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Post Myocardial InfarctionPost Myocardial Infarction
Pharmacotherapy
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Post MI Pharmacologic Intervention
Post MI Pharmacologic Intervention
• ASA & Anti-platelet agents• Anti-coagulation - blockers• ACE inhibitors• Dyslipidemic therapy
– Statins
– Fibrates
© Continuing Medical Implementation …...bridging the care gap
ASA & Anti-platelet agentsASA & Anti-platelet agents
Rationale:
• Ruptured plaque– platelet activation & aggregation– thrombus core– downstream and upstream propagation– cyclical patency and re-occlusion v.s. persistent
thrombus formation
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Mechanism of Anti-platelet Activity
Mechanism of Anti-platelet Activity
• Class I - ASA, NSAIDs & sulfinpyrazone– block CO (cyclo-oxygenase)
• Class II - Dypyridamole– inhibits phosphodiesterase-mediated breakdown of cyclic
AMP– prevents platelet aggregation
• Class III - thienopyridines (ticlopidine&clopidogrel)– block binding of ADP to platelet receptor P2Y12 therby
inhibiting adenylyl cyclase
• Class IV - antibody, peptide & small molecule IIb/IIIA receptor inhibitors
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Antiplatelet Trialists’ Collaboration: Summary
Antiplatelet Trialists’ Collaboration: Summary
• Meta-analysis of 145 trials included about 70,000 high-risk patients
• Anti-platelet drugs reduced risk of composite outcome of ischemic stroke, MI, or vascular death by 27% in high-risk patients
• The relative odds reduction was consistent:– Over a wide range of clinical manifestations
(ischemic cerebrovascular, coronary, and atherosclerotic peripheral arterial disease)– Across subsets of patients at varying risks within specific clinical disorders
Antiplatelet Trialists’ Collaboration. BMJ 1994; 308: 81–106.
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Anti-platelet Trialists’ Collaboration: ResultsAnti-platelet Trialists’ Collaboration: Results
Anti-platelet Trialists’ Collaboration. Anti-platelet Trialists’ Collaboration. BMJBMJ 1994; 1994; 308308: 81–106.: 81–106.
Category of trialCategory of trial
PriorPriorstroke/TIAstroke/TIA
Acute Acute MIMI
Pat
ient
s w
ith s
trok
e, M
I, o
rP
atie
nts
with
str
oke,
MI,
or
vasc
ular
dea
th (
%)
vasc
ular
dea
th (
%)
2525
2020
Antiplatelet therapyAntiplatelet therapyControlControl
1515
1010
55
00Prior MIPrior MI OtherOther
high riskhigh riskAllAll
high riskhigh risk
22% odds reduction22% odds reduction
29% odds29% oddsreductionreduction
25% odds25% oddsreductionreduction
32% odds32% oddsreductionreduction
27% odds27% oddsreductionreduction
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ASA: EfficacyASA: Efficacy
Relative-Relative-risk risk
reductionreduction
ASAASA
25%25%
Antiplatelet Trialists’ Collaboration. Antiplatelet Trialists’ Collaboration. BMJBMJ 1994; 1994; 308 308: 81–106.: 81–106.
ASA reduces the ASA reduces the risk of stroke, risk of stroke, MI, or vascular MI, or vascular death by 25% death by 25% relative to relative to placeboplacebo
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CClopidogrel in lopidogrel in UUnstable Angina nstable Angina
to Prevent to Prevent RRecurrent Ischemic ecurrent Ischemic EEventsvents
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CURE CURE –– Design (3)Design (3)
†† Standard therapy always included ASA, and could also include hepStandard therapy always included ASA, and could also include heparin, LMWH, GParin, LMWH, GP IIbIIb//IIIaIIIa inhibitors inhibitors postpost--randomization, betarandomization, beta--blockers, ACEblockers, ACE--inhibitors, lipidinhibitors, lipid--lowering agents, and/or other therapies or lowering agents, and/or other therapies or interventions (e.g. PTCA, CABG) at physician’s discretion.interventions (e.g. PTCA, CABG) at physician’s discretion.
