Evidence-Based Guidelines for Cardiovascular Disease ...

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  • SPEAKER NOTES: Thank you for participating in this case study-based continuing education workshop on women’s heart health.
  • SPEAKER NOTES: As you may know, this continuing education activity is a part of the American Heart Association’s Go Red For Women national campaign to raise awareness about cardiovascular disease in women. Following this activity, you may be given a card, or at minimum, will be sent an e-mail with a link to the American Heart Association’s Professional Education Center. You will be given step-by-step instructions on how to complete the evaluation and claim the type of CME or CE certificate you need.
  • SPEAKER NOTES: We appreciate the support of Macy’s and Pfizer as national sponsors of the Go Red For Women Campaign. We also appreciate the educational grant provided by PacifiCare Foundation.
  • SPEAKER NOTES: Thanks to a collaborative effort by these expert medical practitioners and researchers, we are able to help make women more aware and better educated about the importance of a heart-healthy lifestyle and proper preventive care for at-risk women.
  • SPEAKER NOTES: As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Association of Critical-Care Nurses (AACN) and the American Council on Pharmaceutical Education (ACPE), the American Heart Association must ensure fair balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Therefore, all faculty and authors participating in continuing education activities sponsored by the American Heart Association must disclose to the audience: (1) any significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and/or the manufacturer(s) of products or devices discussed, and (2) discussion of unlabeled/unapproved uses of drugs or devices. (Note three authors with separate disclosures and four without.)
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  • SPEAKER NOTES: The correct answer is A. Because Mrs. Johnson has established coronary heart disease (CHD), she has a greater than 20% risk of experiencing a coronary heart disease event within 10 years. The presence of atherosclerosis in any vascular bed (coronary, cerebral, peripheral) or one of the “CHD equivalents,” such as diabetes, abdominal aortic aneurysm, or chronic kidney disease (reference National Cholesterol Education Program Adult Treatment Panel III [NCEP-ATP III]), automatically places a patient in the high-risk category regardless of her symptoms or other risk factors. Had the patient not had established coronary artery disease (CAD), her risk score estimate would be 11% to 14%, which is an intermediate risk. Since the patient has documented CAD, the Framingham Calculator is inappropriate and would underestimate the risk.
  • SPEAKER NOTES: The correct answer is C. Mrs. Johnson has metabolic syndrome. The diagnosis of metabolic syndrome requires the presence of three of the following traits: Abdominal obesity measured as a waist circumference of greater than or equal to 35 inches for women and 40 inches for men. Triglyceride levels greater than or equal to 150 mg/dL. Blood pressure greater than or equal to 130/85 mm/Hg. Fasting blood sugar of 100 mg/dL or higher. HDL-C less than 50 mg/dL for women or 40 mg/dL for men. Mrs. Johnson should be counseled that she is at high risk of developing diabetes, and consideration should be made for further evaluation, including glycosylated hemoglobin levels (HbA1C). The diagnosis of diabetes has not yet been established, and insulin is not indicated at present. Stress testing of asymptomatic patients with coronary heart disease is currently not routinely recommended and should be determined on an individual basis.
  • SPEAKER NOTES: She meets all five criteria for identification of the metabolic syndrome: She has abnormal lipids that fit this criteria. TG greater than 150 at 248, HDL less than 40 at 31 FBS greater than 100 at 112 BP greater than 130/85 at 140/85 BMI at 29 we can assume her waist circumference is greater than 40 inches In addition, she smokes, which may exacerbate insulin resistance. Also, besides being overweight, her diet is very high in carbs and low in fiber.
