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  1. Importance of the subject:

In the majority of the countries of Europe cardiovascular diseases are the main reason of premature death. Besides, they serve as the important reasons of invalidity and growth of expenses for health protection.

  • The reason of cardiovascular diseases usually is the atherosclerosis which by degrees develops throughout many years and by the time of occurrence of symptoms usually is in late stage.

  • The Death, myocardium infarction and a stroke often arise suddenly, therefore many medical interventions are impracticable or give only palliative effect.

  • Cardiovascular disease depends on a life style and modified physiological risk factors.

  • Updating of risk factors leads to disease and death rate decrease, especially at patients with the distinguished or not distinguished cardiovascular diseases.

Level of death from cardiovascular diseases depends on age, male, economical conditions, ethnic implements and geographic region.

If the importance of the subject is clear to you pass to study of the goals.

^ II. The goals of study.

The general goal is to make primary and secondary prophylaxis of cardiovascular diseases.

Specific Goals

1. Pick out groups of patients who need prophylactic measures to decrease risk of development and worsening of cardiovascular diseases.

2. Value general risk of cardiovascular events development.

3. Mark out modified and non-modified risk factors at the patient.

4. Devise prophylactic measures taking into account degree of detected risk factors.

5. Value compliance of the patients to recommendations and their efficiency.

You can find the information necessary for filling a gap in basic knowledge and skills in the following references:

  1. Oxford Handbook of Clinical Medicine. Murray Longmore, Ian B.Wilkinson, Supray Rajagopalan. New York, 2004.

  2. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  3. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  4. D. Holdright. 100 questions in cardiology.-BMJ books, 2001

  5. Davidson’s principles and practice of medicine, P.191-303

Initial tests

Test 1. A woman 53 years old has been suffering from diabetes mellitus for 7 years She doesn’t smoke. At the estimation of general risk of fatal cardiovascular events the investigation of cholesterol level was prescribed. What purposeful level of cholesterol is needed for this patient?

A) < 3,8 mmol/l,

B) < 2,8 mmol/l,

C) < 4,5 mmol/l,

D) < 5,0 mmol/l ,

  1. < 5,2 mmol/l.

Test 2. You’ve examined a woman 50years old who has been suffering from diabetes mellitus for 8 years. What laboratory researches are not included in a list of estimation of fatal cardiovascular risk?

A) glucose

B) cholesterol

C) Bilirubin

D) kreatinin

E) Tryglycerids

Test 3. On examination there is a patient of 35 years old, who does not smoke, BP is 125/70 mm HG. It is known that his relatives have had early appearing cardiovascular events. What research will you appoint to the patient for determination of necessity of cardiovascular events risk estimation?

A) blood coagulation


C) LE cells

D) Cholesterol

E) Bilirubin

Test 4. You are examining the patient with obesity of 2nd degree, diabetes mellitus and arterial hypertension of 2nd degree, 3rd stage. Which investigations are not included in the list of necessary ones for prognostication of risk of appearance of fatal cardiovascular events during 10 years?

A) cholesterol

B) triglycerides


4) general blood test

5) НВА1С

Test 5. Man 58 years, who lives in Greece has systolic BP 160 mm of Hg, cholesterol level is 5 mg/dl. How to value the 10year risk of fatal cardiovascular events by the scale of risk SCORE?

A) high

B) middle

C) low

D) very high

E) moderate

Test 6. You’ve examined a man 62 years old. BWI is 28 kg/m2, circumference of waistline is 100 sm, BP is 120/80 mmHg. It is known that he smokes 40 years. Lab data: cholesterol level is 5,3 mmol/l, fasten glucose is 5,4 mmol/l. How many risk factors are take place in this case?

A) 1

B) 2

C) 3

D) 4

E) Absent

Test 7. You are examining the woman of 64 years old. Her level of BP is 170/90 mm HG, she smokes, cholesterol level is 4,0 mg/dl. She lives in Russia. How to value the 10year risk of fatal cardiovascular events by the scale of risk SCORE?

A) high

B) low

C) absent

D) very high

E) moderate

Test 8. The examination of the patient G. of 62 years exposed that 10 year risk of fatal cardiovascular events is 5%. To which risk group does this patient belong?

A) very low

B) low

C) middle

D) high

E) hightened

Test 9. You are examining the man of 42 years old, whose BP is 130|80 mm Hg. Due to modern classification of arterial hypertension specify the level of optimum blood pressure:

A) 130/80 mm Hg

B) 140/90 mm Hg

C) 125/80 mm Hg

D) 120/80 mm Hg

E) 135/70 mm Hg

IV. Subject Material

For achievement of goals of study it is necessary to master the following theoretical questions:


  1. Indications for evaluation of general cardiovascular risk.

  2. Methods of evaluation of cardiovascular risk.

  3. Methods of clinical, laboratory and instrumental diagnostics of cardiovascular diseases, evaluation of modified and non-modified risk factors.