R
Day 0Day 0
12 months12 months
12 months12 months
ClopidogrelClopidogrel300 mg300 mgloading doseloading dose
Clopidogrel 75 mg Clopidogrel 75 mg od od + standard therapy+ standard therapy††
(n=6259)(n=6259)
Placebo 1 tab Placebo 1 tab odod+ standard therapy+ standard therapy††
(n=6303)(n=6303)PlaceboPlaceboloading doseloading dose
Patients with ACSPatients with ACS
(unstable angina or (unstable angina or NQMI without ST NQMI without ST
elevation)elevation)
R=Randomization, occurred within 24 hours of symptom onsetR=Randomization, occurred within 24 hours of symptom onset
Day 1Day 1
Day 1Day 1
LMWH, lowLMWH, low--molecularmolecular--weight heparin; GP,weight heparin; GP, glycoproteinglycoprotein;;PTCA, PTCA, percutaneouspercutaneous transluminaltransluminal coronary angioplasty; CABG, coronary artery bypass graftcoronary angioplasty; CABG, coronary artery bypass graft
CURE Study Investigators. CURE Study Investigators. EurEur Heart JHeart J 2000;21:20332000;21:2033––20412041
The CURE Investigators. The CURE Investigators. N Eng J Med N Eng J Med 2001;345:4942001;345:494--502502
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CURE CURE –– Main Efficacy ResultsMain Efficacy ResultsPrimary endpoint (2)Primary endpoint (2)
20% RRR20% RRRpp=0.00009=0.00009n=12,562n=12,562
Benefits were seen within hours and Benefits were seen within hours and continued to increase over the 12 monthscontinued to increase over the 12 months
00 11 22 33 44 55 66 77 88 99 1010 1111 1212Months of followMonths of follow--upup
% of patients with recurrent ischemic event*% of patients with recurrent ischemic event*
00
1010
1414
1212
44
88
66
22
Standard therapyStandard therapy‡‡
Clopidogrel + standard therapyClopidogrel + standard therapy‡‡
The CURE Investigators. The CURE Investigators. N Eng J Med N Eng J Med 2001;345:4942001;345:494--502502Data on fileData on file
‡‡including ASAincluding ASA*cardiovascular death, MI, or stroke*cardiovascular death, MI, or stroke
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OverallOverall 12 56212 562 11.411.4 9.39.3
ST deviation +ST deviation + 62756275 14.314.3 11.511.5ST deviation ST deviation -- 62876287 8.68.6 7.07.0
Entry enzymes elevated +Entry enzymes elevated + 31763176 13.013.0 10.910.9Entry enzymes elevated Entry enzymes elevated -- 93869386 10.910.9 8.88.8
Diabetes +Diabetes + 28402840 16.716.7 14.214.2Diabetes Diabetes -- 97229722 9.99.9 7.97.9
RiskRisk LowLow 41874187 6.76.7 5.15.1IntermediateIntermediate 41854185 9.49.4 6.56.5HighHigh 41844184 18.018.0 16.316.3
Rev after Rev after randomizationrandomization ++ 45774577 13.913.9 11.511.5Rev after Rev after randomizationrandomization -- 79857985 10.010.0 8.18.1
History of rev + History of rev + 22462246 14.414.4 8.48.4History of rev History of rev -- 10 31610 316 10.710.7 9.59.5
Patient characteristics 2N Patient characteristics 2N % events% eventsStandard Standard Clopidogrel + Clopidogrel + therapytherapy‡‡ standard therapystandard therapy‡‡
0.40.4 0.60.6 0.80.8 1.01.0 1.21.2
RR (95% CI)RR (95% CI)
+ with condition + with condition -- without condition Rev, revascularizationwithout condition Rev, revascularization
The CURE Investigators. The CURE Investigators. N Eng J Med N Eng J Med 2001;345:4942001;345:494--502502
Primary Outcome in Key SubgroupsPrimary Outcome in Key Subgroups
‡‡including ASAincluding ASA
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Unresolved QuestionsUnresolved Questions
• Use in all comers with UAP/NSTEMI?
• With IIB/IIA inhibitors?
• How long to use– With PCI?– Without PCI?
• Cost efficacy?
• Peri-CABG discontinuation?
