CardioVascular CardioVascular Disease PreventionDisease Prevention

CVD preventionCVD prevention

‘‘The evidence that most The evidence that most cardiovascular disease is cardiovascular disease is preventable continues to grow.preventable continues to grow. ’’

‘‘……the majority of the causes of the majority of the causes of cardiovascular disease are known cardiovascular disease are known and modifiable.and modifiable.’’

(Circulation. (Circulation. 2002;106:388-391)2002;106:388-391)

ObjectivesObjectives

Know the core components of a Know the core components of a secondary prevention plan for secondary prevention plan for patients with cardiovascular patients with cardiovascular diseasedisease

Develop a clinician checklist for Develop a clinician checklist for your Post-MI patientyour Post-MI patient

CVD ScopeCVD Scope

Accounts for 17 million Accounts for 17 million annual deaths globallyannual deaths globally

80% of which in developed80% of which in developed

countriescountries

Leading cause of death in Leading cause of death in United States United States (452,327 deaths in the 2004)(452,327 deaths in the 2004)

U.S. Annual cost > 300 U.S. Annual cost > 300 billionbillion

Prevention conceptPrevention concept

Implies ability to evaluate risks, Implies ability to evaluate risks, disease burden, and offer disease burden, and offer effective interventioneffective intervention

CVD Prevention modelCVD Prevention model

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

Post-MI patient office Post-MI patient office carecare Core ComponentsCore Components

Initial risk assessmentInitial risk assessment Pharmacologic therapyPharmacologic therapy Lifestyle changes & Lifestyle changes &

interventionsinterventions Psychosocial evaluationPsychosocial evaluation

Initial Risk AssessmentInitial Risk Assessment

Establish burden of diseaseEstablish burden of disease Evaluate CVD risksEvaluate CVD risks

Disease burdenDisease burden

SymptomsSymptoms– Active or recurrent cardiac ischemiaActive or recurrent cardiac ischemia

Review of coronary interventionsReview of coronary interventions– Angiography, PCI/stent, bypassAngiography, PCI/stent, bypass

Manifest morbidityManifest morbidity– AnginaAngina– CHF / depressed LVEFCHF / depressed LVEF– Dysrhythmia (atrial/ventricular)Dysrhythmia (atrial/ventricular)

Spectrum of diseaseSpectrum of disease

Lower risk patientLower risk patient AsymptomaticAsymptomatic PCI – one stentPCI – one stent Normal LVEFNormal LVEF No dysrhythmiaNo dysrhythmia

Higher risk patientHigher risk patient Recurrent /persistent Recurrent /persistent

anginaangina Multivessel disease / Multivessel disease /

bypassbypass LVEF < 40% (with or LVEF < 40% (with or

without CHF without CHF symptoms)symptoms)

DysrhythmiaDysrhythmia

Higher risk patientsHigher risk patients

Revascularization Revascularization assessmentassessment

More extensive More extensive medication therapymedication therapy

Anticoagulation therapyAnticoagulation therapy Pacemaker / defibrillatorPacemaker / defibrillator Specialist managementSpecialist management

Define CVD risk factorsDefine CVD risk factors

MajorMajor SmokingSmoking HTNHTN DMDM High LDLHigh LDL Low HDLLow HDL Advanced Advanced

ageage

UnderlyingUnderlying ObesityObesity Physical inactivityPhysical inactivity DietDiet Psych/socio economicPsych/socio economic FHxFHx CKDCKD Genetic / racial factorsGenetic / racial factors

May also consider May also consider Emerging risk factorsEmerging risk factors

Other lipid factorsOther lipid factors– Triglycerides, Triglycerides,

apolipoprotein apolipoprotein subfractionssubfractions

Insulin resistanceInsulin resistance Prothrombotic Prothrombotic

markersmarkers Proinflammatory Proinflammatory

markersmarkers

Post-MI Prevention Post-MI Prevention PlanPlan

Aggressive Aggressive Reduction Reduction Modifiable CVD Modifiable CVD Risk FactorsRisk Factors

– Blood PressureBlood Pressure– LipidsLipids– DiabetesDiabetes– DietDiet– WeightWeight– Physical ActivityPhysical Activity– Tobacco Tobacco

CessationCessation

Therapeutic goal Therapeutic goal to Slow, Stop, to Slow, Stop, Reverse disease Reverse disease progressionprogression

