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  • 1. 1 Thomas E. Kottke, MD, MSPH Medical Director for Population Health HealthPartners and Consulting Cardiologist HealthPartners Medical Group Professor of Medicine University of Minnesota thomas.e.kottke@HealthPartners.com The Medical Knowledge Behind Integrated NCD Prevention “Myocardial Infarction” Jorma Turtiainen, 1976 Helsinki, 10 march 2014
  • 2. 2 Grabauskas V, Prochorskas R, Miseviclene I. Risk factors as indicators of ill health. Preventive Cardiology: Proceedings of the International Conference on Preventive Cardiology. Basle: Cardiology, 1985, pp. 301-310. In 1985, Grabauskas observed that most chronic diseases share the same risk factors
  • 3. 3 Heart disease: 3 states and 3 transitions Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation *includes occult HD Apparently Healthy/ No heart disease diagnosis* Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5
  • 4. 4 Heart disease: 3 states Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation *includes occult HD Apparently Healthy/ No heart disease diagnosis* N=90,024 N=8,335 N=1,641 Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5
  • 5. Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation 5 Heart disease: 3 transitions Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation Apparently Healthy/ No heart disease diagnosis* N=325 N=253 STEMI=159 NSTEMI=599 UA/other=1270 Systolic heart failure=345 *includes occult HD **N per 100,000 adults aged 30-84/deaths without treatment Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5
  • 6. 6 Deaths Total deaths=1,328 0 200 400 600 800 1000 Prevalence Pools Acute events Apparently healthy HD without sLVD HD with sLVD Cardiac arrest STEMI nSTEMI Unstable angina Systolic heart failure Ambulatory Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5
  • 7. 7 Risk Factors and Treatments of Known Efficacy/Significant Impact –I Risk Factors 1. tobacco free 2. ideal blood pressure 3. good nutrition 4. adequate physical activity 5. omega-3 fatty acid consumption (fish) Out-of-Hospital Cardiac Arrest 6. Automated external defibrillators Acute/Emergent Presentation 7. rescue angioplasty during acute coronary syndrome 8. thrombolysis 9. anti-platelet therapy and heparin for acute coronary syndrome 10. IV beta-blockers for acute coronary syndrome
  • 8. 8 Risk Factors and Treatments of Known Efficacy/Significant Impact – II Ambulatory/Chronic Heart Disease 11. oral beta-blockers after myocardial infarction 12. statins 13. anti-platelet therapy and anti-coagulation 14. omega-3 fatty acid supplementation 15. coronary artery bypass graft surgery/percutaneous intervention 16. pacemakers 17. ACE inhibitors/ARBs for left ventricular dysfunction 18. spironolactone or eplerinone for left ventricular dysfunction 19. implantable cardioverter defibrillators/biventricular pacemakers 20. cardiac rehabilitation 21. management of supraventricular arrhythmias 22. management of valvular dysfunction
  • 9. 9 Tobacco
  • 10. 10 Mulcahy 1977 Wilhelmssen 1975 Salonen 1980 Subsequent life expectancy is doubled by smoking cessation after a heart attack No other single intervention in cardiology is this effective Life Expectency after MI 100% 200%
  • 11. 11www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf -
  • 12. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 12
  • 13. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 13
  • 14. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 14
  • 15. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 15
  • 16. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 16
  • 17. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf - Treating tobacco use 17
  • 18. The 5 A’s For Patients Willing To Quit ASK about tobacco use. ADVISE to quit. ASSESS willingness to make a quit attempt. ASSIST in quit attempt. ARRANGE for follow-up. 18
  • 19. Treating patients who are not ready to make a quit attempt RELEVANCE: Tailor advice and discussion to each patient. RISKS: Outline risks of continued smoking. REWARDS: Outline the benefits of quitting. ROADBLOCKS: Identify barriers to quitting. REPETITION: Reinforce the motivational message at every visit. 19
  • 20. 20
  • 21. 21
  • 22. 22 Courtesy of People for Ethical Treatment of Animals
  • 23. 23 the rats resisted to the daily loading into the exposure tubes and continued to struggle inside the tubes right after the beginning of the exposure. By and large, the rats of the sidestream groups reacted more vigorously than those of the mainstream group. the rats of the sidestream groups continued to show shaggy fur and some pronounced respiratory symptoms characterized by whistling and rattling sounds. 1 rat of the mainstream group, 9 rats of the puffed and 11 of the nonpuffed sidestream group died “spontaneously”. The rats of the sham and the cage control groups increased their body weight during the 21 days of exposure The sidestream groups showed a decrease to approx. 80 percent of their initial body weight.
