1. CardioVascular Disease Prevention

2. CVD prevention ‘The evidence that most cardiovascular disease is preventable continues to grow.’ ‘The evidence that most cardiovascular disease is preventable continues to grow.’ ‘…the majority of the causes of cardiovascular disease are known and modifiable.’ ‘…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 Know the core components of a secondary prevention plan for patients with cardiovascular disease Develop a clinician checklist for your Post-MI patient Develop a clinician checklist for your Post-MI patient

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

5. Prevention concept Implies ability to evaluate risks, disease burden, and offer effective intervention 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 care Core Components  Initial risk assessment  Pharmacologic therapy  Lifestyle changes & interventions  Psychosocial evaluation

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

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

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

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

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

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

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

16. Post-MI patient office care Core 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 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) 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) Omega-3-Fatty acids (Class II, level B) –Alternative for TG lowering agent (2-4g/day)

20. Antiplatelet agents Aspirin (Class I, Level A) 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. Antiplatelet agents Clopidogrel 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)

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

24. Other Agents – ARBs & Aldosterone blockers Angiotensin receptor 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 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 Goal –Tight glucose control –At minimum A1C less than 7%

27. Pharmacologic Checklist Post-MI Aspirin / Clopidogrel Aspirin / Clopidogrel Statin Statin Beta Blocker Beta Blocker ACE-I ACE-I Consider Consider ARB, Aldosterone blocker, warfarin in appropriate cases 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 care Core 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 Tobacco cessation Healthy food choices Healthy food choices Weight control Weight control Physical activity Physical activity Maintain normal 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...) AHA and AACVPR recommends formal cardiac rehabilitation programs for patients with cardiovascular disease (CAD, Post-MI, chronic CHF, etc...) AHA and AACVPR AHA and AACVPR

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

33. Healthy Food Choices Goal – healthy eating pattern 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) < 1 drink /day (women)

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

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

36. Physical Activity Goal 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) Additional benefit from vigorous intensity exercise (>60%max HR) In sedentary, older, or patients with higher cardiac risk consider ETT In sedentary, older, or patients with higher cardiac risk consider ETT

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

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

39. Post-MI patient office care Core 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) 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) 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 Associated with increased mortality rates Treatment with SSRI have been shown to provide mortality benefit Treatment with SSRI have been shown to provide mortality benefit

42. Post-MI patient office care Core 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)

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