Post-MI patient office Post-MI patient office carecare Core ComponentsCore Components

Initial risk assessmentInitial risk assessment- Lower vs. higher risk patientLower vs. higher risk patient- Defined individual CVD risksDefined individual CVD risks

Pharmacologic therapyPharmacologic therapy Lifestyle changes & interventionsLifestyle changes & interventions Psychosocial evaluationPsychosocial evaluation

Pharmacologic Pharmacologic TherapyTherapy Lipid lowering agent Antiplatelet Beta-blocker ACE-Inhibitor

Lipid Lowering AgentsLipid Lowering Agents

Statins Statins (Class 1, Level A)– Risk reductions > 20% across all Risk reductions > 20% across all

endpoints endpoints (MI, Stroke, mortality, (MI, Stroke, mortality, revascularization)revascularization)

– Start on all post-MI patientStart on all post-MI patient– Goal LDL Goal LDL << 70 with at least 30% 70 with at least 30%

reduction in pretreatment LDLreduction in pretreatment LDL

Lipid Lowering AgentsLipid Lowering Agents

Niacin & FibratesNiacin & Fibrates (Class II, level B)(Class II, level B)– For TG 200 to 499 For TG 200 to 499

**(after LDL lowering therapy)**(after LDL lowering therapy)– Non-HDL-C goal < 130 target ; < 100 reasonable Non-HDL-C goal < 130 target ; < 100 reasonable – For TG >500 Fibrates or Niacin may be used For TG >500 Fibrates or Niacin may be used

before LDL lowering therapybefore LDL lowering therapy

Omega-3-Fatty acidsOmega-3-Fatty acids (Class II, level B)(Class II, level B)– Alternative for TG lowering agent (2-4g/day)Alternative for TG lowering agent (2-4g/day)

Antiplatelet agentsAntiplatelet agents

AspirinAspirin (Class I, Level A)(Class I, Level A)– 10-40% risk reduction of recurrent MI, 10-40% risk reduction of recurrent MI,

Stroke, or vascular deathStroke, or vascular death– Start and continue indefinitely in all Start and continue indefinitely in all

patients post-MI/ACSpatients post-MI/ACS– 75mg daily lowest effective dose for CAD, 75mg daily lowest effective dose for CAD,

160mg daily for additional stroke 160mg daily for additional stroke preventionprevention

Antiplatelet agentsAntiplatelet agents

ClopidogrelClopidogrel– Agent of choice in ASA allergy Agent of choice in ASA allergy

ptspts– In post-MI patients:In post-MI patients:

Minimum 14 days all patientsMinimum 14 days all patients

12 months for post-PCI, stent12 months for post-PCI, stent (Class I, Level B)(Class I, Level B)

Long-term therapy (1 year) is Long-term therapy (1 year) is reasonable in all post-MI patientsreasonable in all post-MI patients

(Class IIa, Level C)(Class IIa, Level C)

Beta-BlockersBeta-Blockers

Start and continue indefinitely in Start and continue indefinitely in all patients s/p MI, ACS, LV all patients s/p MI, ACS, LV dysfunction with or without heart dysfunction with or without heart failure symptoms failure symptoms (Class I, Level (Class I, Level A)A)

– 13-36% mortality risk reduction13-36% mortality risk reduction– Monitor for contraindicationsMonitor for contraindications

ACE-InhibitorsACE-Inhibitors

Start and continue indefinitely in Start and continue indefinitely in all post-MI patients with LVEF all post-MI patients with LVEF <40% and for those with HTN, DM, <40% and for those with HTN, DM, or CKD or CKD (Class I, Level A)(Class I, Level A)– Mortality risk reductions up to 27% in this groupMortality risk reductions up to 27% in this group

Reasonable to start in lower risk Reasonable to start in lower risk post-MI patients (normal LVEF) post-MI patients (normal LVEF) (Class IIa, Level B)(Class IIa, Level B)

Other Agents – Other Agents – ARBs & ARBs & Aldosterone blockersAldosterone blockers

Angiotensin receptor blockersAngiotensin receptor blockers– For ACE-I intolerant patients s/p MI, For ACE-I intolerant patients s/p MI,

HF, LVEF <40% HF, LVEF <40% (Class I, Level A)(Class I, Level A)

