Cardiovascular Risk Factor Overview and Management

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Cardiovascular Risk Factor Overview and Management

  1. 1. New and Evolving Concepts in Cardiovascular Disease Prevention and Management <ul><li>Nathan D. Wong, PhD, FACC </li></ul><ul><li>Professor and Director </li></ul><ul><li>Heart Disease Prevention Program </li></ul><ul><li>University of California, Irvine </li></ul>
  2. 2. Most Myocardial Infarctions Are Caused by Low-Grade Stenoses <ul><ul><li>Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992. (Adapted from Falk et al.) </li></ul></ul><ul><ul><li>Falk E et al, Circulation , 1995. </li></ul></ul>
  3. 3. Coronary Remodeling (Adapted from Glagov et al.) Normal vessel Minimal CAD Progression Compensatory expansion maintains constant lumen Expansion overcome: lumen narrows Severe CAD Moderate CAD Glagov et al, N Engl J Med , 1987.
  4. 4. Women and Heart Disease <ul><li>1 in 2-3 women die of CHD, but only 4% fear of dying of CHD </li></ul><ul><li>1 in 27 women die of breast cancer, but 40% fear of dying of breast cancer </li></ul><ul><li>2/3 of women have at least 1 CHD risk factor, 52% over age 45 have hypertension, 40% over age 55 have high cholesterol </li></ul>
  5. 5. Major Risk Factors <ul><li>Cigarette smoking </li></ul><ul><li>Elevated total or LDL-cholesterol </li></ul><ul><li>Hypertension (BP  140/90 mmHg or on antihypertensive medication) </li></ul><ul><li>Low HDL cholesterol (<40 mg/dL) † </li></ul><ul><li>Family history of premature CHD </li></ul><ul><ul><li>CHD in male first degree relative <55 years </li></ul></ul><ul><ul><li>CHD in female first degree relative <65 years </li></ul></ul><ul><li>Age (men  45 years; women  55 years) </li></ul>† HDL cholesterol  60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.
  6. 6. Other Recognized Risk Factors <ul><li>Obesity: Body Mass Index (BMI) </li></ul><ul><ul><li>Weight (kg)/height (m 2 ) </li></ul></ul><ul><ul><li>Weight (lb)/height (in 2 ) x 703 </li></ul></ul><ul><li>Obesity BMI >30 kg/m 2 with overweight defined as 25-<30 kg/m 2 </li></ul><ul><li>Abdominal obesity involves waist circumference > 40 in. in men, > 35 in. in women </li></ul><ul><li>Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week </li></ul>
  7. 7. BMI and Relative Risk of CHD Over 14 Years: Nurse’s Health Study <ul><li>Relative risk of CHD increases for BMI > 23, diabetes risk increases for BMI > 22. </li></ul><ul><li>Risk also significantly increases for weight gain after age 18 years of 5 kg or more. </li></ul>
  8. 8. Diabetes as a CHD Risk Equivalent <ul><li>10-year risk for CHD  20% </li></ul><ul><li>High mortality with established CHD </li></ul><ul><ul><li>High mortality with acute MI </li></ul></ul><ul><ul><li>High mortality post acute MI </li></ul></ul><ul><ul><li>Prevalence has increased over 25% in past 15 years in California, paralleling 50% increase in overweight/obesity </li></ul></ul>
  9. 9. Probability of Death From CHD in Patients With NIDDM and in Nondiabetic Patients, With and Without Prior MI Kaplan-Meier estimates Haffner SM et al. N Engl J Med 1998;339:229–234 0 1 2 3 4 5 6 7 8 0 20 40 60 80 100 Nondiabetic subjects without prior MI Diabetic subjects without prior MI Nondiabetic subjects with prior MI Diabetic subjects with prior MI Years Survival (%)
  10. 10. <ul><li>General Features of the Metabolic Syndrome </li></ul><ul><li>Abdominal obesity </li></ul><ul><li>Atherogenic dyslipidemia </li></ul><ul><ul><li>Elevated triglycerides </li></ul></ul><ul><ul><li>Small LDL particles </li></ul></ul><ul><ul><li>Low HDL cholesterol </li></ul></ul><ul><li>Raised blood pressure </li></ul><ul><li>Insulin resistance (  glucose intolerance) </li></ul><ul><li>Prothrombotic state </li></ul><ul><li>Proinflammatory state </li></ul>
