Transcript Cardiovascular Disease: Prevention and Treatment

Cardiovascular Disease:
Prevention and Treatment
Dietary Factors that
Affect Blood Lipids
Saturated Fatty Acids
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Elevate blood cholesterol in all lipoprotein
fractions (LDL and HDL) when substituted
for CHO or other fatty acids
Dose-response between SFA and LDL-C
– For every 1% of energy intake increase in sfa,
plasma cholesterol increases 2.7%
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Most hypercholesterolemic sfas are lauric
(C12:0) myristic (C14:0) and palmitic
(C16:0) (palmitic is 60% of sfa intake)
Stearic (C18:0) is neutral
Saturated Fatty Acids
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The most hypercholesterolemic fats
are palm kernel, coconut and palm
oils, lard, and butter
SFAs also associated with CAD
progression: milk, cheese, butter,
lamb, bakery goods, fast foods, snacks
Average American intake is 11% of
kcals
Polyunsaturated Fatty
Acids
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If CHO is replaced by linoleic acid
(C18:2) LDL-C ↓ and HDL-C ↑
When SFA is replaced by PUFA in a low
fat diet, both LDL and HDL ↓
Eliminating SFA is twice as effective in
lowering cholesterol as ↑ PUFA
A 1% increase in PUFA ↓ TC by 1.4
mg/dl
Polyunsaturated Fatty
Acids
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Major source of omega-6 PUFAs are
vegetable oils, salad dressings, and
margarines made with the oil
U.S. population intake 7% of calories
Large amounts may increase LDL
oxidation
Omega-3 Polyunsaturated
Fatty Acids: EPA, DHA
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Found in fish oils, fish oil capsules, and
ocean fish (eicosapentaenoic and
docosahexaenoic acid)
Do not affect TC; may ↑ LDL-C (5-10%) and
decrease TG (25-30%) especially in patients
with high TG
Anticoagulant effect
Decrease vasoconstriction
Improve endothelial dysfunction
Reduce inflammation
Omega-3 Fatty Acids: ALA
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Alpha-linolenic acid
An essential fatty acid
Shorter-chain found in various plant
sources such as flax, canola, walnuts,
and soy
Benefits less clear; may protect
against CVD by reducing inflammation
Omega-3 Fatty Acids
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Consumption of fish and fish oils rich
in EPA, DHA will lower cholesterol,
LDL, and TG and reduce sudden
cardiac death
One fatty fish meal/week resulted in
50% decrease in risk of cardiac arrest
1 g supplement of omega-3 daily
reduced risk of CVD, nonfatal MI,
nonfatal stroke
Cis-Monounsaturated Fat
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Naturally occurring monounsaturated
fat
Found in olive oil, canola oil, avocado,
olives, pecans, peanuts, and other
nuts
Oleic acid is the most prevalent MFA in
the US diet
Cis-Monounsaturated Fat
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When fat is replaced by CHO, it lowers
HDL as well as LDL-C
When sfa is replaced by mfa, lowers
LDL-C without lowering HDL-C
When substituted for carbohydrate,
mfa reduces serum triglyceride levels
Can recommend a higher fat diet if
much of the fat comes from mfa
Cis-Monounsaturated Fat
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Mediterranean diet: high in fat,
especially MFA (olive oil), fish, nuts,
low in red meat associated with ↓ risk
of CVD
Emphasizes fruits, root vegetables,
flax, canola
High fat diets should be used with
caution
Mediterranean vs Standard
AHA Low Fat Diet
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Subjects: 202 post-MI patients
50 put on AHA lowfat diet (30% fat)
51 on Mediterranean (40% fat; fish 3-5
times/week, olive oil, avocado)
Both limited to 7% SFA and 200 mg
cholesterol/day
Both groups received two individual diet
counseling sessions in the first month and
six group sessions over the next two years.
101 controls given advice in the hospital
Tuttle et al, presented at ACC meeting, New Orleans, 3-07
Mediterranean vs Standard
AHA Low Fat Diet
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After 4 years 83% of those on either
therapeutic diet had survived without
problems; cholesterol profile improved in
both groups
People on either diet had one-third the risk
of suffering another heart attack, a stroke,
death or other heart problem as controls