  4. Correction of the life-style of the patient, prescription of medicines and definition of their doses and combinations.

  5. Keep on the patients with cardiovascular diseases.

You can find the information necessary for study of the theoretical questions in the following references:

  1. Oxford Handbook of Clinical Medicine. Murray Longmore, Ian B.Wilkinson, Supray Rajagopalan. New York, 2004.

  2. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  3. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  4. D. Holdright. 100 questions in cardiology.-BMJ books, 2001

  5. Davidson’s principles and practice of medicine, P.191-303

  6. Lectures on Hospital Therapy.

  7. Break-down chart on the subject «Prevention of cardiovascular diseases» (Appendix 1).

Break-down chart on the subject « Prevention of cardiovascular diseases»

Patients who need in examination

Anamnaesis about early appearance of cardiocascular diseases, hyperlypidemia

Wishing of the patient

Presence of 1 or more risk factors, high colesterol level

Smoker or patient of middle age

Presence of syptoms due to which you can suspect cardiocascular diseases

If cardiovascular diseases, diabetes mellites, marked risk factors are absent SCORE scale is used



Glucose level in urine

Protein in urine


Glucose level in blood

Creatinin level in blood

ECG at rest and exertional testing if angina is suspected

ECHO-CG at young patients and patients with high BP

Specific examination

Waist-line, BWI


Risk Score - <5% - advise healthy life-style, regular examinations in the future


2 type of Diabetes melli-tus or 1 type with microal-buminuria

Presense of marked 1 risk factor

Estimated cardiovascular disease

Risk at Score ≥ 5%

Recommendations about life style

Don’t smoke

If BWI≥25kg/м2, to become slimmer

To decrease weigth if waist linei is ≥ 88 sm in women and ≥102 sm in men

30-min of physical activity of middle intensity per day

Healthy meal

^ Medicamental therapy

(If risk by SCORE 5-10% or target-organs are affected)

If BP≥140/90 mm Hg, hypotensive therapy is prescribed

If holesterol level is ≥5 mmol/l or LDLP are ≥ 3 mmol/l, statins are indicated

If cardiovascular disease is present aspirin and statins are indicated

If diabetes mellitus prescribe drugs


Appendix 2.


1. If patient asks about examination

2. Patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease

Assessing Cardiovascular Risk: What Are the Components?

  1. History: Previous CVD or related diseases, family history of premature CVD, smoking, exercise and dietary habits, social and educational status.

  2. Examination: BP, heart rate, heart and lung auscultations, foot pulses, height, weight, BMI, waist circumference. Fundoscopy in severe hypertension.

  3. Lab test: Urine for glucose and protein, microalbuminuria in diabetics. Cholesterol and if practicable, fasting lipids (LDL- and high-density lipoprotein [HDL]-cholesterol, triglycerides) glucose, creatinine.

  4. Electrocardiogram (ECG) and exercise ECG if angina suspected.

  5. ECG and consider echocardiogram in hypertensive persons.

  6. Premature or aggressive CVD especially with a family history of premature CVD: consider high sensitivity C-reactive protein (CRP), lipoprotein (a), fibrinogen, homocysteine if feasible, specialist referral.

Appendix 3.



  • European patients with established atherosclerotic cardiovascular disease (CVD)

  • Asymptomatic individuals in Europe who are at increased risk of CVD because of:

    • Multiple risk factors resulting in raised total CVD risk (≥5% 10 year risk of CVD death)

    • Diabetes-type 2 and type 1 with microalbuminuria

    • Markedly increased single risk factors especially if associated with end organ damage

  • Close relatives of Europeans with premature atherosclerotic CVD or of those at particularly high risk

For an estimation of the general risk it is recommended to use system SCORE (Systematic Coronary Risk Evaluation - a regular estimation of coronary risk). It has been prepared on the basis of results the European researches and it allows predicting death risk from an atherosclerosis within 10 years. Criterion of high risk is the probability of death from cardiovascular complications of ≥5 % (instead of ≥20 % for total risk of coronary complications, as earlier). By means of system SCORE it is possible to develop the risk table of risk for all countries of Europe with allowance for corresponding figures of death rate.

Appendix 4.

SCORE scale

(Systematic Coronary Risk Evaluation)

SCORECARD is an electronic variant of tables SCORE.


