Transcript GET WITH THE GUIDELINES: Closing the Treatment Gap in

AHA Secondary Prevention
Guidelines
“Get with the Guidelines…”
And MORE
Timothy A. Denton, M.D., F.A.C.C.
High Desert Heart Institute
Victorville, CA
329 miles
Cardiovascular Therapeutics
Medical Therapy
Antithrombotics
Anticoagulants
ACE / ARB
Beta blockers
Antiarrhythmics
Cholesterol agents
Ca++ blockers
Nitrates
Diuretics
Interventions
Surgery
PTCA / Stent
Pacemaker
ICD
CABG
Valve repair /
replacement
Arrhythmia
Vascular
LVAD
Transplant
What are the goals of
Medical Care?
1 - Prolong Survival
2 – Improve Quality-of-Life
A Challenge -Today, and for the rest of your
Career -Does this therapy I’m recommending
1 – Improve Survival?
2 – Improve Quality-of-Life?
AHA/ACC Scientific Statement
AHA/ACC Guidelines for Secondary Prevention
in Patients with Coronary and Other Vascular
Disease: 2001 Update
Sidney C Smith, Steven N Blair, Robert O Bonow,
Lawrence M Brass, Manuel D Cerqueira, Kathleen Dracup,
Valentin Fuster, Antonio Gotto, Scott M Grundy,
Nancy Houston Miller, Alice Jacobs, Daniel Jones,
Ronald M Krauss, Lori Mosca, Ira Ockene,
Richard C Pasternack, Thomas Pearson, Marc A Pfeffer,
Rodman D Starke, Kathryn A Taubert
Circulation 2001;104:1577-1579
www.americanheart.org
www.acc.org
To Which Patients do
the Guidelines apply?
• Coronary artery disease
• Carotid disease
• Peripheral vascular disease
• Abdominal aortic aneurysm
• Diabetics
The Guidelines
A
B
C
C
D
C
E
W
H
Therapy
Antiplatelet/warfarin
Beta blockers
Cholesterol
ACE
DM
Smoking
Exercise
Weight control
BP control
ABC2
Goal
ASA 81-325 mg
Post-MI, All
LDL<100 (<70)
Post-MI, EF<40, All
Gluc~100, HbA1c < 7
Complete cessation
30 min, 3-4x/week
BMI 18.5-25 kg/m2
130-140/80-90
DM Cigs Exercise BMI HTN
AHA Secondary Prevention Guidelines
2001
Antiplatelet / anticoagulant therapy
• Intervention recommendations:
–Start and continue indefinitely aspirin
75–325 mg/d if not contraindicated.
–Consider clopidogrel 75 mg/d or
warfarin if aspirin contraindicated.
–Manage warfarin to INR=2.0 to 3.0 in
post-MI patients when clinically
indicated or for those unable to take
aspirin or clopidogrel.
ISSIS-II
Baigent, C. et al. BMJ 1998;316:1337-1343
Diabetics
(BIPS)
20% reduction
cardiac mortality
20% reduction
all cause
Harpaz, et al. Am J Med. 1998;105:494-9
Antiplatelet Trialists
BMJ 1994;308:81-106
Antiplatelet Trialists
BMJ 1994;308:81-106
How long should we give clopidogrel?
Fox, K. A.A. et al. Circulation 2004;110:1202-1208
GWTG and MORE…
What is the correct dose of aspirin?
• Acute MI – 162-325 mg
• Secondary prevention – 75-162 mg
• AHA/ACC MI Guidelines
Circulation 2004;110:588
Primary Prevention?
Start ASA if 5 year risk of CAD > 3%
US Preventive Services Task Force, 2002
AIM 2002;136:131
Women, Primary Prevention, ASA 100 mg qod
>65 yo
Major CV event RR = 0.74 P = 0.008
CVA
RR = 0.78 P = 0.13
Ischemic CVA RR = 0.70 P = 0.05
MI
RR = 0.66 P = 0.04
Ridker et al. NEJM 2005;352:1293
AHA Secondary Prevention Guidelines
2001
Beta blockers
•
Start in all patients post MI and post ACS
•
•
•
Continue indefinitely
Observe usual contraindications.
Use as needed to manage CHF, angina, rhythm,
or blood pressure in all other patients.
Beta blocker Effects
Post-MI
36% mortality reduction
43% reduction CHF admits
CABG
20% mortality reduction
Rochon et al. Lancet. 2000 Aug 19;356(9230):639-44
Ferguson et al., JAMA. 2002;287:2221-2227
Elderly Post-MI
43% mortality reduction
Soumerai, JAMA. 1997 Jan 8;277(2):115-21
Diabetic Post-MI
13% mortality reduction
Insulin treated
23% mortality reduction
non-insulin treated