Those on Mediterranean diet found it harder
to stick to (↑ fish, olive oil)
53% of control patients survived without
problems; cholesterol profile did not
improve
Trans-Monounsaturated
Fats
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Produced in the hydrogenation process
Commonly used in the food industry to
harden unsaturated oils and soft margarines
50% of trans-fatty acids come from animal
foods (beef, butter, milk fats)
Major foods sources in US are stick
margarine, shortening, commercial frying
fats, high fat baked goods
Trans Fatty Acids
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Elaidic acid (trans-isomer of oleic acid)
raises blood cholesterol compared with
PUFA
Has less of a cholesterol raising effect
than sfa
Lowers HDL
Margarine vs Butter
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The combined amount of saturated fat and
trans fat in butter is higher than that in
margarine
Soft or liquid margarine is the preferred
spread
Average intake of trans fats is 7-8% of total
fat intake
Choose lowfat desserts, dairy products,
meats will lower trans fatty acid intakes
Fat Type Per Serving
Product Total
Sfa g
Butter
fat g
10.8
7.2
Trans
fat g
.3
Combi choles
ned
terol
7.5
31.1
Stick
marg
Spread
marg
11
2.1
2.8
4.9
0
9.7
1.8
2.7
4.5
0
Tub
marg
6.7
1.2
.6
1.8
0
Source: FDA http://www.cfsan.fda.gov/~dms/qatrans2.html
Effects of Various Dietary
Fat Sources on TC:HDL Ratio
Mensink RP et al. AJCN 2003;77:1146-1155.
Total Fat Content of Diet
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High fat diets are associated with obesity,
which increases the risk of CHD
Low fat diets (<25% of kcals from fat) raise
triglycerides and lower HDL; however these
changes are not associated with ↑ risk
Low fat diets lower LDL only when they are
low in sfa
AHA: total fat <30% of kcals
ATP III: 25%-35% of kcals from fat
Dietary Cholesterol
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Dietary cholesterol raises total and LDLcholesterol, but less than sfa
A 25 mg increase in dietary cholesterol
raises serum cholesterol 1 mg/dl
At 500 mg intake, increments are even
less; appears to be a threshold for
response
TLC guidelines: <200 mg/day
AHA guidelines: <300 mg/day
Dietary Cholesterol
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Response to dietary cholesterol is
highly variable; hyper-responders may
have poor rates of conversion of
cholesterol to bile acids
Dietary intakes of cholesterol have
been declining since the 1960s
Intake acts synergistically with sfa;
positively related to CHD risk
Fiber
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Soluble fibers (pectins, gums,
mucilages, algal polysaccharides, some
hemicelluloses) in legumes, oats, fruit
and psyllium lower serum cholesterol
and LDL-C
Quantity needed varies by food (more
legumes than pectins or gums)
Fiber
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Average decline in LDL-C is 14% for
hypercholesterolemics and 10% for
normocholesterolemics when soluble
fiber is added to a low fat diet
Fiber may bind bile acids, which
lowers serum cholesterol to replete the
bile acid pool
Fiber
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Insoluble fibers have no effect
(celluloses and lignin)
Of total fiber (25-30 grams) 6 to 10
grams should be from soluble fiber
Can be achieved with 5 or more
servings of fruits or vegetables a day
and 6 or more servings of whole
grains and high-fiber cereals
Alcohol
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Affects total triglyceride and HDL-C
Effects on TG are dose dependent and are
greater in persons with TG>150 mg/dl
Moderate alcohol consumption has been
associated with decreased risk of MI and
CHD mortality in white men
Alcohol raises both HDL2 and HDL3
subfractions
Current intake in US is 2% of total kcals
No increase is recommended to decrease
CHD risk
Coffee
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Mixed results in studies on effect of
coffee on lipids
Heavy intake of regular coffee (720
ml) causes minor increases in TC (9
mg/dl) LDL-C (6 mg/dl) and HDL-C (4
mg/dl)
Boiled coffee (European) produces
greater elevations than filtered coffee
Coffee
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Large population studies have failed to
find associations between coffee