  11. 11. ATP III: The Metabolic Syndrome* *Diagnosis is established when  3 of these risk factors are present. † Abdominal obesity is more highly correlated with metabolic risk factors than is  BMI. ‡ Some men develop metabolic risk factors when circumference is only marginally increased. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. © 2001, Professional Postgraduate Services ® www.lipidhealth.org <40 mg/dL <50 mg/dL Men Women >102 cm (>40 in) >88 cm (>35 in) Men Women  110 mg/dL Fasting glucose  130/  85 mm Hg Blood pressure HDL-C  150 mg/dL TG Abdominal obesity † (Waist circumference ‡ ) Defining Level Risk Factor
  12. 12. Prevalence of Selected Risk Factors in US Adults with the Metabolic Syndrome (without Diabetes) (Wong et al., Am J Cardiol 2003, in press)
  13. 13. Estimated Proportion of CHD Events Preventable by Control of Blood Pressure, HDL-C, LDL-C, and All 3 Factors to “Optimal” Levels in Persons with the Metabolic Syndrome (Wong et al., Am J Cardiol, June 15, 2003) ** * * p<0.05, ** p<0.01 compared to men
  14. 14. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) National Heart, Lung, and Blood Institute National High Blood Pressure Education Program U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute
  15. 15. Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Yes or > 100 > 160 Stage 2 Hypertension Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Yes or 90–99 140–159 Stage 1 Hypertension Drug(s) for compelling indications. ‡ No antihypertensive drug indicated. Yes or 80–89 120–139 Prehypertension Encourage <80 <120 & Normal With compelling indications Without compelling indication Initial drug therapy Lifestyle modification DBP* mmHg SBP* mmHg BP classification
  16. 16. <40 40-49 50-59 60-69 70-79 80+ Age (y) 17% 16% 16% 20% 20% 11% Distribution of Hypertension Subtype in the untreated Hypertensive Population in NHANES III by Age Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age. Franklin et al. Hypertension 2001;37: 869-874 . Frequency of hypertension subtypes in all untreated hypertensives (%) ISH (SBP  140 mm Hg and DBP <90 mm Hg) SDH (SBP  140 mm Hg and DBP  90 mm Hg) IDH (SBP <140 mm Hg and DBP  90 mm Hg) 0 20 40 60 80 100
  17. 17. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. 34 27 29 10 Control 59 54 55 31 Treatment 70 68 73 51 Awareness 1999–2000 II (Phase 2) 1991–94 II (Phase 1) 1988–91 II 1976–80 National Health and Nutrition Examination Survey, Percent
  18. 18. 4-Year Progression To Hypertension: The Framingham Heart Study (<120/80 mm Hg) (130/85 mm Hg) (130-139/85-89 mm Hg) Vasan, et al. Lancet 2001;358:1682-86 Participants age 36 and older
  19. 19. SBP-Associated Risks: MRFIT Adapted from Neaton JD et al. Arch Intern Med . 1992;152:56-64 . SBP versus DBP in Risk of CHD Mortality Diastolic BP (mm Hg) Systolic BP (mm Hg) CHD Death Rate 100+ 90–99 80–89 75–79 70–74 <70 <120 120–139 140–159 160+ 48.3 20.6 10.3 11.8 8.8 8.5 9.2 23.8 16.9 13.9 12.8 12.6 11.8 31.0 25.5 24.6 25.3 25.2 24.9 37.4 34.7 43.8 38.1 80.6
  20. 20. Lifestyle Modification Approximate SBP reduction (range) Modification 5–20 mmHg/10 kg weight loss Weight reduction 8–14 mmHg Adopt DASH eating plan 2–8 mmHg Dietary sodium reduction 4–9 mmHg Physical activity 2–4 mmHg Moderation of alcohol consumption
  21. 21. Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Yes or > 100 > 160 Stage 2 Hypertension Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Yes or 90–99 140–159 Stage 1 Hypertension Drug(s) for compelling indications. ‡ No antihypertensive drug indicated. Yes or 80–89 120–139 Prehypertension Encourage <80 <120 & Normal With compelling indications Without compelling indication Initial drug therapy Lifestyle modification DBP* mmHg SBP* mmHg BP classification