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Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis.Anand SS; Yusuf SJAMA 1999 Dec 1;282(21):2058-67
Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis.Anand SS; Yusuf SJAMA 1999 Dec 1;282(21):2058-67
• 44 Trials-23,397 patients• oral anticoagulation for at least three months• acute MI, unstable angina, CABG• high intensity (INR 2.8-4.8) and moderate intensity (INR
2-3)• Odds Ratio
– death: 22 & 18%– MI: 42 & 52%– CVA: 63 & 53%
• Bleeding: 6 & 2.4 X• No difference in death, MI or CVA v.s. ASA
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Anti-coagulationAnti-coagulation
• Indication post MI:
• LV thrombus or aneurysm
• LVEF < 30%
• CHF
• History of thrombo-embolism
• Chronic atrial fibrillation-continue indefinitely
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LV thrombus or aneurysmLV thrombus or aneurysm
• Up to 40% large Q-anterior MIs– less in smaller MIs– less post-thrombolysis
• Odds ratio 0.14 for embolization with anti-coagulation for 6 months v.s no anticoagulation – Embolic potential, prevention and management of
mural thrombus complicating anterior myocardial infarction: a meta-analysis.Vaitkus PT; Barnathan ESJ Am Coll Cardiol 1993 Oct;22(4):1004-9.
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SELECTED RANDOMIZED TRIALS OF - BLOCKER THERAPY ADMINISTERED DURING AND AFTER AMI
SELECTED RANDOMIZED TRIALS OF - BLOCKER THERAPY ADMINISTERED DURING AND AFTER AMI
- Blockers Agent # Patients Duration RRR of Death
P Value
During MI
•ISIS I Atenolol 16027 7 days 0.85 < 0.04
•MIAMI Metoprolol 5778 15 days 0.87 0.29
•TIMI IIB Metoprolol 1434 6 days 1.0 0.98
After MI
•Norwegian Timolol 1884 33 months 0.61 < 0.001
•BHAT Propranolol 3837 25 months 0.72 < 0.005
ACC/AHA GuidelinesACC/AHA GuidelinesACUTE MI GUIDELINES 11/96
Long-term Beta Blockade
• Contraindications <60bpm, SBP<100, mod-severe CHF, peripheral hypoperfusion, PR>.24, type 1 or 2 AV block or CHB, asthma, ?insulin
• Class I (Treat > 2 years)• All but low risk pts without contraindications
• Class IIA• Low risk patients without contraindications
• Class III • Patients with contraindications
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Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after myocardial infarction. Lancet 2000; 356: 639 - 644
Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after myocardial infarction. Lancet 2000; 356: 639 - 644
• Paula A Rochon, Jack V Tu, Geoffrey M Anderson, Jerry H Gurwitz, Jocalyn P Clark, Paula Lau, John Paul Szalai, Kathy Sykora, C David Naylor
• 13 623 patients aged 66 years or older discharged from hospital post myocardial infarction
• No ß-blocker therapy vs received low, standard, or high doses.
• Of 8232 patients with no previous history of heart failure – ß-blocker therapy was associated with a 43% reduction
in subsequent admission for heart failure
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Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after
myocardial infarction. Lancet 2000; 356: 639 - 644
Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after
myocardial infarction. Lancet 2000; 356: 639 - 644
• Of 4681(57%) patients prescribed ß-blockers
– Risk of admission was greater in the high-dose than in the low-dose group !!!!!
