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CardioVascular Disease Prevention

CardioVascular Disease Prevention. Richard Derby, LtCol , USAF, MC MGMC, Andrews AFB Presentation by H.Shamsolkottabi MD. CVD prevention. ‘ The evidence that most cardiovascular disease is preventable continues to grow. ’

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CardioVascular Disease Prevention

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  1. CardioVascular Disease Prevention Richard Derby, LtCol, USAF, MC MGMC, Andrews AFB Presentation by H.Shamsolkottabi MD

  2. CVD prevention • ‘The evidence that most cardiovascular disease is preventable continues to grow.’ • ‘…the majority of the causes of cardiovascular disease are known and modifiable.’ (Circulation. 2002;106:388-391)

  3. Objectives • Know the core components of a secondary prevention plan for patients with cardiovascular disease • Develop a clinician checklist for your Post-MI patient

  4. CVD Scope • Accounts for 17 million annual deaths globally 80% of which in developed countries • Leading cause of death in United States (452,327 deaths in the 2004) • U.S. Annual cost > 300 billion

  5. Prevention concept • Implies ability to evaluate risks, disease burden, and offer effective intervention

  6. CVD Prevention model

  7. Success? -- Yes! • Age adjusted death rates specific to coronary artery disease have declined by approximately 50% from 1980 - 2000 (men and women) • Secondary prevention initiatives a major factor for this trend • Remaining underutilization

  8. Post-MI patient office careCore Components • Initial risk assessment • Pharmacologic therapy • Lifestyle changes & interventions • Psychosocial evaluation

  9. Initial Risk Assessment • Establish burden of disease • Evaluate CVD risks

  10. Disease burden • Symptoms • Active or recurrent cardiac ischemia • Review of coronary interventions • Angiography, PCI/stent, bypass • Manifest morbidity • Angina • CHF / depressed LVEF • Dysrhythmia (atrial/ventricular)

  11. Spectrum of disease Lower risk patient Higher risk patient Recurrent /persistent angina Multivessel disease / bypass LVEF < 40% (with or without CHF symptoms) Dysrhythmia • Asymptomatic • PCI – one stent • Normal LVEF • No dysrhythmia

  12. Higher risk patients • Revascularization assessment • More extensive medication therapy • Anticoagulation therapy • Pacemaker / defibrillator • Specialist management

  13. Define CVD risk factors Major • Smoking • HTN • DM • High LDL • Low HDL • Advanced age Underlying • Obesity • Physical inactivity • Diet • Psych/socio economic • FHx • CKD • Genetic / racial factors

  14. Other lipid factors Triglycerides, apolipoproteinsubfractions Insulin resistance Prothrombotic markers Proinflammatory markers May also consider Emerging risk factors

  15. Aggressive Reduction Modifiable CVD Risk Factors Blood Pressure Lipids Diabetes Diet Weight Physical Activity Tobacco Cessation Post-MI Prevention Plan • Therapeutic goal to Slow, Stop, Reverse disease progression

  16. Post-MI patient office careCore Components • Initial risk assessment • Lower vs. higher risk patient • Defined individual CVD risks • Pharmacologic therapy • Lifestyle changes & interventions • Psychosocial evaluation

  17. Pharmacologic Therapy • Lipid lowering agent • Antiplatelet • Beta-blocker • ACE-Inhibitor

  18. Lipid Lowering Agents • Statins (Class 1, Level A) • Risk reductions > 20% across all endpoints (MI, Stroke, mortality, revascularization) • Start on all post-MI patient • Goal LDL < 70 with at least 30% reduction in pretreatment LDL

  19. Lipid Lowering Agents • Niacin & Fibrates(Class II, level B) • For TG 200 to 499 **(after LDL lowering therapy) • Non-HDL-C goal < 130 target ; < 100 reasonable • For TG >500 Fibrates or Niacin may be used before LDL lowering therapy • Omega-3-Fatty acids(Class II, level B) • Alternative for TG lowering agent (2-4g/day)

  20. Antiplatelet agents • Aspirin(Class I, Level A) • 10-40% risk reduction of recurrent MI, Stroke, or vascular death • Start and continue indefinitely in all patients post-MI/ACS • 75mg daily lowest effective dose for CAD, 160mg daily for additional stroke prevention

  21. Clopidogrel Agent of choice in ASA allergy pts In post-MI patients: Minimum 14 days all patients 12 months for post-PCI, stent (Class I, Level B) Long-term therapy (1 year) is reasonable in all post-MI patients (Class IIa, Level C) Antiplatelet agents

  22. Beta-Blockers • Start and continue indefinitely in all patients s/p MI, ACS, LV dysfunction with or without heart failure symptoms (Class I, Level A) • 13-36% mortality risk reduction • Monitor for contraindications