  22. 22. Total Cholesterol Distribution: CHD vs Non-CHD Population Castelli WP. Atherosclerosis . 1996;124(suppl):S1-S9.  1996 Reprinted with permission from Elsevier Science. 35% of CHD Occurs in People with TC<200 mg/dL 150 200 Total Cholesterol (mg/dL) 250 300 No CHD CHD Framingham Heart Study—26-Year Follow-up
  23. 23. Low HDL-C Levels Increase CHD Risk Even When Total-C Is Normal (Framingham) Risk of CHD by HDL-C and Total-C levels; aged 48–83 y Castelli WP et al. JAMA 1986;256:2835–2838 0 2 4 6 8 10 12 14 < 40 40–49 50–59  60 < 200 230–259 200–229  260 HDL-C (mg/dL) Total-C (mg/dL) 14-y incidence rates (%) for CHD 11.24 11.91 12.50 11.91 6.56 4.67 9.05 5.53 4.85 4.15 3.77 2.78 2.06 3.83 10.7 6.6
  24. 24. Impact of Lowering LDL-C on CVD Events and Total Mortality % * * † ‡ § *Confidence interval (CI) not reported. † 95% CI, 14%-41%. ‡ 95% CI, 16%-37%. § 95% CI, 12%-31%. Hebert PR et al. JAMA . 1997;278:313-321. Nonfatal/ fatal CHD CVD mortality
  25. 25. Risk Factors <ul><li>Major risk factors account for only about half of the variability in CHD risk in the US population </li></ul><ul><li>Emerging risk factors could enhance predictive power in individuals </li></ul><ul><ul><li>Lipid </li></ul></ul><ul><ul><li>Nonlipid </li></ul></ul>NCEP ATP III. Circulation. 2002;106:3145-3421.
  26. 26. Risk Factors for Future Cardiovascular Events: WHS Relative Risk of Future Cardiovascular Events 0 Ridker PM et al. N Engl J Med 2000;342:836-843. Lipoprotein(a) Homocysteine IL-6 TC LDL-C sICAM-1 SAA Apo B TC:HDL-C hs-CRP hs-CRP + TC:HDL-C 1.0 2.0 4.0 6.0
  27. 27. hs-CRP, Lipids, and Risk of Future Coronary Events: Women's Health Study (WHS) Quartile of TC: HDL-C Quartile of hs-CRP Ridker PM et al. N Engl J Med 2000;342:836-843. 4 3 2 1 1 2 3 4 9 8 7 6 5 4 3 2 1 0
  28. 28. ATP III: Assessment of Risk <ul><li>For persons without known CHD, other forms of </li></ul><ul><li>atherosclerotic disease, or diabetes: </li></ul><ul><li>Count the number of risk factors. </li></ul><ul><li>Use Framingham scoring for persons with  2 risk factors* to determine the absolute 10-year CHD risk. </li></ul>*For persons with 0–1 risk factor, Framingham calculations are not necessary. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. © 2001, Professional Postgraduate Services ® www.lipidhealth.org
  29. 29. Assessing CHD Risk in Men Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Step 2: Total Cholesterol TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1  280 11 8 5 3 1 Point Total 10-Year Risk Point Total 10-Year Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 2%  17  30% 6 2% 7 3% 8 4% 9 5% 10 6% Step 7: CHD Risk ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Step 1: Age Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2 Step 3: HDL-Cholesterol Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2  160 2 3 Step 4: Systolic Blood Pressure Step 5: Smoking Status Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points
  30. 30. Step 1: Age Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Years Points 20-34 -9 35-39 -4 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 11 70-74 12 75-79 13 Women Years Points 20-34 -7 35-39 -3 40-44 0 45-49 3 50-54 6 55-59 8 60-64 10 65-69 12 70-74 14 75-79 16
  31. 31. Step 2: Total Cholesterol Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Men TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 0 200-239 7 5 3 1 0 240-279 9 6 4 2 1  280 11 8 5 3 1 Women TC Points at Points at Points at Points at Points at (mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 <160 0 0 0 0 0 160-199 4 3 2 1 1 200-239 8 6 4 2 1 240-279 11 8 5 3 2  280 13 10 7 4 2 ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org
  32. 32. Step 3: HDL-Cholesterol Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. Men Women ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2 HDL-C (mg/dL) Points  60 -1 50-59 0 40-49 1 <40 2
