicts declared.

Compelling indications

comorbidities Ex: heart failure, post myocardial infarction, CAD/high ASCVD risk, diabetes mellitus A specific high-risk condition for which clinical trial data show that use of a particular anti- hypertensive has benefit in terms of decreasing M/M for that condition.

Forest plots

comparing study results. Bigger box, bigger effect. Systemic review: small studies.

Hyperlipidemia

condition in which there are high levels of fat particles (lipids) in the blood

Regular pulse

consistent rhythm - normal heart sounds (lub dub, lub dub)

Comprehensive lifestyle intervention

consists of a structured program, which includes regular self- monitoring of food intake, physical activity, and weight 1. Increased physical activity, preferably aerobic physical activity (eg, brisk walking) for ≥150 minutes/ week (equal to ≥30 minutes/day on most days of the week), is recommended for initial weight loss. 2. A very-low-calorie diet (defined as <800 kcal/day) should be prescribed only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision 3. Comprehensive life- style intervention has been shown to produce on average 8 kg of weight loss (5% to 10% of initial body weight) in the short term (≤6 months) and intermediate term (6 to 12 months), compared with usual care. 4. Counseling and comprehensive lifestyle interventions, including calorie restriction and adjunctive therapies (eg, FDA-approved drugs, bariatric surgery), have all been associated with significant reductions in waist circumference and improvement in cardiometabolic risk profile

determinate

contributes to generation of a trait.

local policy on tobacco

county laws can prohibit smoke bars

pulse deficit

difference between the apical and radial pulse rates when radial pulse rate is lower than actual heart rate actual heart rate known as the apical heart rate - taken by directly listening to heart with a stethoscope

Pod systems (JUUL, Sourin, Bo, PHIX):

different shape/appearance, liquid in cardridges/pods, produce less vapor compared to tank.

First-generation e-cigs

disposable devices that mimic the appearance and experience of smoking a combustible cigarette

Recommended drugs for type 2 diabetes (T2DM)

diuretics, beta-blocker, ACEI, ARB, CCB

EVALI

electronic-cigarettes or vaping associated lung injury

Public health

epidemiology, disease/injury prevention,environmental safety & hazard protection, access to health services (healthcare, disaster response, grocery stores, etc.), health promotion, disaster response & recovery.

EBM vs EBP

evidence based practice also includes environmental and organizational context they both include individual clinical experience/expertise, patient values and expectations, best external evidence

Grading strengths of recommendation

explain evidence & reasoning, balance of benefits & harms, level of confidence in rec.

CAC score 1-99

favors statin (esp after age 55), discuss with patient

low intensity statin

fluvastatin, pitavastatin, lovastatin, pravastatin, simvastatin

ARRANGE

follow-up care. Tobacco free anniversary

Healthcare sys: complexity & demands

greater self-care req, more meds (formulary, PA, and cost-sharing; med rec), written instructions (gap in reading level & ability), verbal instructions (complex, rapid, easy to forget in stressful situation).

Which interventions for smokers appear to be the most effective to help them quit?

group sessions (multiple) + trained smoking cessation + pharmacotherapy

nicotine cessation recommendations for pregnant patients

gums or lozenges only

Regularly irregular pulse

has a pattern, but not the normal pattern (lub lub dub, lub lub dub)

population health

health care systems, agencies, and *organizations work together to improve health outcomes*

Pre-diabetes

high blood glucose levels but not high enough to be diagnosed with diabetes. A1C ranges from 5.7-6.4, fasting blood glucose from 100-125 and oral glucose tolerance test of 200 or above

DM pt w/ multiple ASCVD risk factors

high intensity statin to reduce LDL-C levels by ≥ 50%

recommendation if ASCVD risk if 5%-<7.5% (borderline risk) *patients 40-75 y/o

if risk enhancers present then discuss moderate intensity statin

epidemic/outbreak

illness or health event in excess of normal expectancy. Epidemic is larger. Pandemic is worldwide.

clinical care

illness prevention, tx, mgmt. preserve mental & physical well-being through services offered by medical & allied health professions; health care.

state policy on tobacco

increase tobacco tax

evidence-based medicine requires...

integrating individual clinical experience with the best available external clinical evidence.

pen style ENDS

larger, with higher battery; refillable cartridge, manual switch to regulate inhalations.

recommendation if ASCVD risk if <5% (low risk) *patients 40-75 y/o

lifestyle changes

what can glycerin cause? (it is in e-cigs)

lipoid pneumonia on inhalation: refill cartridges with high [nicotine] = poisoning risk

Combination NRT

long-acting (patch, constant level) + short-acting (gum, inhaler, ns spray): acute dose titration PRN for withdrawals. Patch 21mg/dayx4-6wk→14mg/dayx2wk→7mg/dayx2wk PLUS Gum/lozenge Q1-2Hprn (>4-5/day) or Inhaler Q1-2H PRN or NS (1spray each nostril Q1-2H PRN) ex: Bupropion SR + Nicotine Patch

20-75 year old w/ LDL-C ≥190 mg/dL

maximally tolerated statin.