consumption and CHD incidence or
mortality
Coffee drinkers consume more
saturated fat and cholesterol, smoked
more cigarettes, and were less likely to
exercise
Antioxidants
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Antioxidants have been studied for possible
role in preventing oxidation of LDL-C
Epidemiological studies suggest vitamin E
and carotenoids are inversely related to
CVD, but randomized trials have not
supported this
Vitamin E: no primary or secondary
prevention trials show positive effect
B-carotene supplements appear to have no
benefits
Use food sources
Calcium
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Supplementation produces small
decreases in LDL-C in
hypercholesterolemic men
May form insoluble soaps with fatty
acids
Soy Protein
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Substituting soy protein lowers TC (9%) and
LDL-C (13%) and TG (11%) with no effect
on HDL-C
Effect in addition to a Step 1 diet; occurs
only in persons with hypercholesterolemia
Dose response
Daily intake of 25 g of soy will lower LDL-C
by 4 to 8% in hypercholesterolemic persons
Stanols/Sterols
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Isolated from soybean oils or pine tree
oil
Lowers blood cholesterol
Esterified and made into margarines
Consuming 2-3 grams/day lowers
cholesterol by 9-20% in persons with
hypercholesterolemia
Inhibits absorption of dietary
cholesterol
Stanols/Sterols
Nuts
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Tree nuts can reduce risk of CHD via lipidlowering effects;
Peanuts also cardioprotective
Almonds, hazelnuts, pecans, pistachio nuts,
and walnuts modestly reduce serum
cholesterol
Nuts are a rich source of fiber, vitamin E,
magnesium, and MUFA and PUFA
ALA in walnuts, arginine, and antioxidant
and antithrombotic effects
May reduce insulin resistance
Nuts
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Epidemiological evidence suggests an
inverse relationship between nut
consumption and CHD risk and type 2
diabetes
Nurses’ Health Study: women who ate
5+ servings lowered risk of CHD by
45%
Nuts
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Recommend 1 to 2 ounces of nuts (1
to 2 large handfuls) in place of other
sources of energy
Choose unsalted, roasted, or raw nuts
AHA 2006 Diet/Lifestyle
Recommendations for CVD Risk
Reduction
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These recommendations apply to the
general public for primary prevention
and can be used clinically
New focus on weight management
More focus on practical strategies for
implementation
AHA 2006 Diet/Lifestyle
Recommendations for CVD Risk
Reduction
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Balance calorie intake and physical
activity to achieve or maintain a
healthy body weight.
Consume a diet rich in vegetables and
fruits
Choose whole-grain, high-fiber foods
Consume fish, especially oily fish, at
least twice a week
Circulation 2006;114:82-96
AHA 2006 Diet/Lifestyle
Recommendations for CVD Risk
Reduction
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Limit your intake of SFA to <7% of
energy, trans fat to <1% of energy,
cholesterol to <300 mg/day by
– Choosing lean meats and vegetable
alternatives
– Selecting fat-free (skim), 1%-fat, and
lowfat dairy products, and
– Minimizing intake of partially hydrogenated
fats
Circulation 2006;114:82-96
AHA 2006 Diet and Lifestyle
Recommendations for CVD Risk
Reduction
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Minimize your intake of beverages and foods
with added sugars
Choose and prepare foods with little or no salt
If you consume alcohol, do so in moderation
When you eat food that is prepared outside of
the home, follow the AHA Diet and Lifestyle
Recommendations
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Know your calorie needs to achieve and
maintain a healthy weight
Know the calorie content of the foods and
beverages you consume
Track your weight, physical activity, and
calorie intake
Prepare and eat smaller portions
Track and, when possible, decrease screen
time
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Incorporate physical movement into
habitual activities
Do not smoke or use tobacco products
If you consume alcohol, do so in
moderation (1 drink/day in women, 2
in men)
