297.1 🎓 醫孞生版

297.1.0.1 📌 䞀頁重點

297.1.0.1.1 CVD Risk Assessment
297.1.0.1.1.1 Tools

Pooled Cohort Equation (PCE) — US (2013 ACC/AHA, updated) - 10-year ASCVD risk - Variables: age 40-79, sex, race, total cholesterol, HDL, SBP, BP treatment, DM, smoking - Outputs: - Low: < 5% - Borderline: 5-7.5% - Intermediate: 7.5-19.9% - High: ≥ 20%

SCORE2 / SCORE2-OP — Europe (2021) - 10-year fatal + non-fatal CVD risk - Age 40-69 (SCORE2) or ≥ 70 (SCORE2-OP) - More accurate in different European regions

PREVENT (2024 AHA) - New PREVENT calculator - Integrates BMI, HbA1c, eGFR, social determinants of health - 10-year + 30-year risk

QRISK3 — UK (2017) - Includes CKD, AF, RA, SLE, severe mental illness, ED, migraine, atypical antipsychotic use

297.1.0.1.1.2 Risk Enhancers (Help Refine Beyond Score)
  • Family hx of premature CVD (♂ < 55, ♀ < 65 in 1st-degree)
  • CKD (eGFR < 60, albuminuria)
  • Metabolic syndrome
  • Chronic inflammatory conditions (RA, SLE, psoriasis, HIV)
  • Premature menopause (< 40), preeclampsia
  • South Asian ethnicity (↑ ASCVD risk)
  • Persistently ↑ LDL (≥ 160), Lp(a) ≥ 50 mg/dL
  • High hs-CRP (≥ 2.0 mg/L)
  • Ankle-brachial index < 0.9
  • Coronary artery calcium (CAC) score > 100 or > 75th percentile for age/sex
297.1.0.1.1.3 Coronary Artery Calcium (CAC) Score
  • Non-contrast CT
  • Agatston units
  • 0: very low risk (consider no statin even if intermediate-high ASCVD)
  • 1-100: borderline

  • 100 or > 75th percentile: high

  • Useful for borderline / intermediate risk decision (CAC = “tie-breaker”)
297.1.0.1.2 Major Risk Factors + Targets
297.1.0.1.2.1 Hypertension (Ch275-278)
  • Goal: < 130/80 (ACC/AHA 2017, Taiwan 2022); < 140/90 (ESC 2023 first step)
  • Lifestyle: DASH, Na < 2.3 g, exercise, weight
  • Drugs: ACEi/ARB + CCB + thiazide-like
  • SPRINT, STEP confirmed < 130 benefits
297.1.0.1.2.2 Dyslipidemia

LDL Targets: - Very high risk (clinical ASCVD, DM with multiple RFs, FH): LDL < 55 mg/dL - High risk (ASCVD ≥ 20%, ≥ 50 yo DM, FH, severe CKD): LDL < 70 - Intermediate risk (ASCVD 7.5-20%): LDL < 100, with 50% reduction from baseline - Low risk + risk enhancers: consider statin if LDL ≥ 100

Drug Therapy: - High-intensity statin (atorvastatin 40-80, rosuvastatin 20-40): ↓ LDL > 50% - Moderate-intensity statin (atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80): ↓ LDL 30-50% - Ezetimibe: ↓ LDL 13-20%; add to statin - PCSK9 inhibitors (alirocumab, evolocumab): ↓ LDL 50-60%; for very high risk or FH not at goal - Inclisiran (siRNA, q6 mo): ↓ LDL 50%; alternative - Bempedoic acid: ↓ LDL 15-20%; for statin-intolerant (CLEAR Outcomes 2023) - Pelacarsen (siRNA): Lp(a) lowering — trials ongoing

Triglycerides: - 150-499 mg/dL: lifestyle, statin if ASCVD risk; consider fenofibrate - ≥ 500: pancreatitis risk; fenofibrate primary - Icosapent ethyl (EPA, Vascepa) (REDUCE-IT 2018): for high TG + ASCVD or DM + risk factors → ↓ CV events