– Iin the cohort, 2326 (17·1%) died by 1 year – Adjusted risk ratio 0·57 [95% CI 0·48-0·69] compared with patients
not dispensed this therapy
• Compared with those not dispensed ß-blocker therapy, the adjusted risk ratio for mortality was lower for all three doses– low 0·40 [0·34-0·47]– standard 0·36 [0·31-0·42]– high 0·43 [0·33-0·56]
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CAPRICORN
CAPRICORNCArvedilol Post-infaRct survIvalCOntRol in LV dysfunctioN
NOT AN APPROVED INDICATION FOR COREG
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Inclusion Criteria
• Confirmed acute myocardial infarction within3–21 days (mean, 10 d)
• LV ejection fraction 40%
• All appropriate treatments for MI including aspirin, thrombolysis, and percutaneous interventions
• Receiving an ACE inhibitor for 48 hours
• Patients were usually hospitalized, but may have been recently discharged
The CAPRICORN Investigators, Lancet 2001 NOT AN APPROVED INDICATION FOR COREG
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Study Plan
Normally 3Normally 3––5 days but 5 days but up to 21 days postup to 21 days post--MIMI
Optimum therapyOptimum therapyat investigator’sat investigator’s
discretiondiscretion
Carvedilol (n=975)
Placebo (n=984)
UptitrationUptitration DowntitrationDowntitration
Initiation with 6.25 mg or 3.125 mg bidInitiation with 6.25 mg or 3.125 mg bidUptitrationUptitration to maximum tolerated dosageto maximum tolerated dosageover 2over 2––4 weeks. Target, 25 mg bid 4 weeks. Target, 25 mg bid
(N=1959)(N=1959)
MaintenanceMaintenance
Time to 633 events Time to 633 events
Mean follow up: 1.3 yearsMean follow up: 1.3 years
The CAPRICORN Investigators, Lancet 2001 NOT AN APPROVED INDICATION FOR COREG
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0.7
0.75
0.8
0.85
0.9
0.95
1
0 0.5 1 1.5 2 2.5
Carvedilol
Placebo
All-Cause Mortality
Years
Pro
port
ion
Eve
nt F
ree
The CAPRICORN Investigators, Lancet 2001 NOT AN APPROVED INDICATION FOR COREG
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All-Cause Mortalityor Recurrent MI
Carvedilol
Placebo
Years
0.7
Pro
port
ion
Eve
nt F
ree
0.8
0.9
1
0 0.5 1 1.5 2 2.5
The CAPRICORN Investigators, Lancet 2001 NOT AN APPROVED INDICATION FOR COREG
© Continuing Medical Implementation …...bridging the care gap
CAPRICORN: Summary
• In patients with LV dysfunction following an acute MI, carvedilol treatment was associated with– 23% lower risk of all-cause mortality– 8% lower risk of mortality or CV hospitalizations– 26% lower risk of sudden death– 14% lower risk of HF hospitalization– 41% lower risk of nonfatal myocardial infarction– 29% lower risk of mortality plus MI
• Carvedilol was well tolerated, and target doses for treatment were reached in the majority of patients
The CAPRICORN Investigators, Lancet 2001 NOT AN APPROVED INDICATION FOR COREG
SELECTED RANDOMIZED TRIALS OFACE INHIBITOR THERAPY ADMINISTERED DURING AND AFTER AMI
SELECTED RANDOMIZED TRIALS OFACE INHIBITOR THERAPY ADMINISTERED DURING AND AFTER AMITrial Agent # Patients Duration RRR of
DeathP Value
During MI & 4-6 weeks after
ISIS – 4 Captopril 58050 35 days 0.93 0.02
GIZZI – 3 Lisinopril 19394 42 days 0.88 0.03
Consensus II Enalaprilat 6090 41-180 days
1.11 0.26
Post MI LV Dysfunction
SAVE Captopril 2231 42 mo. 0.81 0.02
AIRE Ramipril 2006 15 mo. 0.73 0.002
TRACE Trandola-
pril
1749 24-50 mo. 0.78 < 0.001
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Document
ACC/AHA GuidelinesACC/AHA GuidelinesACUTE MI GUIDELINES 11/96
ACE Inhibitors in Acute MI •Class I