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Use the nutrition facts panel and ingredients
list when choosing foods to buy
Eat fresh, frozen, and canned vegetables
and fruits without high-calorie sauces and
added salt and sugars
Replace high-calorie foods with fruits and
vegetables
Increase fiber intake by eating beans, whole
grain products, fruits and vegetables
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Use liquid vegetable oils in place of solid
fats
Limit beverages and foods high in added
sugars (fructose, sucrose, glucose, maltose,
dextrose, corn syrups, concentrated fruit
juice, and honey
Choose foods made with whole grains
Cut back on pastries and high-calorie bakery
products (e.g. muffins, doughnuts)
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Select milk and dairy products that are
either fat free or lowfat
Reduce salt intake by
– Comparing the sodium content of similar
products and choosing those with less
– Choosing processed foods, including
cereals and baked goods that are reduced
in salt
– Limiting condiments, e.g. soy sauce,
catsup
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
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Use lean cuts of meat and remove skin from
poultry before eating
Limit processed meats that are high in
saturated fat and sodium
Grill, bake, or broil fish, meat and poultry
Incorporate vegetable-based meat
substitutes into favorite recipes
Encourage the consumption of whole
vegetables and fruits in place of juices
Circulation 2006;114:82-96
AHA on Antioxidant
Supplements
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Antioxidant vitamin supplements or other
antioxidants such are selenium are not
recommended
Although observational studies suggest
that high intakes of antioxidant vitamins
from food and supplements are associated
with lower risk of CVD, intervention trials
have not confirmed this
Circulation 2006;114:82-96
Antioxidant Supplements
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Trials have documented potential harm, e.g.
higher risk of lung cancer with betacarotene supplements in smokers and
increased risk of heart failure and total
mortality from high dose vitamin E
supplements
Although supplements are not
recommended, food sources of antioxidant
nutrients are
Circulation 2006;114:82-96
AHA on Soy Protein
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Evidence of a direct cardiovascular
health benefit from consuming soy
protein is minimal
However, there may be some benefit if
soy protein is used to replace animal
and dairy products that contain SFA
and cholesterol
Circulation 2006;114:82-96
AHA on Folate and Other
B Vitamins
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Evidence is inadequate to recommend folate
and other B vitamins to reduce heart
disease risk
Folate intake and B6 and B12 are inversely
associated with serum homocysteine levels,
which are associated with increased risk of
CVD
Trials of homocysteine-reducing vitamin
therapy have been disappointing
Circulation 2006;114:82-96
AHA on Fish Oil
Supplements
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Fish intake is associated with decreased risk
of CVD
Patients without documented CHD eat fish,
preferably oil fish, twice a week
Patients with documented CVD should
consume ~1 gram of EPA + DHA per day,
preferably from oily fish, though
supplements can be considered with
physician input
Circulation 2006;114:82-96
Fish Oil Supplements
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For persons with hypertriglyceridemia,
2 to 4 g of EPA + DHA per day,
provided as capsules under a
physician’s care are recommended.
Circulation 2006;114:82-96
Adult Treatment Panel III
(NCEP, 2001)
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First published guidelines 2001
Update published 2004*
Raises diabetes as an important risk factor
for CHD
Uses Framingham projections of 10-year
absolute risk to identify patients for more
intensive treatment
Identifying persons with multiple metabolic
risk factors as candidates for therapeutic
lifestyle changes
*Circulation 2004;110:227-239
ATP III
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Targets LDL-C first with TLC
When LDL-C goals are met, treat
metabolic syndrome by increasing
physical activity and decreasing energy
intake to facilitate weight loss