  23. ACE-Inhibitors • Start and continue indefinitely in all post-MI patients with LVEF <40% and for those with HTN, DM, or CKD (Class I, Level A) • Mortality risk reductions up to 27% in this group • Reasonable to start in lower risk post-MI patients (normal LVEF) (Class IIa, Level B)

  24. Other Agents – ARBs & Aldosterone blockers • Angiotensin receptor blockers • For ACE-I intolerant patients s/p MI, HF, LVEF <40% (Class I, Level A) • For ACE-I intolerant patients with hypertension alone (Class I, Level B) • In combo with ACE-I in systolic HF patients(Class IIb, Level B)

  25. Other Agents – ARBs & Aldosterone blockers • Aldosterone blockers • In post-MI patients without significant renal dysfunction/hyperkalemia (<5.0) who are already on therapeutic ACE-I, Beta-Blocker, have LVEF <40%, and have either HTN or DM (Class I, Level A)

  26. Diabetes Medications • Goal • Tight glucose control • At minimum A1C less than 7%

  27. Pharmacologic Checklist Post-MI • Aspirin / Clopidogrel • Statin • Beta Blocker • ACE-I Consider ARB, Aldosterone blocker, warfarin in appropriate cases

  28. What about NSAID use? Acetametaphen, ASA, tramadol, narcotic analgesics (short term) Non COX-2 selective NSAIDS NSAIDs with some COX-2 activity COX-2 Selective NSAIDS All Level C evidence

  29. Post-MI patient office careCore Components • Initial risk assessment • Lower vs. higher risk patient • Defined individual CVD risks • Pharmacologic therapy • Aspirin/Clopidogrel, Statin, B-Blocker, ACE-I • Lifestyle changes & interventions • Psychosocial evaluation

  30. Lifestyle Changes & Interventions • Tobacco cessation • Healthy food choices • Weight control • Physical activity Maintain normal - BP - BMI - Lipid profile - Sugar control - Fitness level

  31. Administration of lifestyle changes… • AHA and AACVPR recommends formal cardiac rehabilitation programs for patients with cardiovascular disease (CAD, Post-MI, chronic CHF, etc...)

  32. Tobacco cessation • GOAL • complete cessation • no exposure to environmental smoke • Utilize 5 ‘A’ tool • Ask • Advise • Assess • Assist • Arrange f/u

  33. Healthy Food Choices • Goal – healthy eating pattern • Fruits, vegies, whole grains, low/non-fat dairy, fish, legumes, lean meats • Saturated fat < 10% total calories; cholesterol < 300mg / day • Limit salt < 6g / day • Limit Etoh to < 2 drinks / day (men) < 1 drink /day (women)

  34. Diet tools/resources • 5 ‘A’ approach still applies • Nutritional consult • Website for self-help & education

  35. Weight Control • Goal • Achieve & maintain BMI 18.5 to 24.9 kg/m2 • Waist circumference < 40 inches (men) < 35 inches (women) • Weight-management program • Caloric restriction & increased expenditure • If obese reduce weight by 10% in 1st year • 5 ‘A’ approach still applies

  36. Physical Activity • Goal • 30 min moderate intensity (40%-60% max HR) on most (preferably all) days of the week • Additional benefit from vigorous intensity exercise (>60%max HR) • In sedentary, older, or patients with higher cardiac risk consider ETT

  37. Principles Simplify & tailor behavioral change prescription Ask about behavior at every visit Involve family/social support in change process Provide useful & appropriate information Changing behaviors

  38. Tools/strategies Organize support Group programs 5 ‘A’ approach Individual CBT Goal setting / self-efficacy training Changing behaviors

  39. Post-MI patient office careCore Components • Initial risk assessment • Lower vs. higher risk patient • Defined individual CVD risks • Pharmacologic therapy • Aspirin/Clopidogrel, Statin, B-Blocker, ACE-I • Lifestyle changes & interventions - Tob cessation, Diet, Weight, Exercise • Psychosocial evaluation

  40. Psychosocial Evaluation • Psychosocial status should be evaluated specifically for symptoms of depression, anxiety, or sleep disorder along with social support assessment (AHA Class I, Level C) • Treatment with CBT and SSRI is useful in patient with depression occurring up to a year after discharge (AHA Class IIa, Level C)

  41. Depression - Post-MI • Associated with increased mortality rates • Treatment with SSRI have been shown to provide mortality benefit

  42. Post-MI patient office careCore Components • Initial risk assessment • Lower vs. higher risk patient • Defined individual CVD risks • Pharmacologic therapy • Aspirin/Clopidogrel, Statin, B-Blocker, ACE-I • Lifestyle changes & interventions - Tob cessation, Diet, Weight, Exercise • Psychosocial evaluation - Depression screen (SSRI), social support

  43. Summary ‘Health professionals should include prevention of CVD as an integral part of their daily clinical practice.’ • World Heart Federation, World Heart and Stroke Forum (Circulation 2004; 109;3112-3121)

  44. Go Save a heart

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