1. Aggressive Therapy of Hypercholesterolemia in Acute Coronary Syndromes Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center, Los Angeles, CA California Chairman, AHA "Get with the Guidelines"

2. Who are we talking about? Known vascular disease CAD Carotid PVD Aortic Aneurysm Vascular equivalents DM High risk 10 year risk > 20% NCEP III -- JAMA 2000;285:2486

3. LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories  190 (160–189: LDL- lowering drug optional)  160 <160 0–1 Risk Factor 10-year risk 10–20%:  130 10-year risk <10%:  160  130 <130 2+ Risk Factors (10-year risk  20%)  130 (100–129: drug optional)  100 <100 CHD or CHD Risk Equivalents (10-year risk >20%) LDL Level at Which to Consider Drug Therapy (mg/dL) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Goal (mg/dL) Risk Category

4. 1 - Diet 2 - Exercise 3 - Drugs 4 - Partial ileal bypass 5 - Portacaval shunting 6 - Apheresis adsorption column (LDL apheresis) plasma exchange double membrane dextran sulfate precipitation immunoabsorption 7 - Liver transplantation Methods for Modifying Cholesterol Levels

5. Atherosclerosis

6. Egg McMuffin Calories290 Calories from fat110 Total fat12 g Saturated fat4.5 g Cholesterol235 mg Sodium790 mg Carbohydrates27g Protein17g http://www.mcdonalds.com/countries/usa/

7. Ornish D, et al. Lancet 1990;336:129 Lifestyle Heart Trial

8. Ornish D, et al. Lancet 1990;336:129 Lifestyle Heart Trial

9. Ornish D, et al. Lancet 1990;336:129 Lifestyle Heart Trial Intervention group LDL after 1 year Mean = 93 mg/dl + 43 mg/dl NCEP Goal 55.3% 44.7%

10. Mediterranian Diet J. THOMSON "Chart of the Mediterranean Sea" Edin.18I7

11. Lyon Heart Trial De Lorgeril et al Circulation 1999;99:779 First MI Randomized Mediterranian vs Prudent 5 year trial stopped early <35% energy as fat <10% energy saturated fat <4% energy as linoleic acid >0.6% of energy as alpha-linolenic (18:3 or n-3) Eat more bread Eat more fish, less meat Eat more vegetables Must have fruit every day All butter and margarine replaced with olive oil and canola oil

12. Lyon Heart Trial De Lorgeril et al Circulation 1999;99:779 Survival with: No MI Survival with: No MI Angina CHF CVA PE Periph embol Survival with: No MI Angina CHF CVA PE Periph embol Stable angina PTCA, CABG Restenosis

13. Lyon Heart Trial De Lorgeril et al Circulation 1999;99:779 Differences in LDL-C

14. 1. Disease-specific Renal Diabetes 2.Weight loss Thousands 3.Lipid management Hundreds 4.Survival Mediterranian Fish Goals of Diet(s)

15. Exercise

16. Myers, NEJM 2002;346:793 6,213 men ETT for clinical reasons 2,534 normal 3,679 with CAD Mean f/u 6.2 years Age 59 + 11 Peak capacity stronger predictor than cigs, HTN, DM, Chol

17. Effect of Exercise on Lipids Kokkinos Arch Int Med 1995:155:415  2906 men  age 30-64 years  exercise treadmill test to exhaustion  classified into 6 groups based on average miles run per week

18. Effect of Exercise on Lipids Kokkinos Arch Int Med 1995:155:415

19. Cholesterol-Lowering Drugs

20. Cholesterol Modifying Agents

21. 4S

22. Summary of Key End-points Simvastatin vs. placebo Total mortality CAD mortality Major coronary events PTCA/CABG Event-freesurvival 0.20.40.60.81.01.2 p=0.0003 p<0.00001 Relative risk (95% CI) ReducedIncreased

23. Effects of Statin on Total Mortality (4S) Diabetics (n= 201) vs Non-Diabetics (n=4242) 43% risk reduction 28% risk reduction Presented at the ACC Meeting March 19-22, 1995

24. When should we START therapy?

25. MIRACL P=0.048 Schwartz JAMA 2001;285:1711

26. CHAMP Fonarow, AJC 2001;87:819

27. CHAMP

28. When should we START therapy? AS SOON AS POSSIBLE!!!!

29. Why start drugs in the Hospital? Use diet and exercise on all patients, wait 3-6 months for statin therapy: 4% will have LDL < 100 mg/dL Start statin in the hospital, recommend diet and exercise: 96% get needed therapy 4% "overtreated"

30. How do you improve your rate of therapy?

31. Improving Process of Care  Finding a "Champion"  Develop a team  Baseline measurement  Use the team to develop new processes pocket reminders standard orders computer reminders  Follow-up measurement

32. Clinician Checklist

33. Patient Checklist

35. Get With the Guidelines!

36. The Guidelines

37. How often do we provide these therapies?

38. State Standings Jencks et al. JAMA 2000;284:1670 Ranked by CV indicators, mammog, immune, etc

39. What is the GWTG Plan?  Hospitals  Medical Groups Kaiser Tenet CHCW  Large payors  Government  Educational programs  Tools  Carrots  Sticks Everything still in development

40. Management of MedRx  On transfer out of the ICU ABC 2 D aspirin beta blocker cholesterol agent converting enzyme inhibitor (ACE) diabetes  On the ward hypertension therapy smoking cessation BMI recommendations exercise recommendations

41. All CABG-only, 10/1/2001 to 12/31/2001 compare to 1999 data CSMC Cardiothoracic Surgery

42. Effects of Various Cardiac Therapies

45. Why should you do this?  JCAHO  Oryx  HEDIS  Marketing  I swear by Apollo the physician, by Aesculapius, Hygeia, and Panacea, and take to witness all the gods, all the goddesses to keep according to my ability and my judgement the following oath:...

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