1. Global Cardiac Risk Management Anthony Battad CD, MD, MSc., MPH, FRCPC Director // Directeur Ambulatory Care, St. Boniface Hospital // Soins ambulatoire, Hôpital St. Boniface Medical Director //Directeur médical Master of Physician Assistant Studies // Mâitre d’études assitants-médicine University of Manitoba // Université du Manitoba abattad@sbgh.mb.ca

2. Disclosure Conference expenses paid for by University of Manitoba No financial conflicts to disclose

3. Understand the global impact of atherosclerotic disease Name the major risk factors implicated in atherosclerotic disease Recall the important targets for atherosclerotic risk factors Implement a global strategy for the prevention and treatment of atherosclerotic disease Objectives

4. 64 year old male. Previously well (no PMHx) No family history of premature HD Non-smoker; Minimal ETOH use Took his blood pressure at Walmart 162/80 In the office: 156/78 (BP Tru) Remainder of exam is unremarkable Case # 1

5. 56 year old female On a routine physical: LDL = 5, HDL = 1.02, TG = 2.4 No previous medical history FHx: (+) for HD on father’s side BMI = 29 BP = 146/56 Case # 2

6. 55 year old male in for “executive physical” FHx: (+) for MI (father at 52, mother at 56) Smoker 12 pk-yrs; 8 – 10 drinks / week High stress job Case # 3

7. Not every person at high risk will develop disease Not every person at low risk will be event free Estimating the lifetime risk of CV disease can be difficult Most risk factor calculators underestimate or overestimate the risk Risk factor treatment to accepted targets have inherent risks Which asymptomatic patients do you target for screening? Global Risk Management: The Challenge

8. 2013: 15.3 million deaths annually 1 Lifetime risk of CVD: 20 % – 49 % ♂ and 32 % ♀ 2 One half to one third of all CVD attributable to CHD/CAD Over 90% of all CHD events occur in patients with at least one risk factor The “Big 3” modifiable risk factors: Dyslipidemia Hypertension Diabetes Some facts to consider 1 The Farr Institute of Health Informatics Research, 2013 2 Jones, L., Framingham Study, 1999

9. HypertensionDyslipidemiaDiabetes Smoking

10. > 10 % CV deaths worldwide, 30 % North America Pathophysiology: Vasoconstriction  HTN Hypercoagulability  clot formation Endothelial dysfunction  vascular instability Single most effective intervention A few words about smoking

11. Some more facts… 75 000 Canadians/year suffer an MI and 50 000/year suffer stroke 75% of stroke victims survive first event 33% of patients under the age of 65 Hospitalized MI has 8% mortality 1 in 2 MI patients are under the age of 65 ~ $19 billion/year cost to Canadian economy

12. Why is risk assessment and treatment needed? Who Cares !!!!

13. To identify individuals at sufficient risk so appropriate global intervention can be given LDL < 2 BP < 130/80 BMI < 26 A1C < 6 Excercise Smoking Cessation

14. It is NOT unique to any one population

15. 3 Step Approach to Global Risk Management Screening: Who and When Stratify to Risk Group: High, Medium, Low Treat according to risk Specific, easy targets

16. Screening: Who and When Males ≥ 40 / Females ≥ 50 (or post-menopausal) All adults: DM, HTN, smoker, evidence of atherosclerosis, FHx of premature CAD, abdominal obesity When: PHE, routine office visit, even acute unrelated illness Screen with full lipid profile, FBG

17. Figure 1 Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032) Canadian Caridovascular Society, 2012

18. Figure 2 Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032) Canadian Caridovascular Society, 2012

19. Figure 3 Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032) Canadian Caridovascular Society, 2012

20. Stratify to a Risk Group High Risk: FRS > 19% or DM, proven CAD, PVD, CVD Medium Risk: FRS 10% - 19% Low Risk: FRS: < 10%

21. Patient Screened High Risk: LDL < 2 mmol/L BP < 130/80 FBG ≤ 7 Medium Risk: LDL < 3.5 BP <130/80 FBG ≤ 7 Low Risk: LDL < 5 BP and FBG as above Metabolic Syndrome WC > 102 cm male/ 88 cm female TG ≥ 1.7 mmol/L HDL ≤ 1 mmol/L male/ 1.3 female BP ≥ 130/85 FBG 6.2 – 7.0 mmol/L DM or CAD/Surrogates? NoYes

22. Figure 4 Canadian Journal of Cardiology 2013 29, 151-167DOI: (10.1016/j.cjca.2012.11.032) Canadian Caridovascular Society, 2012

23. Targets: Summary Lipid Profile:  Risk: < 2 mmol/L and TC/HDL ratio < 4  Risk: < 3.5 mmol/L (ratio < 5)  Risk: < 5 mmol/L (ratio < 6) Fasting Blood Glucose: < 7 mmol/L (or < 6 if tolerated)

24. PopulationSBP >DBP > Diabetes13080 High risk (TOD or CV risk factors)14090 Low risk (no TOD or CV risk factors) 160100 Very elderly* (≥80 yrs.)160NA Usual blood pressure threshold values for initiation of pharmacological treatment TOD = target organ damage. CHEP, 2015

25. PopulationSBP <DBP < Diabetes 130 80 All others < 80 yrs. (including CKD) 140 90 Very elderly (≥ 80 yrs.) 150 NA Treatment consists of health behaviour ±pharmacological management Recommended Treatment Targets In patients with coronary artery disease be cautious when lowering blood pressure if diastolic blood pressures are < 60mmHg CHEP, 2015

26. FAQ’s What is the role of hs-CRP? What about Lipoproteins? What is the role of homocysteine? Who needs a Graduated Exercise Stress Test? Who needs referral to a “Specialist?”

27. Tool for further risk stratification Useful for low to moderate risk patients Good predictor of CVD events Should we do this test regularly? High sensitivity C-reactive protein (hs – CRP)

28. Provide a more accurate number of “atherogenic” particles Elevated apo B100  elevated LDL or VLDL Lp (a) levels causative for CVD Measured in special cases Not routinely used yet Lipoproteins

29. No role in the diagnosis of CAD in the absence of clinical findings No predictive value May lead to unnecessary invasive work-up Stress Testing

30. Complex or difficult to manage Not at target despite maximal meds Excess medication side-effects Development of symptons consistent with CVD Angina TIA Patient’s request When to Refer

31. 64 year old male. Previously well (no PMHx) No family history of premature HD Non-smoker; Minimal ETOH use Took his blood pressure at Walmart 162/80 In the office: 156/78 (BP Tru) Remainder of exam is unremarkable Case # 1

32. 56 year old female On a routine physical: LDL = 5, HDL = 1.02, TG = 2.4 No previous medical history FHx: (+) for HD on father’s side BMI = 29 BP = 146/56 Case # 2

33. 55 year old male in for “executive physical” FHx: (+) for MI (father at 52, mother at 56) Smoker 12 pk-yrs; 8 – 10 drinks / week High stress job Case # 3

34. Screen patients at any given opportunity Burden of CVD is high Once one traditional risk factor is diagnosed, manage the other risk factors simultaneously Use a risk calculator to determine risk Don’t forget about lifestyle modifications Smoking cessation is the single most important intervention Take Away Points

35. Thank you….Questions?