  • SPEAKER NOTES: The correct answer is D. Mrs. Johnson’s lipid profile is suboptimal, with elevated LDL-C, low HDL-C, and elevated triglycerides. The goal for her LDL-C is less than 100 mg/dL and the goal for triglycerides is less than or equal to 150 mg/dL. Therapeutic lifestyle changes, including exercise and dietary modification, especially if accompanied by weight loss, can be expected to improve her risk-factor profile. The most significant and early beneficial changes will be observed in triglycerides, blood glucose, and blood pressure measures. However, therapeutic lifestyle changes alone are unlikely to lower LDL-C to the target range and, therefore, a higher statin dose should be employed initially to achieve this. If, after 6 to 8 weeks, the LDL-C goal has not been attained, the addition of a second agent, such as ezetimibe, may be indicated. Vitamin E is a Class III intervention that has not proven effective and may be harmful for cardiovascular disease prevention. If Mrs. Johnson is taking vitamin E solely for cardiovascular disease prevention, she should consider stopping it. While achieving significant weight loss may be desirable, the aggressive initial goal weight of 120 pounds would be daunting to almost any patient and is not necessary to achieve significant risk reduction and improvements in blood pressure, glucose, and lipids. Once an intermediate goal of a 5% to 10% weight reduction is achieved, another goal can be set. Although a multivitamin with vitamin C is a relatively benign intervention, there is no evidence to recommend its use for the prevention of cardiovascular disease.
  • SPEAKER NOTES: The correct answer is E. You may disappoint the patient and will undoubtedly need to thoroughly explain why you are advising her to increase, rather than reduce, the number of prescribed medications. In addition to increasing her statin dose, you should also optimally treat Mrs. Johnson with both a beta-blocker and an ACE inhibitor. Both drug classes have Class I indications for women with chronic coronary heart disease and are better choices for her hypertension management than a calcium channel blocker. Doses of both drugs can be titrated to the desired blood pressure goal. Both classes of drugs are available in generic form and are generally well tolerated. Angiotensin II type 1 receptor blockers (ARBs) are a reasonable alternative to ACE inhibitors if a cough develops. The benefit of a higher aspirin dose has not been established.
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Transcript

  • 1.  
  • 2. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women A Case-Study Approach
  • 3. This educational offering is supported by Macy’s and Pfizer, national sponsors of the American Heart Association’s Go Red For Women campaign. _____________________ An educational grant was also supplied by PacifiCare Foundation.
  • 4. COURSE CHAIR Nanette K. Wenger, MD Professor of Medicine (Cardiology) Emory University School of Medicine Chief of Cardiology Grady Memorial Hospital Atlanta, GA E-mail: [email_address] AUTHORS Kathy Berra, MSN, ANP, FAAN Stanford Prevention Research Center Stanford University School of Medicine Stanford, California E-mail: [email_address] Linda Casebeer, PhD Associate Director University of Alabama Division of CME Birmingham, Alabama E-mail: [email_address] Sharonne N. Hayes, MD, FACC Director, Women’s Heart Clinic Mayo Clinic College of Medicine Rochester, Minnesota E-mail: [email_address] Paula A. Johnson, MD, MPH Executive Director, Connor’s Center for Women’s Health and Gender Biology Chief, Division of Women’s Health Brigham and Women’s Hospital Boston, Massachusetts E-mail: [email_address] Luella Klein, MD Charles Howard Candler Professor Department of Gynecology and Obstetrics Emory University School of Medicine Director, Maternal and Infant Project Grady Healthcare System Atlanta, Georgia E-mail: [email_address] Cathy A. Sila, MD, FAHA Associate Director, Cerebrovascular Center Section of Stroke and Neurologic Intensive Care Department of Neurology Cleveland Clinic Cleveland, Ohio E-mail: [email_address]
  • 5.
    • Disclosure Statement
    • As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Association of Critical-Care Nurses (AACN) and the American Council on Pharmaceutical Education (ACPE), the American Heart Association must ensure fair balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Therefore, all faculty and authors participating in continuing education activities sponsored by the American Heart Association must disclose to the audience: (1) any significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and/or the manufacturer(s) of products or devices discussed, and (2) discussion of unlabeled/unapproved uses of drugs or devices .