Chen et al, J Am Coll Cardiol. 1999 Nov 1;34(5):1388-94
Copyright ©1998 BMJ Publishing Group Ltd.
GWTG and MORE…
How aggressive can we be with beta blockers?
Using CARDIOSELECTIVE beta-blockers
There was no change in FEV1 or COPD
exacerbations (up to 12 weeks).
Atenolol, bisoprolol, metoprolol
block β1 > β2 20:1
Salpeter et al. AIM 2002;137:715
“…unfounded fears…”
AHA Secondary Prevention Guidelines
2001
ACE inhibitors
•
•
Treat all patients indefinitely post MI
Consider use in all patients with coronary or
other vascular disease
•
Early use in anterior MI, previous MI, Killip
Class II (S3 gallop, rales, radiographic CHF)
GWTG and MORE…
ACE
HOPE Trial, NEJM 2000;342:145-153
Can you identify these?
AHA Secondary Prevention Guidelines
2001
Lipid management
•
•
•
•
LDL-cholesterol goal < 100 mg/dl
Statins as first line therapy for LDL lowering
If LDL low but HDL < 40 mg/dl, consider fibrate or
niacin as first line therapy (especially in diabetes)
If TG’s are high, do not use a resin
• TG 200-499, use fibrate/niacin after statins
• TG >500, use fibrate/niacin before statins
• Omega-3 FA’s for high TG’s
Cholesterol Outcomes
4S
Pfeffer, M. A. et al. J Am Coll Cardiol 1999;33:125-130
Cholesterol Outcomes
How LOW do we go?
REVERSAL
Reversal of Atherosclerosis with Aggressive Lipid Lowering
3
2.5
Percent Change
2
1.5
1
•DB Random
atorv v. prava
(79 v. 110)
•IV US
•Atheroma vol
2.7
0.5
0
-0.5
Atorv
-0.4
Prava
-1
P=0.02
Nissen JAMA 2004;291:1071
Guidelines
• With known vascular disease or equivalent
LDL goal < 100 mg/dl
• “Optional” for Higher Risk patients
LDL goal < 70 mg/dl
Grundy et al. Circ 2004;110:227
TNT
LaRosa,
LaRosa,
J. J.
C.C.
et et
al.al.
NN
Engl
Engl
J Med
J Med
2005;352:1425-1435
2005;352:1425-1435
TNT
2.2% absolute reduction
LaRosa, J. C. et al. N Engl J Med 2005;352:1425-1435
100
Event Rate
80
60
40
20
WOSCOPS
AFCAPS
ASCOT
0
0
50
100
150
200
LDL Cholesterol
250
300
Niacin (Arbiter)
• Known CAD
• Must be on statin
• Long-acting niacin vs placebo
Taylor, A. J. et al. Circulation 2004;110:35123517
Niacin (Arbiter)
Taylor, A. J. et al. Circulation 2004;110:35123517
“Efficient” Secondary Prevention
• A strategy to reduce cardiovascular
disease by more than 80%
Wald, Law
BMJ 2003;326:1419
• The “PolyPill”
Statin
Diuretic
ACE
Beta blocker
folic acid
ASA
• Reduce CAD events by 88%
• Reduce CVA by 80%
AHA Secondary Prevention Guidelines
2001
Diabetes
•
•
Measure HbA1c
Appropriate hypoglycemic therapy to
achieve near-normal plasma glucose as
determined by Hgb A1c < 7.0
•
Treatment of other risks
(weight, activity, BP, lipids)
ADA Standards of Medical Care
for Patients with Diabetes
•
•
•
•
Glycemic control: HbA1C <7%
Blood pressure control: <130/80 mm Hg
Target lipid levels:
 LDL-C <100 mg/dL (<70)
 HDL-C >45 mg/dL in men, >55 mg/dL in
women
 TG <150 mg/dL
Smoking cessation
ADA. Diabetes Care 2002;25:S33–S49.
But…tight glycemic control has
little effect on survival
You get more SURVIVAL benefit in
diabetics if you start:
A Statin
An ACE inhibitor
ADA. Diabetes Care 2002;25:S33–S49.
AHA Secondary Prevention Guidelines
2001
Smoking
•
•
•
Goal is complete cessation
Avoid second hand smoke
Provide:
• counseling
• tobacco cessation programs
• pharmacologic therapy including
nicotine replacement and buproprion
Survival Effects of Cigarette Smoking
Overall Survival
All levels of
smoking
Doll et al. BMJ 1994;309:901-911
Smoking Cessation and Mortality
• Lung Health Study
• RCT
• Smoking intervention vs standard care
• Endpoint – All cause mortality
• Cessation – 21.7% vs 5.4%
Anthonisen et al. AIM 2005;142:233
AHA Secondary Prevention Guidelines
2001
Physical activity
•
GOAL

