Preventive Cardiology and Cardiovascular Risk Factors
The exam tests risk-score interpretation, statin intensity and add-on therapy, lipid targets by risk category, and the correct place of aspirin and new antidiabetic agents in prevention.
Risk assessment
- Use a validated score (SCORE2 or the pooled cohort equations) to classify risk; diabetes, familial hypercholesterolaemia, and established ASCVD automatically place the patient in a high or very high category.
- Very high risk: documented ASCVD, diabetes with target-organ damage, or severe chronic kidney disease.
Lipid management
- LDL-C targets: below 55 mg/dL with at least 50% reduction in very high risk; below 70 mg/dL in high risk.
- High-intensity statins: atorvastatin 40-80 mg or rosuvastatin 20-40 mg.
- Escalate with ezetimibe, then a PCSK9 inhibitor if targets are not met.
- Suspect familial hypercholesterolaemia with LDL-C above 190 mg/dL, tendon xanthomas, or a family history of premature disease.
Other risk factors
- Blood pressure target below 130/80 when tolerated.
- Smoking cessation: varenicline plus behavioural support is the most effective strategy.
- Diabetes: SGLT2 inhibitors and GLP-1 receptor agonists reduce cardiovascular events in patients with established disease or high risk.
- Aspirin for primary prevention is now restricted; it is not started routinely above age 60.
Worked example
A 60-year-old smoker with prior MI has LDL-C 130 mg/dL on atorvastatin 40 mg. He is very high risk, so atorvastatin is increased to 80 mg and ezetimibe added; if LDL-C remains above 55 mg/dL, a PCSK9 inhibitor is indicated.
Traps
- Do not stop a statin for vague muscle aches before checking creatine kinase and assessing timing.
- Statins raise the risk of myopathy when combined with fibrates, macrolides, or CYP3A4 inhibitors.
- Recheck lipids 4-12 weeks after any change and again after dose stabilisation.