  • 24. 24 Which of the following statements is correct:* 1. 3 non-smokers die from other peoples’ cigarette smoke for every person killed by a drunk driver 2. 1 non-smoker dies from other peoples’ cigarette smoke for every 10 people killed by drunk drivers 3. 3 people are killed by drunk drivers for every individual who dies from other peoples’ cigarette smoke. *Based on National Highway Traffic Safety Administration data and studies published in the scientific literature
  • 25. 25 Which of the following statements is correct in the US?* 1. 3 non-smokers die from other peoples’ cigarette smoke for every person killed by a drunk driver 2. 1 non-smoker dies from other peoples’ cigarette smoke for every 10 people killed by drunk drivers 3. 3 people are killed by drunk drivers for every individual who dies from other peoples’ cigarette smoke. *Based on National Highway Traffic Safety Administration data and studies published in the scientific literature
  • 26. 26 Blood Pressure
  • 27. 27 Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5–20 mmHg/10 kg weight loss Adopt DASH eating plan 8–14 mmHg Dietary sodium reduction 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg
  • 28. 28 Diet & Dyslipidemia
  • 29. 29 Which of the following is true? 1. A Mediterranean diet has been shown to reduce total mortality by 40% 2. A Mediterranean diet has been shown to reduce cardiac events by 50% 3. The cardiac benefits of a Mediterranean diet are offset by an increased risk of cancer. 4. A and B are true 5. A, B and C are true
  • 30. 30 Which of the following is true? 1. A Mediterranean diet has been shown to reduce total mortality by 40% 2. A Mediterranean diet has been shown to reduce cardiac events by 50% 3. The cardiac benefits of a Mediterranean diet are offset by an increased risk of cancer. 4. A and B are true 5. A, B and C are true
  • 31. 31 0 5 10 15 20 25 Control (n=303) Treatment (n=302) Total Deaths (.58) Cardiac Death (.32) Cancers (.41) All comparisons significant
  • 32. 32 0 2 4 6 8 10 12 14 16 Control Indo Medit Total Cardiac Endpoints (.52) Non-fatal MI (.49) Fatal MI (.71) Sudden Cardiac Death (.38) % (NS)
  • 33. 33
  • 34. 34 EVOO = extra virgin olive oil
  • 35. 35 EVOO = extra virgin olive oil
  • 36. Healthy diets are available everywhere 36
  • 37. 37 Omega-3 Fatty Acids Despite the association of fish consumption with positive health outcomes, trials of omega-3 fatty acid supplements have repeatedly failed to show any effect
  • 38. 38 Optimum Diet for CHD Prevention
  • 39. 39
  • 40. 40 -80 -70 -60 -50 -40 -30 -20 -10 0 Wine (150 ml/d) Fish (114 g 4x/wk) Dark chocolate (100g/d) Fruit and vegetables (400 g/d) Garlic (2.7g/d) Almonds (68 g/d) Combined effect
  • 41. 41 0.85 0.80 0.00 0.0 1.00 0.95 0.90 Proportionalive Years placebo simvastatin 64321 5 Log rank p=0.0003 The Scandinavian Simvastatin Survival Study Group. Lancet 1994;344:1383–1389 4S: Total Mortality Reduction with Simvastatin in CHD Patients
  • 42. 42 The Scandinavian Simvastatin Survival Study Group. Lancet 1994;344:1383–1389 4S: Cardiovascular Endpoints Outcomes Number of events Placebo (n=2223) Simvastatin (n=2221) Relative risk reduction (%) p-value Total mortality* 256 182 30 <0.001 Coronary death 189 111 42 <0.001 Major coronary events 622 431 34 <0.001 PCTA/CABG 383 252 37 <0.001 * primary endpoint
  • 43. 43 Thrombolysis reduces STEMI mortality by 18%
  • 44. 44 Rescue angioplasty and stenting: 28% mortality reduction over thrombolysis Keely EC et al Lancet 2003;361:13-20
  • 45. 45 RAAS Blockade in Heart Failure
  • 46. 46 RALES All-Cause Mortality CP1137489-36 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1,0 0 3 6 9 12 15 18 21 24 27 30 33 36 Probabilityofsurvival(%) Months Pitt et al: NEJM 341:709, 1999 Risk reduction 30% 95% CI (18-40%), P<0.001 Spironolactone + standard therapy Standard therapy (ACEI + loop diuretic ± digoxin)
  • 47. 47 0 2 4 6 8 10 12 14 16 18 20 22 0 3 6 9 12 15 18 21 24 27 30 33 36 CP1137489-40 Months since randomization Cumulativeincidence Pitt et al: N Engl J Med 348:1309, 2003 EPHESUS Relative Risk of Total Mortality Placebo 3,313 3,054 2,983 2,830 2,418 1,801 1,213 709 323 99 2 0 0 Eplerenone 3,319 3,125 3,044 2,806 2,463 1,857 1,260 728 336 110 0 0 0 Placebo Eplerenone RR=0.85 (95% CI, 0.75-0.96) P=0.008
  • 48. 48 ICDs and Cardiac Resynchron- ization
  • 49. 49 ICD Trials: SCD-HeFT Bardy GH et al. NEJM 2005;352:225-37
  • 50. 50 NEJM 2005;352:1539
  • 51. 51 Population expected mortality hazard ratio, 0.63; 95 percent CI, 0.51 to 0.77; P<0.001
  • 52. 52 Cardiac Rehabilitation
  • 53. 53 Total Mortality Cardiac Mortality Comprehensive Cardiac Rehab (n = 27) RR = 0.87 95% CI = 0.74 to 1.02 RR = 0.80 95% CI = 0.65 to 0.99 Exercise Cardiac Rehab (n = 19) RR = 0.76 95% CI = 0.59 to 0.98 RR = 0.73 95% CI = 0.56 to 0.96
  • 54. 54 Effects of Combination Therapy in Primary Care
  • 55. 55 For patients with coronary heart disease, the combination of aspirin, beta blocker and statin appears to reduce events and mortality by: 1. 25-30% 2. 40-50% 3. 70-85% 4. Patients don’t live longer, they just feel like they do.
