Cardiovascular diseases, Prevention & Screening tests

Dr. dr. Armyn Nurdin. M.Sc

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 Tetanusdiphtheria(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
1

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.
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 costeffective 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,
2

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 high-density
lipoprotein (HDL)-cholesterol levels or fasting lipid panels that include the lowdensity 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
3

(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
4

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.