– For ACE-I intolerant patients with For ACE-I intolerant patients with hypertension alone hypertension alone (Class I, Level B)(Class I, Level B)

– In combo with ACE-I in systolic HF In combo with ACE-I in systolic HF patientspatients (Class IIb, Level B)(Class IIb, Level B)

Other Agents – Other Agents – ARBs & ARBs & Aldosterone blockersAldosterone blockers

Aldosterone blockersAldosterone blockers– In post-MI patients without In post-MI patients without

significant renal significant renal dysfunction/hyperkalemia (<5.0) dysfunction/hyperkalemia (<5.0) who are already on therapeutic ACE-who are already on therapeutic ACE-I, Beta-Blocker, have LVEF <40%, I, Beta-Blocker, have LVEF <40%, and have either HTN or DM and have either HTN or DM (Class I, (Class I, Level A)Level A)

Diabetes MedicationsDiabetes Medications

GoalGoal– Tight glucose controlTight glucose control– At minimum A1C less than 7%At minimum A1C less than 7%

Pharmacologic Checklist Pharmacologic Checklist Post-MI Post-MI

Aspirin / ClopidogrelAspirin / Clopidogrel StatinStatin Beta BlockerBeta Blocker ACE-IACE-I

ConsiderConsider

ARB, Aldosterone blocker, ARB, Aldosterone blocker, warfarin in appropriate caseswarfarin in appropriate cases

What about NSAID use?

Acetametaphen, ASA, tramadol, Acetametaphen, ASA, tramadol,

narcotic analgesics (short term) narcotic analgesics (short term)

Non COX-2 selective NSAIDS Non COX-2 selective NSAIDS

NSAIDs with some NSAIDs with some

COX-2 activity COX-2 activity

COX-2 Selective COX-2 Selective

NSAIDS NSAIDS

All Level C All Level C evidenceevidence

Post-MI patient office Post-MI patient office carecare Core ComponentsCore Components

Initial risk assessmentInitial risk assessment- Lower vs. higher risk patientLower vs. higher risk patient- Defined individual CVD risksDefined individual CVD risks

Pharmacologic therapyPharmacologic therapy- Aspirin/Clopidogrel, Statin, B-Blocker, Aspirin/Clopidogrel, Statin, B-Blocker,

ACE-IACE-I

Lifestyle changes & interventionsLifestyle changes & interventions Psychosocial evaluationPsychosocial evaluation

Lifestyle Changes & Lifestyle Changes & InterventionsInterventions

Tobacco Tobacco cessationcessation

Healthy food Healthy food choiceschoices

Weight controlWeight control Physical Physical

activityactivity

Maintain Maintain normalnormal- BP- BP

- BMI- BMI

- Lipid profile- Lipid profile

- Sugar control- Sugar control

- Fitness level- Fitness level

Administration of Administration of lifestyle changes…lifestyle changes…

AHA and AACVPR recommends recommends formal formal cardiac rehabilitation cardiac rehabilitation programsprograms for patients for patients with cardiovascular with cardiovascular disease disease (CAD, Post-MI, (CAD, Post-MI, chronic CHF, etc...)chronic CHF, etc...)

Tobacco cessationTobacco cessation

GOALGOAL– complete cessationcomplete cessation– no exposure to no exposure to

environmental smokeenvironmental smoke

Utilize 5 Utilize 5 ‘‘AA ’’ tool tool– AskAsk– AdviseAdvise– AssessAssess– AssistAssist– Arrange f/uArrange f/u

Healthy Food ChoicesHealthy Food Choices

Goal – healthy eating patternGoal – healthy eating pattern

– Fruits, vegies, whole grains, low/non-fat Fruits, vegies, whole grains, low/non-fat dairy, fish, legumes, lean meatsdairy, fish, legumes, lean meats

– Saturated fat < 10% total calories; Saturated fat < 10% total calories; cholesterol < 300mg / day cholesterol < 300mg / day

– Limit salt < 6g / dayLimit salt < 6g / day

– Limit Etoh to < 2 drinks / day (men) Limit Etoh to < 2 drinks / day (men)

< 1 drink /day (women)< 1 drink /day (women)