ATP III Risk Factors That
Modify LDL Goals
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Cigarette smoking
Hypertension >140/90 mmHg or on
medication
Low HDL-C (<40 mg/dl)
Family history of premature CHD (male
first degree relative<55; female<65)
Age (men >45 years, women >55 years
LDL-C Goals and Cutpoints for TLC
and Drug Therapy by Risk Categories
LDL Goal
(mg/dL)
Risk Category
CHD or CHD Risk
Equivalents
(10-year risk
>20%)
2+ Risk Factors
(10-year risk
20%)
0–1 Risk Factor
<100
Optional Goal:
< 70 mg/dl
LDL Level to
Initiate
Therapeutic
Lifestyle Changes
(TLC) (mg/dL)
LDL Level at
Which
to Consider
Drug Therapy
(mg/dL)
100
130
(100–129: drug
optional)
10-year risk 10–
20%: 130
<130
130
10-year risk
<10%: 160
<160
160
190
(160–189: LDLlowering drug
optional)
Therapeutic Lifestyle Changes in
LDL-Lowering Therapy
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TLC Diet
– Reduced intake of cholesterol-raising nutrients
(same as previous Step II Diet)
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Saturated fats <7% of total calories
Dietary cholesterol <200 mg per day
– LDL-lowering therapeutic options
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Plant stanols/sterols (2 g per day)
Viscous (soluble) fiber (10–25 g per day)
Weight reduction
Increased physical activity
Steps in
Therapeutic Lifestyle Changes
Visit I
Visit 2
Evaluate LDL
6 wks
response
Begin
Lifestyle
Therapies
• Emphasize
reduction in
saturated fat &
cholesterol
• Encourage
moderate physical
activity
Visit 3
Evaluate LDL
6 wks response
If LDL goal not
achieved, intensify
LDL-Lowering Tx
• Reinforce reduction
in saturated fat and
cholesterol
• Consider adding
plant stanols/sterols
• Increase fiber intake
• Consider referral to
• Consider referral to
a dietitian
a dietitian
Q 4-6 mo
If LDL goal not
achieved,
consider
adding drug Tx
• Initiate Tx for
Metabolic
Syndrome
• Intensify weight
mgt &
physical activity
• Consider referral
to a dietitian
Visit N
Monitor
Adherence
to TLC
The Metabolic Syndrome as a
Secondary Target of Therapy
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Abdominal obesity
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Atherogenic dyslipidemia
– Elevated triglycerides
– Small LDL particles
– Low HDL cholesterol
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Raised blood pressure
Insulin resistance ( glucose intolerance)
Prothrombotic state
Proinflammatory state
Therapeutic Lifestyle
Changes (TLC)
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TLC Diet
– Saturated fat <7% of calories, cholesterol
<200 mg/dal
– Consider increased viscous (soluble) fiber
(10-25 g/day) and plant stanols/sterols
(2g/day)
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Weight management
Increased physical activity
Nutrient Composition of TLC
Diet
Nutrient
 Saturated fat
 Polyunsaturated fat
 Monounsaturated fat
 Total fat
 Carbohydrate
 Fiber
 Protein
calories
 Cholesterol
 Total calories (energy)
expenditure
Recommended Intake
Less than 7% of total calories
Up to 10% of total calories
Up to 20% of total calories
25–35% of total calories
50–60% of total calories
20–30 grams per day
Approximately 15% of total
Less than 200 mg/day
Balance energy intake and
to maintain desirable body
weight
ATP III Recommendations
Compared with the American
Diet
American Diet
ATP III
Total fat %
25-35
32.8
SFA %
11.3
<7
MUFA
12.5
<20
PUFA
6.4
<10
Cholesterol mg 256
<200
Dietary fiber g
20-30
15.1
Carson JA, Grundy SM, VanHorn L, Stone N. MNT in prevention and management of
coronary heart disease. In Carson JS et al. Cardiovascular Nutrition. Am Diet Assoc 2004
TLC Diet
Food
Amount
Breads and cereals >6 servings (adjust to
meet energy needs)
Vegetables and
3-5 servings vegetables
fruits
2-4 servings fruits
Dairy products
2-3 servings
Eggs
<2 yolks per week
Meat, fish, poultry
<5 ounces per day
Fats and oils
Adjust to caloric level
TLC: Healthy Cooking
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Bake, steam, roast, broil, stew or boil
instead of frying
Remove poultry skin before eating
Use a nonstick pan with cooking oil
spray or small amount of liquid
vegetable oil instead of lard, butter,
shortening, other solid fats
Trim visible fat before you cook meats
Chill meat and poultry broth until fat
becomes solid, remove
TLC Diet: Eat More
