Cardiovascular diseases, Prevention & Screening tests Dr. dr. Armyn Nurdin. M.

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Case
A 52 year old man comes to your office for a routine physical examination. He is a new patient to your practice. He has no significant medical history and takes no medications regularly. His father died at the age of 74 of a heart attack. His mother is alive at the age of 80. She has hypertension. He has two younger siblings with no known chronic medical conditions. He does not smoke cigarettes, drink alcohol, use any recreational drugs, and does not exercise. On examination, his blood pressure is 127/82 mmHg, pulse is 80 beats/min, respiratory rate is 18 breaths/min, height is 67 in, and weight is 190 lb. On careful physical examination, no abnormalities are noted. What screening test(s) for cardiovascular disease should be recommended for this patient? What immunization(s) should be recommended ?

ANSWERS TO CASE 1 : Adult Male Health Maintenance Summary : A 52-year-old man with no active medical problemsis being evaluated during an annual physical. He has no complaints on history and has a normal physical examination. - Recommended screening tests for cardiovascular conditions: Blood pressure measurement (screening for hypertension) and lipid measurement (screening for dyslipidemia) Recommended immunizations:Tetanus toxoid, reduced diphtheria toxoid, and acellular pertusis vaccine (Tdap) if he has not had one before and if it has been 10 yearsor more since he has had a Tetanus-diphtheria(Td) vaccine or if he requires booster protection against pertusis, influenza vaccine annualy, in the fall or winter months. ANALYSIS Objectives 1. Know the components of an adult health-maintenance visit 2. Learn the screening tests and immunizations that are routinely recommended for adult men Considerations The patient described is a healthy 52-year-old man. Health maintenance should be employed to prevent future disease. In general, the approach is immunizations, and screening for common diseases. Generally colon cancer screening should be initiated at age 50 an beyond. The influenza vaccine should be recommended annualy, and the tetanus vaccine every 10 years. The acellular pertussis vaccine is also recommended as many adults have had waning immunity to pertussis and occasional outbreaks of whooping cough have been noted. Since cardiovascular disease is the most common cause of mortality in his age group, screening for cardiovascular disease or risk factors is appropriate. 1

DEFENITIONS SCREENING TEST : Assessment device or test that should be cost effective with high sensitivity and can be used on a large population. HEALTH MAINTENANCE: Preventative care for patients prior to development of disease. CLINICAL APPROACH For years, one of the cornerstones of primary care was the annual physical, which often consisted of a complete physical examination, blood test, including complete blood counts (CBCs) and multichemistry panels, and, frequently, annual chest x-rays and electrocardiograms (ECGs). The concept of theannual physical, or health-maintenance examination is still important; however, the components of the examination have changed over time. The purposes of the health-maintenance visit are to identify the individual patients health concerns, manage the patients current medical conditions, identify the patients risks for future health problems, perform rational and cost-effective health screening tests and promote a healthy lifestyle. Prevention is divided into primary prevention and secondary prevention. Primary prevention is an intervention designed to prevent a disease before it occurs. It usually involves the identification and management of risk factors for a disease. Examples of this would be the use of a statin medication to reduce low density lipoprotein (LDL)cholesterol in order to lower the risk of coronary artery disease or the removal of colon polyps to prevent the development of colon cancer. Secondary prevention is an intervention intended to reduce the recurrence or exacerbation of a disease.anexample of secondary prevention is the use of a statin medication after a person has had a myocardial infarction (MI) so as to reduce the risk of a second heart attack. Effective screening for diseases or health conditions should meet several established criteria. First, the disease should be of high enough prevalence in the population to make the screening effort worthwhile. There should be a time frame during which the person is a symptomatic, but during which the disease orrisk factor can be identified. There needs to be a test available for the disease that has sufficient sensitivity and spesificity, is cost-effective, and is acceptable to patients. Finnaly, there must be an intervention that can be made during the asymptomatic period that will prevent the development of the disease or reduce the morbidity/mortality of the disease process. The United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and preventive medicine that reviews evidence and makes recommendations on the effectiveness of clinical preventive services, specifically in the areas of screening, immunizations, preventive medications, and conseling. USPSTF recommendations are gold standards for clinical preventive medicine. The recommendations of the USPSTF are available online for free at www.preventiveservices.ahrq.gov.USPSTF grades its recommendations in five categories: A :There is strong evidence that the intervention improves health outcomes and its benefits substantially outweigh its potential harms. These services are strongly recommended B :There is at least fair evidence that the intervention improves health outcomes and its benefits overweigh its potential harms. These services are recommended.

