Post on 21-Jan-2015
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New and Evolving Concepts in Cardiovascular Disease
Prevention and Management
Nathan D. Wong, PhD, FACC
Professor and Director
Heart Disease Prevention Program
University of California, Irvine
Most Myocardial Infarctions Are Causedby Low-Grade Stenoses
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.)
Falk E et al, Circulation, 1995.
(Adapted from Glagov et al.)(Adapted from Glagov et al.)
Coronary RemodelingCoronary Remodeling
NormalNormalvesselvessel
MinimalMinimalCADCAD
ProgressionProgression
Compensatory expansionCompensatory expansionmaintains constant lumenmaintains constant lumen
Expansion Expansion overcome:overcome:
lumen narrowslumen narrows
SevereSevereCADCAD
ModerateModerateCADCAD
Glagov et al, Glagov et al, N Engl J MedN Engl J Med, 1987., 1987.
Women and Heart Disease• 1 in 2-3 women die of CHD, but only
4% fear of dying of CHD
• 1 in 27 women die of breast cancer, but 40% fear of dying of breast cancer
• 2/3 of women have at least 1 CHD risk factor, 52% over age 45 have hypertension, 40% over age 55 have high cholesterol
Major Risk Factors
• Cigarette smoking• Elevated total or LDL-cholesterol• Hypertension (BP 140/90 mmHg or on
antihypertensive medication)• Low HDL cholesterol (<40 mg/dL)† • Family history of premature CHD
– CHD in male first degree relative <55 years– CHD in female first degree relative <65 years
• Age (men 45 years; women 55 years)† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its
presence removes one risk factor from the total count.
Other Recognized Risk Factors• Obesity: Body Mass Index (BMI)
– Weight (kg)/height (m2)– Weight (lb)/height (in2) x 703
• Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2
• Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women
• Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week
BMI and Relative Risk of CHD Over 14 Years: Nurse’s Health Study
• Relative risk of CHD increases for BMI > 23, diabetes risk increases for BMI > 22.
• Risk also significantly increases for weight gain after age 18 years of 5 kg or more. 0
0.5
1
1.5
2
2.5
3
3.5
<21 21-22.9 23-24.9 25-28.9 >29
Diabetes as a CHD Risk Equivalent
• 10-year risk for CHD 20%• High mortality with established CHD
– High mortality with acute MI– High mortality post acute MI
Prevalence has increased over 25% in past 15 years in California, paralleling 50% increase in overweight/obesity
Probability of Death From CHD in Patients With NIDDM and in Nondiabetic Patients,
With and Without Prior MI
Kaplan-Meier estimatesHaffner SM et al. N Engl J Med 1998;339:229–234
0 1 2 3 4 5 6 7 80
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
Surv
ival (%
)
General Features of the Metabolic Syndrome
• Abdominal obesity• Atherogenic dyslipidemia
– Elevated triglycerides
– Small LDL particles
– Low HDL cholesterol
• Raised blood pressure• Insulin resistance ( glucose intolerance)• Prothrombotic state• Proinflammatory state
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 ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
<40 mg/dL<50 mg/dL
MenWomen
>102 cm (>40 in)>88 cm (>35 in)
MenWomen
110 mg/dLFasting glucose130/85 mm HgBlood pressure
HDL-C150 mg/dLTG
Abdominal obesity† (Waist circumference‡)
Defining LevelRisk Factor
© 2001, Professional Postgraduate Services®
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Prevalence of Selected Risk Factors in US Adults with the Metabolic Syndrome (without Diabetes)
(Wong et al., Am J Cardiol 2003, in press)
80.584.2
76.7
84.6
73.2
82.986.5
57.662.6
22.216.7
95.1
0
10
20
30
40
50
60
70
80
90
100
Men Women
Pe
rce
nt
(%)
of
Me
tab
oli
c S
yn
dro
me
Su
bje
cts
Waist Cir >40cm M/>35 cm W Blood Pressure >=130/85 or RxFasting Trig. >=150 mg/dl HDL-C <40 mg/dl M/<50 mg/dl WLDL-C >=130 mg/dl Fasting Glucose 110-125 mg/dl
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)
28.2
51.2 50.646.2
38.1
80.5 82.1
45.1
0
10
20
30
40
50
60
70
80
90
Men Women
Pro
po
rtio
n o
f C
HD
Ev
en
ts P
rev
en
ted
(P
AR
%)
BP only HDL-C only LDL-C only All 3 factors
***
* p<0.05, ** p<0.01 compared to men
U.S. Department of Health and Human
Services
National Institutes of Health
National Heart, Lung, and Blood Institute
The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)
National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program
National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program
Classification and Management of BP for adults
BP classificati
on
SBP* mmHg
DBP* mmHg
Lifestyle modificati
on
Initial drug therapy
Without compelling indication
With compelling indications
Normal <120 & <80 Encourage
Prehypertension
120–139 or 80–89 Yes No antihypertensive drug indicated.