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Fresh, frozen, canned vegetables without added fat,
sauce, salt
Fresh, frozen, canned or dried fruit
Nonfat, ½%, and low-fat milk, buttermilk, yogurt,
cheese
Unsaturated oils, soft or liquid margarines and
spreads, salad dressings, seeds and nuts
Lean cuts of meat; extra lean hamburger, fish;
meat alternatives made with soy or TVP
Whole grain breads and cereals, pasta, rice,
potatoes, dried beans and peas, lowfat crackers,
pretzels, cookies
TLC Diet: Eat Less
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High-fat bakery products (doughnuts,
biscuits, croissants, pies, cookies
Chips, cheese puffs, snack mix, regular
crackers, buttered popcorn
Whole and reduced-fat milk and dairy
products, ice cream, cream, half and
half, cream cheese, sour cream and
cheese
TLC Diet: Eat Less
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Whole eggs, yolks
Fatty meat such as ribs, tbone steak,
regular hamburger, bacon, sausage,
salami, hot dogs, organ meats, liver,
brains, sweetbreads, fried meat,
poultry and fish
Butter, shortening, stick margarine,
chocolate, tropical oils, coconut, palm
and palm kernel
Dealing with Problem
Foods
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Reduce the portion size
Prepare the food more healthfully
Reduce the frequency it is eaten
Substitute a more healthful food for
the problem food
TLC: Healthy Shopping
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Choose chicken breast or drumstick
instead of wing and thigh
Select skim milk or 1 percent instead
of 2 percent or whole milk
Buy lean cuts of meat such as round,
sirloin, and loin
Buy more vegetables, fruits and grains
Read nutrition labels on food packages
TLC: Dining Out
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Choose restaurants that have low fat
options available
Ask that sauces, gravies, and salad
dressings be served on the side
Control portions by asking for an
appetizer serving or sharing with a
friend
TLC: Dining Out
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At fast food restaurants, go for salads,
grilled (not fried or breaded) skinless
chicken sandwiches, regular-sized
hamburgers, or roast beef sandwiches
Avoid regular salad dressings and fatty
sauces. Limit jumbo or deluxe burgers,
sandwiches, french fries, and other foods.
Lipid-Lowering Drugs
Added if Diets Are Not Successful
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After a 6-month trial on each diet, drugs are
added to the treatment.
Types:
 Nicotinic acid and lovastatin
 Gemfibrozil, probucol, clofibrate—for high
TGs
 Cholestyramine and colestipol (bile acid
sequestrants)—to lower high cholesterol;
may increase TGs
HMG CoA Reductase Inhibitors
(Statins)
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Reduce LDL-C 18–55% & TG 7–
30%
Raise HDL-C 5–15%
Major side effects
– Myopathy
– Increased liver enzymes
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Contraindications
– Absolute: liver disease
– Relative: use with certain drugs
HMG CoA Reductase
Inhibitors (Statins)
Statin
Lovastatin
Pravastatin
Simvastatin
Fluvastatin
Atorvastatin
Cerivastatin
Dose Range
20–80 mg
20–40 mg
20–80 mg
20–80 mg
10–80 mg
0.4–0.8 mg
HMG CoA Reductase
Inhibitors (Statins) (continued)
Demonstrated Therapeutic
Benefits
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Reduce major coronary events
Reduce CHD mortality
Reduce coronary procedures
(PTCA/CABG)
Reduce stroke
Reduce total mortality
Figure 35. Cholesterol-lowering statin drug visits among adults 45
years of age and over by sex: United States, 1995-2002
Men, 65 years and over
Women, 65 years and over
Men, 45-64 years
Women, 45-64 years
Year
NOTES: Cholesterol-lowering statin drug visits are physician
office and hospital outpatient department visits with
cholesterol-lowering statin drugs prescribed, ordered, or
provided. See Data Table for data points graphed, specific
drugs included, standard errors, and additional notes.
SOURCES: Centers for Disease Control and Prevention,
National Center for Health Statistics, National Ambulatory
Medical Survey and National Hospital Ambulatory Medical
Care Survey.
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
Bile Acid Sequestrants
Major actions
– Reduce LDL-C 15–30%
– Raise HDL-C 3–5%
– May increase TG