297.1.0.1.2.3 Diabetes Mellitus (Ch399)
  • HbA1c < 7% (individualized)
  • BP < 130/80
  • LDL < 70 (high risk) or < 55 (very high)
  • Statin for primary prevention in DM age 40-75 (most)
  • ACEi/ARB for albuminuria or HTN
  • SGLT2i + GLP-1 RA for ASCVD + DM (preferred)
  • Aspirin: only in select high-ASCVD, low-bleeding patients
297.1.0.1.2.4 Tobacco Cessation
  • Single largest modifiable CV risk
  • Smoking cessation ↓ CV risk 50% within 2 years
  • Methods: counseling, NRT, varenicline, bupropion, e-cig harm reduction (debated)
  • Vaping not “safe” but maybe transition
297.1.0.1.2.5 Obesity / Metabolic Syndrome
  • BMI < 25 ideal
  • Weight loss 5-10% → significant metabolic improvement
  • Lifestyle, GLP-1 RA, bariatric surgery
  • Tirzepatide (SURMOUNT-1): significant weight loss
  • Semaglutide (STEP, SELECT): weight loss + CV benefit in obesity + ASCVD (SELECT 2023)
  • Bariatric surgery: durable, CV mortality ↓ in severe obesity
297.1.0.1.2.6 Diet
  • Mediterranean diet (PREDIMED, CORDIOPREV)
  • DASH diet (HTN-specific)
  • Limit sat fat, processed food
  • ↑ Fruits, vegetables, whole grains, nuts, fish
  • Limit Na, sugar, alcohol
297.1.0.1.2.7 Exercise / Physical Activity
  • 150 min/week moderate OR 75 min/week vigorous
  • Resistance training 2-3x/week
  • ↓ CV mortality 20-30%
  • Improves BP, lipids, glucose, weight, mental health
297.1.0.1.2.8 Alcohol
  • ≀ 2 drinks/day men, ≀ 1 woman
  • Heavy drinking: HTN, cardiomyopathy, AF
  • “Healthy” amount controversial (newer data less protective than thought)
297.1.0.1.2.9 Sleep
  • 7-9 hours/night
  • Sleep apnea: ↑ HTN, AF, stroke, HF
  • Treat with CPAP
297.1.0.1.2.10 Stress + Mental Health
  • Depression + anxiety: ↑ CV risk
  • Screen + treat
  • Stress management, CBT, mindfulness
297.1.0.1.3 Aspirin for Primary Prevention — 2024 Update
297.1.0.1.3.1 Major Trials
  • ASPREE (2018): ASA in elderly (≥ 70 in healthy) → ↑ bleeding, no CV benefit, ↑ all-cause mortality
  • ARRIVE (2018): moderate risk → no CV benefit
  • ASCEND (2018): DM → modest CV benefit but ↑ bleeding (net wash)
297.1.0.1.3.2 Current Guidelines (2024 ACC/AHA)
  • AVOID routine ASA in primary prevention ≥ 70 yo
  • Consider in 40-59 yo with high ASCVD ≥ 10% AND low bleeding risk (shared decision)
  • NOT recommended if low ASCVD risk
  • NOT recommended if ↑ bleeding risk (prior bleed, anticoagulant, NSAID, low platelet)
297.1.0.1.3.3 Secondary Prevention
  • ASA Class I for established ASCVD (post-MI, stroke, PAD)
297.1.0.1.4 Emerging Therapies + Approaches
297.1.0.1.4.1 Anti-Inflammatory
  • Colchicine 0.5 mg/d (LoDoCo2 2020 for CCS; COLCOT 2019 post-MI)
  • Class IIa for high-risk in 2023 AHA/ACC
297.1.0.1.4.2 Bempedoic Acid (CLEAR Outcomes 2023)
  • For statin-intolerant patients
  • ↓ MACE 13%
  • Side effects: hyperuricemia, gout
297.1.0.1.4.3 GLP-1 RA in Non-DM Obesity
  • Semaglutide SELECT (2023): obese without DM + ASCVD → ↓ MACE 20%
  • Tirzepatide SURPASS / SURMOUNT: weight + glycemic
  • Expanding indication
297.1.0.1.4.4 SGLT2 Inhibitors
  • Dapagliflozin DAPA-CKD: CKD without DM → ↓ CV death + worsening renal
  • Empagliflozin EMPA-KIDNEY: similar
  • DM and non-DM cardio-renal benefit
297.1.0.1.4.5 Lp(a) Lowering (Future)
  • Pelacarsen, olpasiran, lepodisiran, muvalaplin: Lp(a)-specific
  • HORIZON, OCEAN-α trials ongoing
297.1.0.1.4.6 CAC + Other Imaging
  • CAC for borderline/intermediate decisions
  • CCTA + plaque characterization
  • AI integration emerging
297.1.0.1.4.7 Wearables + Digital Health
  • Continuous BP, glucose, HR monitoring
  • Mobile apps for adherence
  • Telemedicine for prevention

297.1.0.2 🩺 床邊速查

  • ASCVD ≥ 7.5%: statin consideration; ≥ 20%: high-intensity statin
  • LDL target: very high risk < 55, high risk < 70
  • ASA primary prevention 2024: avoid ≥ 70; consider 40-59 + high ASCVD + low bleeding
  • BP target: < 130/80 (ACC/AHA)
  • HbA1c target: < 7% (individualized)
  • Lifestyle: Mediterranean diet + 150 min/wk exercise + 戒菞 + 限酒 + 控重
  • Emerging: colchicine (LoDoCo2), bempedoic acid (CLEAR Outcomes), GLP-1 (SELECT), CAC for borderline