  • 56. 56 For patients with coronary heart disease, the combination of aspirin, beta blocker and statin appears to reduce events and mortality by: 1. 25-30% 2. 40-50% 3. 70-85% 4. Patients don’t live longer, they just feel like they do.
  • 57. 57
  • 58. 58 Hippisley-Cox, BMJ 2005;330:1059
  • 59. 59 Current use of studied drugs Unadjusted odds ratio Adjusted odds ratio None 1.00 1.00 Statins, ASA, BB 0.16 0.17 ACE, ASA, BB 0.41 0.34 Statins, ACE, ASA, BB 0.31 0.25
  • 60. 60 Putting It All Together Smoke-free - No smoking, no exposure to tobacco smoke Diet - Mediterranean, olive or canola oil, red meat = salmon, white meat = tuna, daily serving of nuts Physical Activity - 10,000 steps/day Pharmacoprophylaxis - lifelong ASA, beta- blocker, statin. Goal LDL<100 mg/dl. Goal SBP<140 mm Hg. If reduced LV function - Beta-blocker, ACE inhibitor, spironolactone, ICD, consider biventricular pacemaker if QRS is wide
  • 61. 61 Based on current estimates, the greatest potential impact of intervention on heart disease mortality in a population would come from: 1. Encouraging patients to buy defibrillators for their homes and cars 2. Reducing door-to-balloon time for patients with ST elevation myocardial infarction 3. Convincing eligible patients to accept an implantable defibrillator 4. Improving risk profiles in individuals who are not known to have heart disease
  • 62. 62 Based on current estimates, the greatest potential impact of intervention on heart disease mortality in a population would come from: 1. Encouraging patients to buy defibrillators for their homes and cars 2. Reducing door-to-balloon time for patients with ST elevation myocardial infarction 3. Convincing eligible patients to accept an implantable defibrillator 4. Improving risk profiles in individuals who are not known to have heart disease
  • 63. 63 Deaths Prevented or Postponed (DPP) with perfect care Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 Achieved
  • 64. 64 Mortality Changes in North Karelian (Finland) Men Ages 35-64 years: 1970- 2006 http://www.ktl.fi/eteo/cindi/northkarelia.html -90 -80 -70 -60 -50 -40 -30 -20 -10 0 All causes All cardiovascular Coronary heart disease All Cancers Lung cancers
  • 65. 65 Increasing Life Expectancy: Finland 60 65 70 75 80 85 Men Women 65,9 74,2 75,8 82,9 1971 2007 Personal communication: Pekka Puska. 2008.11.04
  • 66. Correlation of life expectancy with healthy life expectancy among 26 European Union countries -0,20 0,00 0,20 0,40 0,60 0,80 1,00 F M r http://nui.epp.eurostat.ec.europa.eu/nui/setupModifyTableLayout.do
  • 67. 67 ICSI Healthy Lifestyle Guideline  Focuses on nutrition, physical activity, avoiding tobacco/tobacco smoke, avoiding risky drinking and healthy thinking  Documents that intervention does change behavior  Recognizes that employers are key members of the health care team  Advocates annual assessment when the individual enters labor force  Notes that health plans are ideally suited to administer health risk assessment (HRA) and offer intervention programs when indicated https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/c atalog_prevention__screening_guidelines/healthy_lifestyles/
  • 68. 68 Objectives  Describe a model of heart disease and heart disease risk that is composed of 3 prevalence pools and 3 event streams.  Describe the potential reduction in total mortality in the United States in terms of deaths prevented or postponed (DPP) as a result of perfect care for heart disease and heart disease risk factors.  Describe the contribution to total deaths prevented or postponed by a) acute events and b) treatment of individuals before or between events as a result of perfect care.
  • 69. 69 Thomas E. Kottke, MD, MSPH Medical Director for Population Health HealthPartners and Consulting Cardiologist HealthPartners Medical Group Professor of Medicine University of Minnesota thomas.e.kottke@HealthPartners.com The Medical Knowledge Behind Integrated NCD Prevention “Myocardial Infarction” Jorma Turtiainen, 1976 Helsinki, 10 march 2014