Side effects
– GI distress/constipation
– Decreased absorption of other drugs

Contraindications
– Dysbetalipoproteinemia
– Raised TG (especially >400 mg/dL)
Bile Acid Sequestrants
Drug
Range
Cholestyramine
Colestipol
Colesevelam
Dose
4–16 g
5–20 g
2.6–3.8 g
Bile Acid Sequestrants
(continued)
Demonstrated Therapeutic
Benefits


Reduce major coronary
events
Reduce CHD mortality
Nicotinic Acid

Major actions
– Lowers LDL-C 5–25%
– Lowers TG 20–50%
– Raises HDL-C 15–35%


Side effects: flushing, hyperglycemia,
hyperuricemia, upper GI distress,
hepatotoxicity
Contraindications: liver disease, severe
gout, peptic ulcer
Nicotinic Acid
Drug Form
Range
Immediate release
(crystalline)
Extended release
Sustained release
Dose
1.5–3 g
1–2 g
1–2 g
Nicotinic Acid (continued)
Demonstrated Therapeutic
Benefits


Reduces major coronary events
Possible reduction in total mortality
Fibric Acids
Major actions
–
–
–
–


Lower LDL-C 5–20% (with normal TG)
May raise LDL-C (with high TG)
Lower TG 20–50%
Raise HDL-C 10–20%
Side effects: dyspepsia, gallstones,
myopathy
Contraindications: Severe renal or
hepatic disease
Fibric Acids
Drug



Gemfibrozil
BID
Fenofibrate
QD
Clofibrate
BID
Dose
600 mg
200 mg
1000 mg
Fibric Acids (continued)
Demonstrated Therapeutic
Benefits


Reduce progression of coronary
lesions
Reduce major coronary events
Secondary Prevention
Patients with established CHD have 5-7x
greater risk of subsequent MI
 Smoking cessation
 Reducing BP to <140/90 or 130/85
with CHF, renal insufficiency, DM
 Reduce LDL-C to <100 mg/dl; nonHDL levels to <130 mg/dl
Secondary Prevention
(cont)





Moderate physical activity for 30
minutes daily 3-4 days a week
Weight management to attain BMI<25
A1C<7%
Use of 75 to 325 mg aspirin daily
unless contraindicated
Use of ACE inhibitors and B-blockers
indefinitely
CVD: Medical
Intervention
Coronary Angioplasty
(PTCA)



Percutaneous coronary intervention
(PCI) uses a balloon to break up
plaque in an occluded artery
Performed under local anaesthetic so
recovery quicker than with bypass
surgery
Persons with no more than 2
blockages are candidates
Angioplasties



601,000 angioplasties done in 1999;
1.2 million last year
Most common problem is restenosis of
the artery (10-20%)
Require intensive lifestyle
management
Angioplasties




Study by Boden, et al suggests that in low risk
pts lifestyle changes and medications are just as
effective as PCI
Angioplasties did not prevent heart attacks or
save lives; angioplasties produced a slight and
temporary improvement in chest pain symptoms
Angioplasty costs $30,000 to $40,000. The drugs
used in the study are almost all available in
generic form.
Many health insurers including Medicare do not
cover MNT for cardiovascular diseases
Boden et al, NEJM 2007 Volume 356:1503-1516
PCI with Stent
Coronary Artery Bypass
Surgery




Candidates have more than two
occluded arteries
Procedures have decreased since 1995
because of ↑ angioplasties
Does not cure atherosclerosis; new grafts
are also susceptible
Restonosis is common within 10 years of
surgery
CABG