  33. 33. Step 4: Systolic Blood Pressure Note: The average of several BP measurements is needed for an accurate measurement of baseline BP. If an individual is on antihypertensive treatment, extra points are added. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 0 1 130-139 1 2 140-159 1 2  160 2 3 Women Systolic BP Points Points (mm Hg) if Untreated if Treated <120 0 0 120-129 1 3 130-139 2 4 140-159 3 5  160 4 6
  34. 34. Step 5: Smoking Status Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Men Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 8 5 3 1 1 Women Points at Points at Points at Points at Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79 Nonsmoker 0 0 0 0 0 Smoker 9 7 4 2 1
  35. 35. Step 6: Adding Up the Points (Sum From Steps 1–5) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total
  36. 36. Step 7: CHD Risk for Men Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ® www.lipidhealth.org Point Total 10-Year Risk Point Total 10-Year Risk <0 <1% 11 8% 0 1% 12 10% 1 1% 13 12% 2 1% 14 16% 3 1% 15 20% 4 1% 16 25% 5 2%  17  30% 6 2% 7 3% 8 4% 9 5% 10 6%
  37. 37. CHD Risk Equivalents <ul><li>> 20% 10-year risk of CHD </li></ul><ul><li>(Framingham projections) (downloadable risk algorithms at www.nhlbi.nih.gov) </li></ul><ul><li>Diabetes </li></ul><ul><li>Other forms of clinical atherosclerotic disease </li></ul><ul><ul><li>Peripheral arterial disease </li></ul></ul><ul><ul><li>Abdominal aortic aneurysm </li></ul></ul><ul><ul><li>Carotid artery disease </li></ul></ul>NCEP ATP III. JAMA. 2001;285:2486-2497.
  38. 38. ACC 34 th Bethesda Conference Task Force 4: How do We Select Patients for Atherosclerosis Imaging? <ul><li>The ability to select higher risk asymptomatic subsets from the population that would benefit from an earlier or more aggressive risk factor intervention is a key advantage of subclinical disease screening </li></ul><ul><li>Persons with diabetes are considered CHD risk equivalents already warranting aggressive treatment as such; screening for atherosclerosis is not needed </li></ul>Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)
  39. 39. <ul><li>Patients at intermediate risk for total CHD comprise about 40% of the adult population. </li></ul><ul><li>They have at least 1 major risk CHD factor and have a 6-20% 10-year risk of a hard CHD event, possibly warranting further risk stratification by noninvasive tests to assess atherosclerotic burden. </li></ul>Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)
  40. 40. Significant Coronary Artery Calcium (Score >400)
  41. 41. ATP III: Nutritional Components of the TLC Diet Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA . 2001;285:2486-2497. *Trans fatty acids also raise LDL-C and should be kept at a low intake. Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight. © 2001, Professional Postgraduate Services ® www.lipidhealth.org <200 mg/d Cholesterol ~15% of total calories Protein 20–30 g/d Fiber 50%–60% of total calories Carbohydrate (esp. complex carbs) 25%–35% of total calories Total fat Up to 20% of total calories Monounsaturated fat Up to 10% of total calories Polyunsaturated fat <7% of total calories Saturated fat* Recommended Intake Nutrient
  42. 42. Possible Benefits From Other Therapies Therapy Result <ul><li>Soluble fiber in diet (2 – 8 g/d) (oat bran, fruit, and vegetables) </li></ul><ul><li>Soy protein (20 – 30 g/d) </li></ul><ul><li>Stanol esters (1.5 – 4 g/d) (inhibit cholesterol absorption) </li></ul><ul><li>Fish oils (3 – 9 g/d) </li></ul><ul><li>(n-3 fatty acids) </li></ul> LDL-C 1% to 10%  LDL-C 5% to 7%  LDL-C 10% to 15%  Triglycerides 25% to 35% Jones PJ. Curr Atheroscler Rep. 1999;1:230-235. Lichtenstein AH. Curr Atheroscler Rep. 1999;1:210-214. Rambjor GS et al. Lipids. 1996;31:S45-S49. Ripsin CM et al. JAMA. 1992;267:3317-3325.