Drug(s) for compelling indications. ‡
Stage 1 Hypertension
140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Drug(s) for the compelling indications.‡
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension
>160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
*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.
<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 Distribution of Hypertension Subtype in the untreated Hypertensive Population in NHANES III by AgeHypertensive Population in NHANES III by Age
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
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 (%)
BP Control RatesTrends in awareness, treatment, and control of high
blood pressure in adults ages 18–74National Health and Nutrition Examination Survey, Percent
II1976–80
II(Phase 1)1988–91
II(Phase 2)1991–94 1999–2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
4-Year Progression To Hypertension: The Framingham Heart Study
5
18
37
0
10
20
30
40
50
Optimal Normal High-Normal
Pat
ien
ts (
%)
(<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
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
80–8975–79
70–74<70 <120
120–139
140–159
160+
48.3
20.6
10.311.8
8.88.5
9.2
23.8
16.9
13.912.8
12.611.8
31.0
25.524.6 25.3
25.224.9
37.434.7
43.8
38.1
80.6
Lifestyle ModificationModification 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
Classification and Management of BP for adults
BP classification
SBP* mmHg
DBP* mmHg
Lifestyle modificati
on
Initial drug therapy
Without compelling indication
With compelling indications
Normal <120 &
<80 Encourage
Prehypertension
120–139
or 80–89
Yes No antihypertensive drug indicated.
Drug(s) for compelling indications. ‡
Stage 1 Hypertension
140–159
or 90–99
Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Drug(s) for the compelling indications.‡
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension
>160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
*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.
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 35% of CHD Occurs in Occurs in People with People with TC<200 mg/dLTC<200 mg/dL
150 200
Total Cholesterol (mg/dL)
250 300
No CHD
CHD
Framingham Heart Study—26-Year Follow-up
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 yCastelli WP et al. JAMA 1986;256:2835–2838
02468
101214
< 40 40–49 50–59 60< 200
230–259200–229
260
HDL-C (mg/dL) Tota
l-C (m
g/dL
)
14
-y in
cid
en
ce
rate
s (%
) fo
r C
HD
11.24
11.91
12.50
11.91
6.56
4.67
9.05
5.53
4.85
4.153.77
2.782.06
3.83
10.7
6.6
-30-33
-29 -28-22
-40
-30
-20
-10
0LDL-C Stroke
Totalmortality
%
**
† ‡
§
*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.
Impact of Lowering LDL-C on CVD Events and Total Mortality
Nonfatal/fatal CHD
CVDmortality
Risk Factors
• Major risk factors account for only about half of the variability in CHD risk in the US population
• Emerging risk factors could enhance predictive power in individuals– Lipid– Nonlipid
NCEP ATP III. Circulation. 2002;106:3145-3421.
Risk Factors for Future Cardiovascular Events: WHS
Relative Risk of Future Cardiovascular Events0
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-C1.0 2.0 4.0 6.0
Quartile of TC: Quartile of TC:
HDL-CHDL-C
Quartile Quartile of hs-CRP of hs-CRP
43
21 1
23
4
9
8
7
6
5
4
3
2
1
0
hs-CRP, Lipids, and Risk of Future Coronary Events: Women's Health Study (WHS)
Ridker PM et al. N Engl J Med 2000;342:836-843.
ATP III: Assessment of Risk
For persons without known CHD, other forms of
atherosclerotic disease, or diabetes:
• Count the number of risk factors.