C :The balance of the benefits and potential harms is too close to justify making a general recommendation. D :There is at least fair evidence that the service is ineffective or the potential harms overweigh the benefits. These services are not recommended. E :There is insufficient evidence, or the available evidence is of such poor quality, that the balance of benefits and harms cannot be weighed and recommendations for or against the service cannot be made. SCREENING TESTS Cardiovascular Diseases Diseases of the cardiovascular system are the leading cause of death in adult men and the management of risk factors for these diseases reduces both morbidity and mortality from these diseases. The USPSTF strongly recommends (Level A) screening of adults for hypertension by measurement of blood pressure, as screening causes little harm and management of hypertension is effective at reducing the risk of cardiovascular diseases. USPSTF also strongly recommends (Level A) screening men aged 35 years or more and women aged 45 years or more for lipid disorders and recommends (Level B) screening adults older than 20 years who are at increased risk for cardiovascular diseases. The screening can take the form of nonfasting total cholesterol and highdensity lipoprotein (HDL)-cholesterol levels or fasting lipid panels that include the low-density lipoprotein (LDL))-cholesterol. Ultrasonography to assess for abdominal aortic aneurysm is recommended (Level B) for men aged 65 to 75 years who have ever smoked. There is no recommendation (Level C) for abdominal aortic aneurysm screening for men who have never smoked and it is recommended against (Level D) for women, regardless of smoking status. The routine use of electrocardiogram (ECG), exercise stress testing, or computed tomography (CT) scanning for coronary calcium is not recommended (Level D) for screening for coronary artery disease in adults at low risk for coronary events. There is insufficient evidence to recommend for or against these modalities. (Level I) in adults at higher risk of coronary events. Screening for peripheral arterial disease in asymptomatic adults is not recommended (Level D) because of the low prevalence of the problem in asymptomatic adults and the lack of evidence for improved outcomes from treatment in the asymptomatic stage. Other Health Conditions Screening for obesity by measuring body mass index (BMI) and providing counseling and behavioral interventions to promote weight loss are recommended for all adults (Level B). there is insufficient evidence to recommend screening of asymptomatic adults for type II diabetes mellitus (Level I), although screening is recommended (Level B) for adults with hypertension or hyperlipidemia. Depression screening is recommended (Level B) if there are mechanism in place for assuring accurate diagnosis, treatment, and follow-up. Screening and counseling to identify and promote cessation of tobacco use is strongly recommended (Level A). Screening and counseling to identify and prevent the misuse of alcoholis also recommended (Level B).

IMMUNIZATIONS
As in the case for well child care, the provision of age and condition appropriate immunizations is an important component of well adult care. Recommendations for immunizations change from time to time and the most up-to-date source of vaccine recommendations is the Advisory Committee on Immunization Practices. Its immunization schedules are widely published and are available at the Centers for Disease Control and Prevention Web site (among other places), www.cdc.gov The CDC has recently recommended that all adults between 19 and 65 years of age should receive a booster of Tdap in place of a scheduled dose of Td booster in 10 years or more and who have never had a dose of Tdap. Persons who may need an increase in protection against pertussis, including health care workers, childcare providers, or those who anticipate having close contact with infants younger than 1 year, should receive a Tdap booster. An interval of 2 years from the last Td is recommended, although a shorter interval may be used if necessary. Influenza vaccination is recommended every year for adults older than 50 years. It is also recommended annually for those younger than 50 years with certain medical conditions and for persons who may transmit the infection to others who are at high risk (health care or nursing home workers, household contacts of high risk individuals,etc). High risk conditions include chronic diseases of the cardiovascular, pulmonary, and renal systems and metabolic diseases such as diabetes, hemoglobinopathies, and immunodeficiencies. Pneumococcal polysaccharide vaccination is recommended as a single dose for all adults aged 65 years or older. It is also recommended for adults younger than 65 years who have chronic cardiovascular, pulmonary, renal, or hepatic diseases, diabetes, or an immunodeficiency, or who are functionally asplenic. One time revaccination after 5 years is recommended for those older than 65 years if they were vaccinated longer than 5 years previously and were younger than 65 years at the time of initial vaccination. Other vaccinations may be recommended for specific populations, although not for all adults. Hepatitis B vaccination should be recommended for those at high risk of exposure, including health care workers, those exposed to blood or blood products, dialysis patients, intravenous drug users, persons with multiple sexual partners or recent sexually transmitted diseases, and men who engage in sexual relations with other men. Hepatitis A vaccine is recommended for persons with chronic liver disease, who use clotting factors, who have occupational exposure to the hepatitis A virus, who use IV drugs, men who have sex with men, or who travel to countries where hepatitis A is endemic. Varicella vaccination is recommended for those with no reliable history of immunization or disease, who are seronegative on testing for varicella immunity, and who are at risk for exposure to varicella virus. Meningococcal vaccine is recommended for persons with certain complement deficiencies, functional or anatomic asplenia, or who travel to countries where the disease is endemic. tREFERENCES Blaha, MJ et al. A Practical ABCDE Approach to the Metabolic Syndrome. Mayo Clinic Proceedings. August 2008;83(8): 932-943. Centers for Disease Control and Prevention Web site: http://www.cdc.gov. United States Preventive services Task Force Web site: http://www.preventivesrvices.ahrq.gov.