  43. 43. Dietary Approaches to Stop Hypertension (DASH) <ul><li>Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet </li></ul><ul><li>Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. </li></ul><ul><li>NEJM 1997; 366: 1117-24. </li></ul>
  44. 44. AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update – Risk Assessment Circulation 2002; 106: 388-391 <ul><li>Beginning age 20: </li></ul><ul><ul><li>Regularly assess family history, smoking status, diet, alcohol intake, and physical activity </li></ul></ul><ul><ul><li>BP, BMI, waist circumference, pulse assessed at last every 2 years; fasting lipid profile and glucose measured every 5 years (2 yrs if other risk factors present. </li></ul></ul><ul><ul><li>Beginning age 40: </li></ul></ul><ul><ul><li>Assess 10-year risk of CHD using a multiple risk factor score (start younger if 2+ risk factors present); those at greater than 20% risk considered CHD risk equivalent </li></ul></ul>
  45. 45. AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update (cont.)– Risk Intervention <ul><li>Smoking – complete cessation and no exposure to environmental tobacco smoke </li></ul><ul><li>BP control - <140/90 (<130/85 if renal insufficiency or CHF, <130/80 for diabetes) </li></ul><ul><li>Dietary intake - <10% calories from saturated fat, <300 mg/d cholesterol, <6g/d salt, limit alcohol to 2 drinks/d in men or 1 drink/d women if drinking </li></ul><ul><li>Aspirin – consider 75-160 mg/d for those at 10-y risk of 10% or greater </li></ul><ul><li>Lipids – goals per NCEP guidelines </li></ul><ul><li>Physical activity – At least 30 minutes/d on most or all days of week </li></ul><ul><li>Weight management – Achieve desirable BMI 18.5-<25, waist cir <=40 in men and <=35 in women </li></ul><ul><li>Diabetes management – Goal fasting glucose <110 mg/dl and HgbA1c <7% </li></ul>
  46. 46. Considerations for Secondary Prevention <ul><li>CVD event rates in those with pre-existing disease are 5-7 times greater than healthy individuals. </li></ul><ul><li>Diabetics run a similar event rate as those with a previous myocardial infarction (Haffner) </li></ul><ul><li>Risk factor modification is the cornerstone of secondary prevention efforts </li></ul><ul><li>Categories of patients for secondary prevention efforts: 1) stable CHD, 2) unstable angina, 3) prior MI, 4) prior CABG, and 5) prior PTCA </li></ul>
  47. 47. Get with the Guidelines- CVD and Stroke AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary Prevention Guidelines
  48. 48. AHA Guidelines <ul><ul><li>Cessation of smoking </li></ul></ul><ul><ul><li>Lipid Management Goals </li></ul></ul><ul><ul><li>Physical activity </li></ul></ul><ul><ul><li>Weight management </li></ul></ul><ul><ul><li>Antiplatelet/anticoagulants </li></ul></ul><ul><ul><li>ACE inhibitors </li></ul></ul><ul><ul><li>Beta blockers </li></ul></ul><ul><ul><li>Blood pressure control </li></ul></ul><ul><ul><li>Early Aspirin </li></ul></ul><ul><ul><li>Early Beta-Blockers </li></ul></ul><ul><ul><li>Reperfusion for AMI </li></ul></ul><ul><ul><li>Stroke: Atrial Fibrillation and Alcohol Use </li></ul></ul>Adapted from Smith, Circulation 2001