Taking a pulse

measuring the rate and rhythm of a patient's arterial pulse

Systemic review of evidence

meets standard of IOM

moderation in alcohol goal to reduce CV event

men: <2 drinks daily woman: <1 drink daily

statin recommendation for adults 40-75 w/ diabetes: regardless of estimated 10-year ASCVD risk

moderate-intensity statin therapy is indicated

Familial Hyperlipidemia

most common genetic disorder that increases blood fats. It can cause early heart attacks. Diabetes, alcoholism, and hypothyroidism make the condition worse. Risk factors include a family history of high cholesterol and early coronary artery disease It is associated with very high levels of bad cholesterol

tank style ENDS

much larger; higher battery; large refillable cartridge; modifiable.

Group composition

multidisciplinary, clinicals, pt advocates

Updating

new evidence modify recommendations

PK of nicotine

nicotine quickly distributes to brain: 10-20 s.Binds to: CV, CNS, exocrine, adrenal medulla, GI, PNS

Irregularly irregular pulse

no pattern at all (lub dub dub, lub lub dub, lub dub lub)

risks of second-hand smoke (SHS) exposure

nonsmokers exposed to secondhand tobacco smoke have a 25% to 30% increased risk of CVD exposure to secondhand smoke is causally linked to cancer, respiratory, and cardiovascular diseases, and to adverse effects on the health of infants and children.

At-risk populations

o : lower education level, lower socioeconomic status, certain cultural groups (black/Hispanic), disabled people, elderly

how CPGs (clinical practice guidelines) are developed

o Define clinical problem, assemble multidisciplinary team, identify, assess, and synthesize evidence, produce systematic review report, appraise systematic revies and other evidence, incorporate expert opinion and patient preferences and characteristics, produce CPG, use guidance to make better informed decisions

CPGs

o Statements that include recommendation intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options

reduced intake of sodium goal to reduce CV event

optimal goal is <1500mg/day but aim for at least 1000mg/day in most adults

Organizational health literacy

organizations equitably enable individuals to find, understand, and use info and services...

peak time of nicotine lozenge

peak at 30-60 min

counseling for nicotine lozenge

place in mouth & dissolve slowly, do not chew/swallow, rotate to different areas, dissolve completely in 20-30 min. use at least 9 daily in 1st 6 wks

public health

policy recommendations, health education, outrace, research for disease and detection, injury prevention *society collectively does*

Transparency

process of funding of guideline development

PULSE & BP Indirect measures:

rate, regularity, max pressure (arterial of beating), min pressure (relaxed arteries) = cardiac performance (targets of drug therapy or ADE)

Level (quality) of Evidence (LOE)

rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources

what can propylene glycol cause? (it is in e-cigs)

respiratory irritation & ↑ asthma risk

Arrhythmias

rhythm irregular. cardiac output & BP varies greatly from beat to beat→ error in traditional BP measurement.

high intensity statins

rosuvastatin and atorvastatin

nicotine inhaler

rx only mouthpiece & cartridge (10mg nicotine & 1mg menthol) 4mg vapor absorbed via buccal mucosa.

Bupropion SR increases

seizure risk, and has several contraindications and precautions

hemoglobin A1C

simple blood test that measures your average blood sugar levels over the past 3 months. It's one of the commonly used tests to diagnose prediabetes and diabetes

Elevated Blood Pressure

slightly increased blood pressure; not definite diagnosis of hypertension SBP of 120-129 AND DBP of <80

where PCE may overestimate risk

studies have found overestimation of risk with the PCE, particularly among those with higher socioeconomic position and those with continual access to care and preventive services, which could lead to overtreatment of individuals less likely to receive net benefit from preventive pharmacotherapies over the next decade

2ndary studies

summarizes primary literature, be aware of bias. Ex. Systematic reviews, clinical practice guidelines *Cochrane*, *PubMed clinical queries*, *TRIP*(turning research into practice), *DARE* (database of abstracts of review of effects).

coronary artery calcium (CAC) score

test that measures the amount of calcium in the walls of the heart's arteries.

One of the greatest achievements of evidence-based medicine

the development of systematic reviews and meta-analyses, which summarize the best available evidence on a topic.

Statin benefit group

there are four groups of this → 1. Patients with clinical ASCVD 2.patients when high baseline LDL (>190) 3. diabetics aged 40-75 4. patients with other risk factors

why is BP taken twice?

to better evaluate for atherosclerotic changes and CV/stroke risk

use and limitations of CPGs in patient-centered care

uses: Gives guidance but not specific answer limitations: Potential for bias and not updated all the time (potential for new treatment to exist that is not included in guidelines)

Partial nicotinic receptor agonist

varenicline: oral, non-nicotinic

Coronary artery calcium score zero

withhold statin & reassess in 5 - 10 years, as long as higher-risk conditions are absent

dosing of nicotine lozenge

wk1-6: 1Q1-2H Wk7-9: 1Q2-4H wk10-12: Q4-8H max 20

what does public health include?

▪ Epidemiology and disease prevention ▪ Environmental safety and hazard protection ▪ Injury prevention ▪ Health promotion ▪ Disaster response and recovery ▪ Access to health services

public health approach includes:

▪ Surveillance: what is the problem? ▪ Risk factor identification: What is the cause? ▪ Intervention evaluation: What works? ▪ Implementation: How do you do it? SIRI