  • Use the low risk chart in Belgium*, France, Greece*, Italy, Luxembourg, Spain*, Switzerland and Portugal; use the high risk chart in other countries of Europe.

*Updated, recalibrated charts are now available for Belgium, Germany, Greece, the Netherlands, Poland, Spain and Sweden.

  • Find the cell nearest to the person's age, cholesterol and BP values, bearing in mind that risk will be higher as the person approaches the next age, cholesterol or BP category.

  • Check the qualifiers.

  • Establish the absolute 10 year risk for fatal CVD. Note that a low absolute risk in a young person may conceal a high relative risk; this may be explained to the person by using the relative risk chart. As the person ages, a high relative risk will translate in to a high absolute risk. More intensive lifestyle advice will be needed in such persons.

Risk estimation using the Systematic Coronary Risk Evaluation (SCORE) risk prediction system, considering age, gender, smoker status, systolic blood pressure, and cholesterol level

Risk Estimation Using SCORE: Qualifiers

  • The charts should be used in the light of the clinician's knowledge and judgement, especially with regard to local conditions.

  • As with all risk estimation systems, risk will be overestimated in countries with falling CVD mortality rate, and underestimated if it is rising.

  • At any given age, risk appears lower for women than men. This is misleading since, ultimately, more women than men die from CVD. Inspection of the charts shows that their risk is merely differed by 10 years.

  • Risk may be higher than indicated in the chart in:

    • Sedentary or obese subjects, especially those with central obesity

    • Those with a strong family history of premature CVD

    • The socially deprived

    • Subjects with diabetes – risk may be 5 fold higher in women with diabetes and 3 fold higher in men with diabetes compared to those without diabetes

    • Those with low HDL cholesterol or high triglycerides

    • Asymptomatic subjects with evidence of preclinical atherosclerosis, for example, a reduced ankle-brachial index or on imaging such as carotid ultrasonography or computed tomography (CT) scanning

Appendix 5.

Principles of Behaviour Change and Management of Behavioural Risk Factors

Goal Complete cessation. No exposure to environmental tobacco smoke.

  • Ask about tobacco use status at every visit.

  • Advise every tobacco user to quit.

  • Assess the tobacco user's willingness to quit.

  • Assist by counseling and developing a plan for quitting.)

  • Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion).

Urge avoidance of exposure to environmental tobacco smoke at work and home

Physical Activity

Goal: 30 minutes, 7 days per week (minimum 5 days per week)

  • For all patients, assess risk with a physical activity history and/or an exercise test, to guide prescription.

  • For all patients, encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).

  • Encourage resistance training 2 days per week.

Advise medically supervised programs for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure).

AHA 2006 Diet and Lifestyle Recommendations for Cardiovascular Disease Risk Reduction

  • Balance calorie intake and physical activity to achieve or maintain a healthy body weight.

  • Consume a diet rich in vegetables and fruits.

  • Choose whole-grain, high-fiber foods.

  • Consume fish, especially oily fish, at least twice a week.

  • Limit your intake of saturated fat to <7% of energy, trans fat to <1% of energy, and cholesterol to <300 mg per day by

    • Choosing lean meats and vegetable alternatives

    • Selecting fat-free (skim), 1%-fat, and low-fat dairy products

    • Minimizing intake of partially hydrogenated fats

  • Minimize your intake of beverages and foods with added sugars.

  • Choose and prepare foods with little or no salt.

  • If you consume alcohol, do so in moderation

  • When you eat food that is prepared outside of the home, follow the AHA Diet and Lifestyle Recommendations.

Weight Management

Goal: Body mass index: 18.5 to 24.9 kg/m2
Waist circumference: men < 102 sm, women <80 sm

  • Assess body mass index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioural programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2.

  • If waist circumference (measured horizontally at the iliac crest) is >80 sm in women and >102 sm in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.)

  • The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment.

Appendix 6.



BMI (kg/m2)







Obese I


Obese II


Obese III


Appendix 7.

Classification of Arterial hypertension













High normal




Grade 1 hypertension




Grade 2 hypertension




Grade 3 hypertension




Isolated systolic hypertension




Isolated systolic hypertension should be graded (1, 2, 3) according to systolic blood pressure values in the ranges indicated, provided that diastolic values are <90 mmHg. Grades 1, 2 and 3 correspond to a classification in mild, moderate and severe hypertension, respectively. These terms have now been omitted to avoid confusion with quantification of total cardiovascular risk.