  49. 51. Comprehensive Medical Therapy For Patients with CHD or Other Atherosclerotic Vascular Disease <ul><li>Risk Reduction </li></ul><ul><li>ASA 20-30% </li></ul><ul><li>Beta Blockers 20-35% </li></ul><ul><li>ACE inhibitors 22-25% </li></ul><ul><li>Statins 25-42% </li></ul><ul><ul><li>LDL Target < 100 mg/dl </li></ul></ul><ul><li>Smoking Cessation 50% </li></ul>Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III2001
  50. 52. Implement Guidelines HERE Healthy Population Undiagnosed or Untreated In Treatment Acute Event Post Event
  51. 53. Implementation Statistics <ul><li>Indicator Rate Optimal </li></ul><ul><li>ASA 85%* 100% </li></ul><ul><li>Beta Blocker 72%* 100% </li></ul><ul><li>ACE-I 71%* 100% </li></ul><ul><li>Smoking Cessation 40%* 100% </li></ul><ul><li>Lipid Lowering 37%** 96% </li></ul><ul><li>*HCFA, 1998 **NRMI 2nd Q 2000 </li></ul>
  52. 54. Improvement in Treatment Utilization is Associated With A Marked Reduction in Clinical Events RR0.43 p<0.01 256 AMI pts discharged in92/93 Pre-CHAMP- compared to 302 pts in 94/95 Post-CHAMP ASA 78% vs 92%; BetaBlocker12% vs 61%; ACEI 4% vs 56%; Statin 6%vs 86% Fonarow ,American Journal of Cardiology 2001(in press)
  53. 55. CAD Treatment Gap - Community Provider awareness does not equal successful implementation Pearson Arch Intern Med 2000;160:459-67
  54. 56. <ul><li>Outcomes associated with an intervention under ideal circumstances </li></ul><ul><ul><li>Clinical trial reported in literature </li></ul></ul><ul><ul><li>Benchmarking </li></ul></ul>EFFICACY EFFECTIVENESS <ul><li>Outcomes associated with an intervention in the real world </li></ul><ul><ul><li>Hospital </li></ul></ul><ul><ul><li>Outpatient </li></ul></ul><ul><ul><li>Across Continuum </li></ul></ul>Bridging the Gap Between Efficacy and Effectiveness <ul><li>Systems to Translate Efficacy Effectiveness </li></ul>SYSTEMS
  55. 57. We are in a new business, from development of guidelines to implementation of guidelines
  56. 58. Assess CHD Treatment Rates Analyze Discharge Rates Evaluate Assessment GWTG Team Reviews Summary Reports Refine Protocol GWTG Team Identifies Areas for Improvement Implement Refined Protocol GWTG Team Coordinates Implementation of Refined Protocol Find & Support a Champion
  57. 59. Building the Hospital Team <ul><li>Physicians </li></ul><ul><li>Nurses </li></ul><ul><li>Pharmacists </li></ul><ul><li>Hospital Administrators </li></ul><ul><li>Directors of Quality Improvement and Case Management </li></ul><ul><li>Cardiac Rehab Team </li></ul>
  58. 60. It’s never too early to Get With The Guidelines! If Get With The Guidelines is implemented, more than 40,000+ lives could be saved every year!
  59. 61. The UCI Heart Disease Prevention Program see us at: www.heart.uci.edu

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