•

Minimum: 30 minutes 3–4 days/week
Optimal: daily
Intervention recommendations:




Assess risk, preferably with exercise test, to guide
prescription.
Encourage minimum of 30–60 minutes of activity
(walking, jogging, cycling, or other aerobic activity),
preferably daily or at least 3–4 times weekly.
Supplement with increased daily lifestyle activities
(walking breaks at work, gardening, household work).
Advise medically supervised programs for moderate- to
high-risk patients.
Exercise
Leon et al. Circ 2005;111:369
GWTG and MORE…
The more you walk
the longer you’ll live…
Barney Gumble
• 57 year old male
• Central obesity
• LDL-C 190 mg/dl
• TG’s 280 mg/dl
• HDL 30 mg/dl
• BP 158/96
AHA Secondary Prevention
Guidelines
Weight Management
•
•
Goal: BMI 18.5–24.9 kg/m2
Intervention recommendations:
 Calculate BMI and measure waist circumference
as part of evaluation.
 Start weight management and physical activity as
appropriate.
 Monitor response of BMI and waist circumference
to therapy.
 If BMI 25 kg/m2, goal for waist circumference is
40 inches in men, 35 inches in women.
Smith SC Jr et al. Circulation 2001;104:1577-1579.
BMI and All-Cause Mortality
Calle, NEJM 1999;341:1097
Expected mean body weight over time, by diet group
Yancy, W. S. et. al. Ann Intern Med 2004;140:769-777
AHA Secondary Prevention Guidelines
2001
Blood pressure
•
•
•
•
•
General goal:
BP < 140/90
Diabetes:
BP < 130/80 (ADA)
Renal failure/heart failure:
BP < 130/85 (JNC6)
Lifestyle modification
Dietary management
• restrict salt intake
• fresh fruits and vegetables
HOT Trial
Diastolic blood pressure
Systolic blood pressure
70 75 80 85 90 95 100 105
120 130 140 150 160 170 180 190
Lancet 1998;351(9118):1755-62
AHA Secondary Prevention Guidelines
2001
Hormone replacement therapy
•
Do not start HRT for secondary prevention
Circulation 2001;104:499
www.americanheart.org
GWTG and MORE…
www.srmjol.is
GWTG and MORE…
Fish Oil
Blue Whiting
Capelin
Herring
www.srmjol.is
Lipids
C = 8 - 24
Fatty Acids
HO
O
O
O
Triglycerides
O
O
O
O
O
G
P
O
O
Phospholipids
O
O
O
O
PUFA (polyunsaturated fatty acid)
Nomenclature
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18
O   

HO
18 17 16 15 14 13 12 11 10
9
8
7
 

6
4
5
3
2
1
Common name
- -Linoleic acid
Systematic name
- all cis-9,12-octadecadienoic acid
Systematic name
- cis-9, cis-12-octadecadienoic acid
Chemist’s name
- 18:2 (9Z, 12Z) (Z=cis, E=trans)
Chemist’s name
- 18:2 9,12
(assume cis, indicate tran
Nutritionist’s name #1 - 18:2 (n-6)
Nutritionist’s name #2 - 18:2 -6
Fish Oil
30
23
20
• 9 patients
10
• 6 weeks
1 g/d N-3 PUFA 0
1 U tocopherol/d
-10
• 6 weeks
5 g/d fish oil
-20
TG
VLDL TG
VLDL-C
LDL
-30
• Slower VLDL and
LDL oxidation
-40
-40
-50
-60
-54
-56
Hau et al. Arterio Thromb Vasc Biol 1996;16:1197
GISSI-Prevenzione
Marchioli, R. et al. Circulation 2002;105:18971903
Fish Consumption and CHF, Afib
CHF
Mozaffarian et al. JACC
2005;45:2015
Afib
Mozaffarian et al. Circ 2004;110:368
GWTG and MORE…
Fish Oil
EPA + DHA
Lyon Heart Trial
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
De Lorgeril et al Circulation 1999;99:779
Small Molecules
1 drink = 12 ml of EtOH
= 250 ml of beer
= 100 ml of wine
= 35 ml liquor
Small Molecules
Alcohol type
Relative Risk of CVA
Multivariate RR
Red Wine
0 grams per day
0.1-9.9 g / day
> 10.0 g / d
1.0
0.78
0.54
1.0
0.77
0.54
White wine
0 grams per day
0.1-9.9 g / day
> 10.0 g / d
1.00
0.96
0.74
1.0
1.14
0.89
Beer
0 grams per day
0.1-9.9 g / day
> 10.0 g / d
1.00
1.01
1.07
1.00
1.09
1.23
Liquor
0 grams per day
0.1-9.9 g / day
> 10.0 g / d
1.0
0.79
0.97
1.00
0.84
1.14
Mukamal et al. AIM 2005;142:11
The Guidelines
A
B
C
C
D
C
E
W
H
Therapy
Antiplatelet/warfarin
Beta blockers
Cholesterol
ACE
DM
Smoking
Exercise
Weight control
BP control
ABC2
GWTG Goal
Start the Rx
Start the Rx
Start the Rx
Start the Rx
Start the Rx
Counseling
Counseling
Counseling
130-140/80-90
DM Cigs Exercise BMI HTN
…and MORE
• Goals are Survival and Quality-of-Life
• All vascular disease and Equivalents
• Clopidogrel benefits out to 1 year
• More aggressive use of Beta blockers
don’t stop because of COPD
• Lower LDL levels – new goal < 70
• the Polypill – ABC2
• Smoking cessation ATTEMPTS
• Fish oil
• Niacin
• Mediterranean diet
The END