    • The following authors have declared financial interest(s) and / or affiliations:
    • • Kathy Berra, MSN, ANP, FAAN—Research Support: Guidant Foundation
      • Speakers Bureau/Honoraria: Pfizer, KOS Pharmaceuticals
      • Consultant/Advisory Board: Pfizer, KOS Pharmaceuticals
    • • Sharonne Hayes, MD, FACC—Consultant/Advisory Board: WomenHeart; Cardiovision 2020
    • • Nanette Wenger, MD—Research Grant: Bristol-Myers Squibb, Eli Lilly and Company, AstraZeneca
      • Speakers Bureau/Honoraria: Aventis Pharmaceuticals, Pfizer, Merck, Bristol-Myers Squibb, Wyeth Ayerst, Eli Lily and Company,
      • Consultant/Advisory Board: Eli Lilly Raloxifene Advisory Committee; Heart Disease in Women, MED-ED, Pfizer; Aventis Pharmaceuticals Consultant and Cardiology Advisory Board; Cardiology/Lipidology Advisory Board Merck; Consultant, Women First Healthcare Inc.; Cardiology Consultant, Bristol-Myers Squibb; Ranolazine Advisory Board, CV Therapeutics
    • The following authors have declared NO financial interest(s) and or affiliations:
    • • Linda Casebeer, PhD
    • • Paula A. Johnson, MD, MPH
    • • Luella Klein, MD
    • • Cathy Sila, MD, FAHA
    Case 2 “Management of the Patient with Heart Disease”
  • 6. Case 2 “Management of the Patient with Heart Disease”
  • 7.
    • Case Presentation
    • Mrs. Johnson is a 68-year-old woman who presents for her periodic health examination. She reports that she has had a good year, but is concerned about her risk of breast cancer and wants to schedule her yearly mammogram. Aside from some left hip discomfort for which she takes occasional ibuprofen, she has no other complaints.
    Case 2 “Management of the Patient with Heart Disease”
  • 8.
    • Past Medical History
    • At age 62, Mrs. Johnson developed unstable angina. Coronary angiography showed a 90% mid-right coronary artery lesion and a 30% distal left anterior descending artery lesion. She had successful stenting of her right coronary artery with a good result and has had no recurrent angina. She has not seen a cardiologist for four years.
    • Mrs. Johnson had a hysterectomy at age 40 for dysfunctional uterine bleeding.
    • (Continued on next slide)
    Case 2 “Management of the Patient with Heart Disease”
  • 9.
    • Past Medical History (cont’d.)
    • Hypertension for 20 years
    • Smoked half a pack per day for 30 years and quit when her coronary artery disease was diagnosed six years ago
    • Hyperlipidemia
    • Not physically active (in spite of recommendations)
    • Does not follow any “diet” (in spite of recommendations)
    Case 2 “Management of the Patient with Heart Disease”
  • 10.
    • Family History
    • One sister has postmenopausal breast cancer.
    • A brother is diabetic and had myocardial infarction and coronary artery bypass grafting at age 60.
    • Her mother died of myocardial infarction at age 64.
    • Her father died of a stroke at age 72.
    Case 2 “Management of the Patient with Heart Disease”
  • 11.
    • Medications
    • Aspirin, 81 mg p.o. daily
    • Hydrochlorothiazide, 25 mg p.o. daily
    • Amlodipine, 5 mg p.o. daily
    • Simvastatin, 10 mg p.o. daily
    • Vitamin E, 400 IU p.o. daily
    Case 2 “Management of the Patient with Heart Disease”
  • 12.
    • Physical Examination
    • Well-appearing, obese woman in no acute distress
    • Height: 5 feet 5 inches
    • Weight: 188 pounds
    • BMI: 31.3 (Waist circumference: 36 inches)
    • Blood pressure (left arm, seated): 144/78 mm Hg
    • Pulse: 78 BPM
    • Breasts: No masses or discharge
    • Lungs: Clear
    • (Continued on next slide)
    Case 2 “Management of the Patient with Heart Disease”
  • 13.