Appendix 8

^ Blood Pressure Control

<140/90 mm Hg
<130/80 mm Hg if patient has diabetes or chronic kidney disease

^ Management of Total CVD – Blood Pressure

In all cases, look for and manage all risk factors. Those with established CVD, diabetes or renal disease are at markedly increased and BP of <130/80 is desirable if feasible. For all other people, check SCORE risk. Those with target organ damage are managed as 'increased risk.'



High Normal

Grade 1

Grade 2

Grade 3 ≥180/110


Lifestyle advice

Lifestyle advice

Lifestyle advice

Drug Rx if persists

Drug Rx


Lifestyle advice

Lifestyle advice

+ consider Drug Rx

Drug Rx if persists

Drug Rx


Lifestyle advice

+ consider Drug Rx

Drug Rx

Drug Rx

Drug Rx

Markedly increased

Lifestyle advice

+ consider Drug Rx

Drug Rx

Drug Rx

Drug Rx

Mod = moderate; Rx = treatment

^ For patients with blood pressure >140/90 mm Hg (or >130/80 mm Hg for individuals with chronic kidney disease or diabetes):

  • As tolerated, add blood pressure medication, treating initially with beta-blockers and/or angiotensin-converting enzyme (ACE) inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure.

^ Antihypertensive Treatment: Preferred Drugs

Subclinical Organ Samage



Asymptomatic atherosclerosis




Renal dysfunction


Clinical Event

Previous stroke

Any BP lowering agent

Previous MI


Angina pectoris


Heart failure

Diuretics, BB, ACEI, ARB, antialdosterone agents

Atrial fibrillation




BB, non-dihydropyridine CA


ACEI, ARB, loop diuretics

Peripheral artery disease



ISH (elderly)

Diuretics, CA

Metabolic syndrome


Diabetes mellitus



CA, methyldopa, BB


Diuretics, CA

Abbreviations: LVH: left ventricular hypertrophy; ISH: isolated systolic hypertension; ESRD: renal failure; ACEI: ACE inhibitors; ARB: angiotensin recepter antagonists; CA: calcium antagonists; BB: beta-blockers

Appendix 9.

Classification of Serum Lipids

Total Cholesterol (TC) mg/dL (mmol/L)


<200 (<5.2)
200 to 239 (5.2 to 6.1)
>240 (> 6.2)

Borderline high

LDL-Cholesterol mg/dL (mmol/L)

<100 (<2.6)
100 to 129 (2.6 to 3.3)
130 to 159 (3.4 to 4.0)
160 to 189 (4.1 to 4.8)
>190 (>4.9)

Above, near optimal
Borderline high
Very high

HDL- Cholesterol mg/dL (mmol/L)

<40 (<1.0)
>60 (>1.6)


Triglycerides (TG) mg/dL (mmol/L)

<150 mg/dL (<1.7)
150 to 199 mg/dL (1.7 to 2.2)
200 to 499 mg/dL (2.3 to 5.6)
>500 mg/dL (>5.6)

Borderline High
Very High

Appendix 10.

Recommendations for healthy persons to prevent lipid pathology

  • Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/dL).

  • Adding plant stanol/sterols (2 g/day) and viscous fiber (>10 g/day) will further lower LDL-C

  • Promote daily physical activity and weight management.

  • Encourage increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction.

For lipid management:

Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiate lipid-lowering medication as recommended below before discharge according to the following schedule:

  • LDL-C should be <100 mg/dL

  • Further reduction of LDL-C to <70 mg/dL is reasonable.

  • If baseline LDL-C is >100 mg/dL, initiate LDL-lowering drug therapy.

  • If on-treatment LDL-C >100 mg/dL, intensify low-density lipoprotein (LDL)-lowering therapy (may require LDL-lowering drug combination).

  • If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL.

  • If triglycerides are 200 to 499 mg/dL, non-HDL-C should be <130 mg/dL. and

  • Further reduction of non-HDL-C to <100 mg/dL is reasonable.

  • Therapeutic options to reduce non-HDL-C are:

    • More intense LDL-C–lowering therapy or

    • Niacin (after LDL-C–lowering therapy), or

    • Fibrate therapy (after LDL-C–lowering therapy)

  • If triglycerides are >500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C <130 mg/dL if possible.

Appendix 11.

Diabetes Management

Goal: Glycosylated hemoglobin (HbA1c) <7%

^ Treatment Targets in Patients with Type 2 Diabetes




HbA1c (Diabetes Control and Complications Trial [DCCT]-aligned)

HbA1c (%)

≤6.5 if feasible

Plasma Glucose

Fasting/pre-prandial mmol/(mg/dl)

<6.0 (110) if feasible

Post-prandial mmol/l(mg/dl)

<7.5 (135) if feasible

Blood pressure



Total cholesterol

mmol/l (mg/dl)
mmol/l (mg/dl)

<4.5 (175)
<4.0 (155) if feasible


mmol/l (mg/dl)
mmol/l (mg/dl)

<2.5 (100)
<2.0 (80) if feas

  • Initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c.