Diet tools/resourcesDiet tools/resources

5 5 ‘‘AA ’’ approach approach still appliesstill applies

Nutritional Nutritional consultconsult

Website for for self-help & self-help & educationeducation

Weight Weight ControlControl GoalGoal

– Achieve & maintain BMI 18.5 to 24.9 kg/m2Achieve & maintain BMI 18.5 to 24.9 kg/m2– Waist circumference Waist circumference << 40 inches (men) 40 inches (men)

<< 35 inches (women) 35 inches (women)

Weight-management programWeight-management program– Caloric restriction & increased expenditureCaloric restriction & increased expenditure– If obese reduce weight by 10% in 1If obese reduce weight by 10% in 1stst year year

5 5 ‘‘AA ’’ approach still applies approach still applies

Physical ActivityPhysical Activity

GoalGoal– 30 min moderate intensity 30 min moderate intensity (40%-60% max HR)(40%-60% max HR)

on most on most (preferably all)(preferably all) days of the week days of the week

Additional benefit from Additional benefit from vigorous intensity vigorous intensity exercise exercise (>60%max HR)(>60%max HR)

In sedentary, older, or In sedentary, older, or patients with higher patients with higher cardiac risk consider cardiac risk consider ETTETT

Changing behaviorsChanging behaviors

PrinciplesPrinciples– Simplify & tailor Simplify & tailor

behavioral change behavioral change prescriptionprescription

– Ask about behavior at Ask about behavior at every visitevery visit

– Involve family/social Involve family/social support in change support in change processprocess

– Provide useful & Provide useful & appropriate informationappropriate information

Changing behaviorsChanging behaviors

Tools/strategiesTools/strategies– Organize supportOrganize support– Group programsGroup programs– 5 5 ‘‘AA ’’ approach approach– Individual CBTIndividual CBT– Goal setting / self-Goal setting / self-

efficacy trainingefficacy training

Post-MI patient office Post-MI patient office carecare Core ComponentsCore Components

Initial risk assessmentInitial risk assessment- Lower vs. higher risk patientLower vs. higher risk patient- Defined individual CVD risksDefined individual CVD risks

Pharmacologic therapyPharmacologic therapy- Aspirin/Clopidogrel, Statin, B-Blocker, ACE-IAspirin/Clopidogrel, Statin, B-Blocker, ACE-I

Lifestyle changes & interventionsLifestyle changes & interventions- - Tob cessation, Diet, Weight, ExerciseTob cessation, Diet, Weight, Exercise

Psychosocial evaluationPsychosocial evaluation

Psychosocial Psychosocial EvaluationEvaluation

Psychosocial status should be Psychosocial status should be evaluated specifically for symptoms of evaluated specifically for symptoms of depression, anxiety, or sleep disorder depression, anxiety, or sleep disorder along with social support assessment along with social support assessment (AHA Class I, Level C)(AHA Class I, Level C)

Treatment with CBT and SSRI is useful Treatment with CBT and SSRI is useful in patient with depression occurring up in patient with depression occurring up to a year after discharge to a year after discharge (AHA Class IIa, (AHA Class IIa, Level C)Level C)

Depression Depression - Post-MI- Post-MI

Associated with Associated with increased mortality increased mortality ratesrates

Treatment with SSRI Treatment with SSRI have been shown to have been shown to provide mortality provide mortality benefitbenefit

Post-MI patient office Post-MI patient office carecare Core ComponentsCore Components

Initial risk assessmentInitial risk assessment- Lower vs. higher risk patientLower vs. higher risk patient- Defined individual CVD risksDefined individual CVD risks

Pharmacologic therapyPharmacologic therapy- Aspirin/Clopidogrel, Statin, B-Blocker, ACE-IAspirin/Clopidogrel, Statin, B-Blocker, ACE-I

Lifestyle changes & interventionsLifestyle changes & interventions- Tob cessation, Diet, Weight, Exercise- Tob cessation, Diet, Weight, Exercise

Psychosocial evaluationPsychosocial evaluation- Depression screen (SSRI), social support- Depression screen (SSRI), social support

SummarySummary

‘Health professionals should include prevention of CVD as an integral part of their daily clinical practice.’

– World Heart Federation, World Heart and World Heart Federation, World Heart and Stroke Forum Stroke Forum (Circulation 2004; 109;3112-(Circulation 2004; 109;3112-3121)3121)

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