    • Physical Examination (cont’d.)
    • Heart: Regular rate and rhythm. Normal jugular venous pressure. Normal first and second heart sounds. No murmur or third heart sound. Fourth heart sound present.
    • Abdomen: Nontender, no hepatosplenomegaly, no bruit
    • Extremities: No edema
    • Vessels: Femoral and carotid pulses are full and without bruit
    Case 2 “Management of the Patient with Heart Disease”
  • 14.
    • Laboratory Evaluation
    • Electrocardiogram: heart rate 82 BPM. Normal sinus rhythm with nonspecific ST-T wave changes.
    • Lipids:
      • Total cholesterol: 209 mg/dL
      • LDL-C: 133 mg/dL
      • HDL-C: 38 mg/dL
      • Triglycerides: 188 mg/dL
      • AST (SGOT): 32 IU/L; ALT (SGPT): 46 IU/L
      • Fasting blood glucose: 122 mg/dL
    • Mammogram: Benign calcifications in left breast, otherwise negative.
    Case 2 “Management of the Patient with Heart Disease”
  • 15.
    • Question 1
    • Based on the patient’s clinical data, Mrs. Johnson has a ___10-year risk of experiencing a coronary heart disease event.
      • Greater than 20%
      • 10%–20%
      • Less than 10%
      • None of the above
    Case 2 “Management of the Patient with Heart Disease”
  • 16.
    • Question 2
    • Current guidelines suggest that Mrs. Johnson should be advised:
      • That she has diabetes and should consider insulin therapy.
      • To undergo stress echocardiography to exclude silent ischemia.
      • That she has metabolic syndrome.
      • None of the above.
    Case 2 “Management of the Patient with Heart Disease”
  • 17. Clinical Identification of the Metabolic Syndrome From: Circulation 2005;112:2735-2752 Case 2 “Management of the Patient with Heart Disease” ≥ 100 mg/dL Elevated fasting glucose ≥ 130/85 mmHg Elevated blood pressure <40 mg/dL <50 mg/dL Reduced HDL-C Men Women ≥ 150 mg/dL Elevated triglycerides Waist circumference > 102 cm ( > 40 in) > 88 cm (> 35 in) Elevated waist circumference Men Women Categorical cutpoints Measure (any 3 of 5 constitute diagnosis of metabolic syndrome)
  • 18.
    • Question 3
    • You advise Mrs. Johnson to increase her physical activity and refer her for nutritional consultation. You also:
      • Recommend increasing her vitamin E to 800 IU per day.
      • Tell her to try to achieve a BMI of 20 (lose 68 pounds and exercise daily).
      • Add a multivitamin with at least 500 mg of vitamin C each day.
      • Increase her simvastatin dose to 40 mg per day and make sure that she is taking it in the evening.
    Case 2 “Management of the Patient with Heart Disease”
  • 19.
    • Question 4
    • Mrs. Johnson tells you that she really wants to minimize the number of medications she is taking and wonders if you would be willing to consider stopping some or all of them. You recommend:
      • She stop taking her vitamin E and hydrochlorothiazide and increase the dose of her amlodipine to 10 mg to achieve better control of her blood pressure.
      • Adding an ACE-inhibitor and stopping the amlodipine.
      • Increasing her aspirin dose to 325 mg per day.
      • Adding a beta-blocker.
      • Both B and D.
    Case 2 “Management of the Patient with Heart Disease”
  • 20.
    • In Summary
    • For this 68-year-old woman with established coronary heart disease (CHD) and stenting of her right coronary artery, she should be advised that she meets all five criteria for identification of the metabolic syndrome. Since she is well above her LDL goal of <100 mg/dL, she should increase her simvastatin dose to 40 mg per day and make sure that she is taking it in the evening. You should also treat her with a beta-blocker and an ACE inhibitor. Both drug classes have Class I indications for women with chronic CHD.
    Case 2 “Management of the Patient with Heart Disease” Conclusion