  • Begin vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended above).

  • Coordinate diabetic care with patient's primary care physician or endocrinologist.

Appendix 12.

Diagnosis of Metabolic Syndrome ["Third Report," 2002]

^ Three or more of the following risk factors indicate metabolic syndrome:

Defining Level

Abdominal Obesity:

Waist Circumference (WC):


Greater than 102 cm (>40 in)


Greater than 88 cm (>35 in)


Greater than or equal to 150 mg/dL

HDL cholesterol:



Less than 40 mg/dL


Less than 50 mg/dL

Blood pressure

Greater than or equal to 130/85 mmHg

Fasting glucose

Greater than or equal to 110 mg/dL

Final tests

Тест№1. To the patient who suffers from Arterial hypertension of the 2 degree, was recommended as one of the methods of prophylaxis cardiovascular risk of death physical activity. What level of it was indicated?

A) strict limitation of physical activity

B) 30 min low intensity physical activity a day

C) 15 min high intensity physical activity a day

D) 30 min mild intensity physical activity a day

E) 60 min low intensity physical activity a day

Тест№2. Patient E 68 years who suffers from Arterial hypertension of the 2 degree, 2 stage, has a high risk of cardiovascular events has come to the dietiterian. What diet will you recommend him with the purpose of decrease risk of fatal cardiovascular events?

A) unfatted sorts of fish, fruit, vegetables

B) products which are rich in iodine

C) limited sugar and carbonhydrates

D) pork, mutton

E) limited fluid intake


Тест№3. At objective examination of the patient Å. 46 years were observed vesicular breathing above lungs. Heart activity was normal. Heart rate was 68 per minute. BP was 160/90 mm HG. There were no edemas. Is it needed to begin medicament therapy with the purpose to decrease general risk of development of cardiovascular disorders?

A) possible

B) no, it isn’t

C) yes, it is

D) only if cholesterol level is increased

E) only if level of fasten glucose increased

Тест№4. Patient D. complains of headache, frequent palpitation, lowering of work capacity. The examination exposed Heart rate of 100 beats a minute, BP 140 / 90 mm Hg. What doesn’t influence on the decision about prescription of medicamental treatment?

A) level of BP

B) existence of clinically exposed cardiovascular risk events

C) existence of other cardiovascular risk factors

D) existence of subclinic cardiovascular risk events or damage of target organs

E) existence of thyrotoxicosis

Тест № 5. The objective examination of 40-year-old woman who has been suffering from arterial hypertension for 15 years exposed that the circumference of waistline is 90 cm. What can you recommend her to improve her health?

A) control of body mass

B) body mass lowering

C) glucose restriction

D) change in diet is not needed

E) to heighten content of fat cultured milk foods in diet

Тест№6. What correction of general cardiovascular risk would you recommend to a patient of 48 years with arterial hypertension of the 2nd degree and cardiovascular risk 4% according to the SCORE?

A) change of life style

B) change of life style + medicamental therapy

C) medicamental therapy

D) in a case of arterial hypertension retention – medicamental therapy

E) possible medicamental therapy

Тест№7. A patient with arterial hypertension of the 1st degree and cardiovascular risk 8% according to SCORE is recommended medicamental therapy to bring down the general cardiovascular risk. What group of hypotensive medicines are not recommended as the 1st line for the treatment of such a patient?

A) ß-blockers

B) Ca antagonists

C) α-adrenoceptors blockers

D) ACE-inhibitors

E) diuretics

Тест№8. A patient with IHD, heightened level of general cholesterol were recommended medicines to bring down general cardiovascular risk. Which of the medicines can not bring down high cholesterol level?

A) fibrates

B) statins

C) sequestrants of fat acids

D) nicotinic acid

E) sildenaphil

Тест№9. A patient with diabetes mellitus of the 2nd type is recommended to control the level of НВА1C regularly. What is the purpose level of it?

A) ≤ 3%

B) ≤ 4%

C) ≤ 5,5%

D) ≤ 6,5%

E) ≤ 6%

Тест№10. You are examining the patient M. of 56 years. The objective examination exposed that circumference of waistline is 98 cm. To confirm the diagnosis of Metabolic syndrome it’s necessary to perform several investigations. What of the following isn’t included in the list?

A) triglyceride


C) level of BP

D) level of fasten glucose

E) creatinine level


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