• Use Framingham scoring for persons with 2 risk factors* to determine the absolute 10-year CHD risk.
*For persons with 0–1 risk factor, Framingham calculations are not necessary.
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services®
www.lipidhealth.org
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.
Assessing CHD Risk in MenStep 1: Age
YearsPoints
20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total Cholesterol
TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 <160 0 0 0 0
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
HDL-C(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points atPoints at
Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79
Nonsmoker 0 0 0 00
Smoker 8 5 3 11
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 118%
0 1% 1210%
1 1% 1312%
2 1% 1416%
3 1% 1520%
4 1% 1625%
5 2% 1730%
6 2%7 3%8 4%9 5%
10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
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Men
YearsPoints20-34 -935-39 -440-44045-49350-54655-59860-641065-691170-741275-7913
Step 1: Age
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Women
YearsPoints20-34 -735-39 -340-44 045-49 350-54 655-59 860-641065-691270-741475-7916
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
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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 BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
MenTC 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
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
WomenTC 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
0160-199 4 3 2 1
1200-239 8 6 4 2
1240-279 11 8 5 3
2280 13 10 7 4
2
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
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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 BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Men
HDL-C(mg/dL)
Points60 -1
50-59 0
40-49 1
<40 2
Women
HDL-C(mg/dL)
Points60 -1
50-59 0
40-49 1
<40 2
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 4: Systolic Blood PressureMen
Systolic BP Points Points(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3
Note: The average of several BP measurements is needed for an accuratemeasurement of baseline BP. If an individual is on antihypertensive treatment,extra points are added.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
WomenSystolic BP Points
Points(mm Hg) if Untreated if
Treated <120 0 0
120-129 1 3130-139 2 4140-159 3 5160 4 6
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 5: Smoking Status
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
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 00
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 00
Smoker 9 7 4 2 1
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 6: Adding Up the Points(Sum From Steps 1–5)
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
AgeTotal cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
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 BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 118%
0 1% 1210%
1 1% 1312%
2 1% 1416%
3 1% 1520%
4 1% 1625%
5 2% 1730%
6 2%7 3%8 4%9 5%10 6%
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
CHD Risk Equivalents• > 20% 10-year risk of CHD
(Framingham projections) (downloadable risk algorithms at www.nhlbi.nih.gov)
• Diabetes
• Other forms of clinical atherosclerotic disease
– Peripheral arterial disease
– Abdominal aortic aneurysm
– Carotid artery disease
NCEP ATP III. JAMA. 2001;285:2486-2497.
ACC 34th Bethesda Conference Task Force 4: How do We Select Patients for Atherosclerosis Imaging?
• 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
• Persons with diabetes are considered CHD risk equivalents already warranting aggressive treatment as such; screening for atherosclerosis is not needed
Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)
• Patients at intermediate risk for total CHD comprise about 40% of the adult population.
• 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.
Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)
Significant Coronary Artery Calcium (Score >400)
ATP III: Nutritional Components of the TLC Diet
Expert Panel on Detection, Evaluation, and Treatment ofHigh 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 tomaintain desirable body weight.
<200 mg/dCholesterol
~15% of total caloriesProtein
20–30 g/dFiber
50%–60% of total caloriesCarbohydrate (esp. complex carbs)
25%–35% of total caloriesTotal fat
Up to 20% of total caloriesMonounsaturated fat
Up to 10% of total caloriesPolyunsaturated fat
<7% of total caloriesSaturated fat*
Recommended IntakeNutrient
© 2001, Professional Postgraduate Services®
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Possible Benefits From Other Therapies
Therapy Result
• Soluble fiber in diet (2–8 g/d) (oat bran, fruit, and vegetables)
• Soy protein (20–30 g/d)
• Stanol esters (1.5–4 g/d) (inhibit cholesterol absorption)
• Fish oils (3–9 g/d) (n-3 fatty acids)
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.
Dietary Approaches to Stop Hypertension (DASH)
• 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
• 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.
• NEJM 1997; 366: 1117-24.
AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update – Risk
Assessment
Circulation 2002; 106: 388-391 • Beginning age 20:
– Regularly assess family history, smoking status, diet, alcohol intake, and physical activity
– 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.
