Preventive Cardiology

CVD Risk Stratification - Spotting Trouble Early

• Goal: Identify high-risk individuals for targeted CVD prevention.
• Key Modifiable: Hypertension (HTN), Dyslipidemia, Diabetes Mellitus (DM), Smoking, Obesity (Asian BMI >23 kg/m²), Sedentary lifestyle.
• Indian Context: ↑Lp(a), ↑hs-CRP, Central Obesity (Waist: Men >90cm, Women >80cm), Low HDL.
• Tools: WHO/ISH charts (Indian adaptation), Framingham (less ideal for Indians), ASCVD Pooled Cohort Equations.
• Risk Tiers (10-yr CVD event):
  • Low: <10%
  • Moderate: 10-20%
  • High: >20%

⭐ For the Indian population, target LDL cholesterol < 70 mg/dL in very high-risk individuals (e.g., established CVD, DM + multiple risk factors), and maintain BP < 130/80 mmHg.

Lipid & BP Targets - Numbers Game

• Lipid Targets (mg/dL):
  • Very High Risk (ASCVD): LDL-C < 55; Non-HDL-C < 85
  • High Risk: LDL-C < 70; Non-HDL-C < 100
  • Moderate Risk: LDL-C < 100; Non-HDL-C < 130
  • Triglycerides: Ideal < 150. Target if > 200 (Non-HDL-C), or if > 500 (pancreatitis risk).
• Statin Intensity:
  • High (↓LDL ≥50%): Atorvastatin 40-80mg, Rosuvastatin 20-40mg
  • Moderate (↓LDL 30-49%): Atorvastatin 10-20mg, Rosuvastatin 5-10mg
  • 📌 High & Mighty: Atorva 40-80, Rosuva 20-40.
• BP Targets (mmHg) - General Indian Context:
  • Standard Target: < 140/90.
  • High-Risk (DM, CKD, ASCVD): < 130/80 (if tolerated).
  • Age >65 yrs (not frail): SBP 130-139.

⭐ First-line antihypertensives (India): A (ACEi/ARB), C (CCB), D (Diuretics). β-blockers for CAD/HF.

Lifestyle Rx - Daily Dose Prevention

• Diet:
  • Focus: Fruits, vegetables, whole grains, lean protein.
  • Limit: Sodium (<2.3g/d), saturated/trans fats, added sugars.
  • 
  • Key Diets:

    Diet	Focus	Benefit
    DASH	↑F/V, low-fat dairy; ↓Na, fat	↓BP
    Mediterranean	↑F/V, nuts, olive oil, fish; ↓red meat	CVD health

• Exercise:
  • Aerobic: 150+ min moderate OR 75+ min vigorous/week.
  • Strength: ≥2 days/week.
• Smoking: Cessation crucial. 5 A’s (Ask, Advise, Assess, Assist, Arrange).
  • 📌 CVD risk ↓ significantly in 1 yr.
• Weight (Indians):
  • BMI: <23 kg/m².
  • Waist: ♂ <90cm, ♀ <80cm.
• Alcohol: Limit intake.

⭐ High refined carb/trans-fat Indian diets ↑CVD risk; traditional plant-based diets are protective.

Pharmaco-Prevention & Diabetics - Targeted Shields

• Aspirin Therapy:

  • Primary Prevention: 75-100 mg/day for select high ASCVD risk (e.g., 10-yr risk >20% or DM + multiple risk factors) & low bleed risk individuals. Indian guidelines emphasize careful selection.
  • Secondary Prevention (established CVD): 75-100 mg/day (lifelong); often with P2Y12 inhibitor (e.g., Clopidogrel 75mg) post-ACS/PCI.

• Diabetics & CVD Shielding:

  • HbA1c goal: Generally <7%; individualize (e.g., <6.5% if new/young, <8% if elderly/comorbid).
  • SGLT2 inhibitors (e.g., Empagliflozin 10/25mg, Dapagliflozin 10mg) & GLP-1 RAs (e.g., Liraglutide, Semaglutide) ↓CV events & mortality.
  • Statins: Essential for most T2DM >40 yrs or with CVD risk factors.

• Antiplatelet/Anticoagulant Choices (Prevention Focus):

  Scenario	Drug(s) of Choice	Key Doses (daily)
  Primary Prevention (High ASCVD Risk)	Aspirin	75-100 mg
  Secondary Prevention (Stable CAD)	Aspirin ± Clopidogrel	Asp: 75-100 mg, Clop: 75 mg
  AF (CHADS-VASc ≥2 M, ≥3 F)	DOACs (Apixaban, Rivaroxaban) or Warfarin	INR 2.0-3.0 for Warfarin

• Flowchart: Aspirin Primary Prevention (Indian Context)

![SGLT2 and GLP-1 RA effects on metabolic, renal, CV](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Internal_Medicine_Cardiology_Preventive_Cardiology/f6595316-b104-4abe-97bb-b22aa96b6c9a.png)

• ⭐ > Latest Indian guidelines recommend SGLT2 inhibitors or GLP-1 RAs for T2DM patients with established ASCVD or multiple risk factors, independent of HbA1c, for CV protection.

High‑Yield Points - ⚡ Biggest Takeaways

• Aspirin: Selective for primary prevention; essential for secondary prevention.
• Statins: Cornerstone for prevention; know high-intensity regimens (e.g., Atorva 40-80mg, Rosuva 20-40mg).
• Hypertension: Target <130/80 mmHg; lifestyle modifications are crucial.
• Diabetes Mellitus: Aggressive CV risk reduction; SGLT2 inhibitors & GLP-1RA provide CV benefits.
• Smoking cessation: Single most effective preventive strategy.
• Diet (DASH/Mediterranean) & Physical Activity (≥150 min/week moderate) are vital.
• Key Lipid Targets: LDL-C <70 mg/dL (secondary), <55 mg/dL (very high-risk).