Beginning age 40: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
AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update (cont.)– Risk
Intervention• Smoking – complete cessation and no exposure to
environmental tobacco smoke • BP control - <140/90 (<130/85 if renal insufficiency or CHF,
<130/80 for diabetes)• 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
• Aspirin – consider 75-160 mg/d for those at 10-y risk of 10% or greater
• Lipids – goals per NCEP guidelines• Physical activity – At least 30 minutes/d on most or all days of
week• Weight management – Achieve desirable BMI 18.5-<25, waist
cir <=40 in men and <=35 in women• Diabetes management – Goal fasting glucose <110 mg/dl and
HgbA1c <7%
Considerations for Secondary Prevention
• CVD event rates in those with pre-existing disease are 5-7 times greater than healthy individuals.
• Diabetics run a similar event rate as those with a previous myocardial infarction (Haffner)
• Risk factor modification is the cornerstone of secondary prevention efforts
• Categories of patients for secondary prevention efforts: 1) stable CHD, 2) unstable angina, 3) prior MI, 4) prior CABG, and 5) prior PTCA
Get with the Guidelines-CVD and Stroke
AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary
Prevention Guidelines
Adapted from Smith, Circulation 2001Adapted from Smith, Circulation 2001
AHA GuidelinesAHA Guidelines• Cessation of smoking• Lipid Management Goals• Physical activity• Weight management• Antiplatelet/anticoagulants• ACE inhibitors• Beta blockers • Blood pressure control
• Early Aspirin• Early Beta-Blockers• Reperfusion for AMI
• Stroke: Atrial Fibrillation and Alcohol Use
Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III2001Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III2001
Comprehensive Medical Therapy For Patients with CHD or Other
Atherosclerotic Vascular Disease Risk Reduction
• ASA 20-30%• Beta Blockers 20-35%• ACE inhibitors 22-25%• Statins 25-42%
– LDL Target < 100 mg/dl
• Smoking Cessation 50%
Implement Guidelines HERE
HealthyPopulation
Undiagnosedor Untreated
In Treatment
AcuteEvent
PostEvent
Implementation Statistics
Indicator Rate Optimal
ASA 85%* 100%
Beta Blocker 72%* 100%
ACE-I 71%* 100%
Smoking Cessation 40%* 100%
Lipid Lowering 37%** 96%
*HCFA, 1998 **NRMI 2nd Q 2000
Improvement in Treatment Utilization is Associated With A Marked Reduction in
Clinical Events
14.8%
6.4%
0
5
10
15
20
Pre-CHAMP Post-CHAMP
Death or Recurrent MI%RR0.43p<0.01
256 AMI pts discharged in92/93 Pre-CHAMP- compared to 302 pts in 94/95 Post-CHAMPASA 78% vs 92%; BetaBlocker12% vs 61%; ACEI 4% vs 56%; Statin 6%vs 86%
Fonarow ,American Journal of Cardiology 2001(in press)
CAD Treatment Gap - Community95
18
0102030405060708090
100
Physician Awareness of NCEPGuideline
Patient Treated to Goal
Provider awareness does not equal successful implementation
Pearson Arch Intern Med 2000;160:459-67
• Systems to Translate Efficacy Effectiveness
SYSTEMS• Outcomes associated
with an intervention under ideal circumstances– Clinical trial
reported in literature
– Benchmarking
EFFICACY EFFECTIVENESS
• Outcomes associated with an intervention in the real world – Hospital– Outpatient– Across
Continuum
Bridging the Gap Between Efficacy and Effectiveness
We are in a new business, from development of
guidelines to implementation of guidelines
Assess CHD Treatment RatesAnalyze
Discharge Rates
Evaluate AssessmentGWTG Team Reviews
Summary Reports
Refine ProtocolGWTG Team Identifies Areas for Improvement
Implement Refined ProtocolGWTG Team Coordinates Implementation of Refined
Protocol
Find & Support a Find & Support a ChampionChampion
Building the Hospital Team
• Physicians• Nurses• Pharmacists • Hospital Administrators• Directors of Quality
Improvement and Case Management
• Cardiac Rehab Team
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!
The UCI Heart Disease Prevention Program
see us at: www.heart.uci.edu