• In 1st 24 hrs if anterior ST MI or clinical CHF • Early or late post MI if EF <40% or clinical CHF
•Class IIa• All other patients in 1st 24hrs
• Asymptomatic patients with mild EF(40-50%)
•Class IIb Ptswith normal or mildly reduced EF
Dose: Captopril 6.25mg, 12.5 2h later, 25mg 10-12h later, then 50bidStop at ~ 6 weeks if no LV dysfunction (asymptomatic or symptomatic)
Heart Outcomes Prevention Evaluation Study
A large, simple, randomized trial of Ramipril and vitamin E in patients at high risk for cardiovascular events
Nov. 20, 1999
Final
Key Inclusion/Exclusion Criteria
Inclusion CriteriaPatients (age 55) at high risk for cardiovascular
events because of:• any evidence of vascular disease (CHD, stroke, PVD)
• diabetes + one other coronary risk factor
Exclusion CriteriaHeart failure or low EF
On ACE-I or Vitamin E
Nov. 20, 1999
Final
Primary Adjudicated Events -Ramipril vs Placebo 1/2
Ramipril(%)
Plac(%)
RR 95% CI pNo. Rand. 4645 46521 Outcome
MI,Stroke,CVDth 14.1 17.7 0.78 0.70-0.86 0.000002CV Death* 6.1 8.1 0.75 0.64-0.87 0.0002MI* 9.9 12.2 0.80 0.71-0.91 0.0005Stroke* 3.4 4.9 0.69 0.56-0.84 0.0003
Non-CV Death 4.3 4.1 1.03 0.84-1.25 0.78Mortality 10.4 12.2 0.84 0.75-0.95 0.0058
*not mutually exclusive
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N o v . 2 0 , 1 9 9 9
F in a l
0
0.05
0.1
0.15
0.2
0 500 1000 1500
Days of Follow-up
Kapl
an-M
eier R
ates
Ramipril Placebo
© Continuing Medical Implementation …...bridging the care gap Nov. 20, 1999
Final
Prespecified Subgroups -Ramipril vs Placebo
0.6 0.8 1.0 1.2RR (95% CI)
CVD+
CVD-
Diabetes+
Diabetes-
No. Of Pts.
8160
1137
3578
5719
Placebo Rate
18.7
10.1
19.8
16.5
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Final
Other Subgroups of Prior Stated Interest: Ramipril vs Placebo (1/2)
0.6 0.8 1.0 1.2
RR (95% CI)
Age<65Age 65+
MaleFemale
Hypertension+Hypertension-
CAD+CAD-
No. Of Pts.41695128
68172480
43554942
74751822
PlaceboRate14.120.7
18.714.8
19.416.3
18.514.2
© Continuing Medical Implementation …...bridging the care gap Nov. 20, 1999
Final
Ramipril vs Placebo Patients with Documented normal EF
[N= 4759; mean 0.59 (SD 0.11)]
Ramipril(%)
Placebo(%)
RR 95% CI P
N 2387 2372PrimaryOutcome
14.0 18.9 0.73 (0.63-0.84) 0.00001
CV death 5.2 7.5 0.68 (0.54-0.86) 0.0009
MI 10.7 14.1 0.75 (0.64-0.88) 0.0005
Stroke 2.9 4.3 0.67 (0.50-0.91) 0.0104
All HF 8.3 10.5 0.78 (0.65-0.94) 0.0082
Revasc. 19.9 24.0 0.80 (0.71-0.91) 0.0004
© Continuing Medical Implementation …...bridging the care gap Nov. 20, 1999
Final
Conclusions: Ramipril vs Placebo
There is overwhelming evidence that Ramipril prevents:– CV death, strokes and MI– Heart Failure, Revascularization– Development of diabetes– Diabetic microvascular complications and
NephropathyThese benefits are consistently observed in a very
broad range of high risk patients and in addition to other effective therapies
The only adverse event is a 5% excess of cough
© Continuing Medical Implementation …...bridging the care gap
Major Statin TrialsMajor Statin Trials
Trial Statin Cholesterol at baseline
Total MI or CV Death
Secondary Prevention Control %
ARR NNT
4S Simva 6.7 21.5 8.0 13
LIPID Prava 5.6 17.2 3.9 26
CARE Prava 5.4 13.7 2.7 37
Primary PreventionWOSCOPS Prava 7.0 8.4 2.6 38AFCAPS Lova 5.7 3.6 1.4 71
© Continuing Medical Implementation …...bridging the care gap
ACUTE MI GUIDELINES 11/96
Drug Rx Peri MI: Meta-Analyses
Beta blocker during MI
Beta blocker post MI
ACEI during MI
ACEI post MI if LV dysfxn
Nitrates during MI
Ca++ blockers
Magnesium
Lidocaine
Class I Antiarrhythmics
Number RR Death p value
28,970
24,298
100,963
5,986
81,908
20,342
61,860
9,155
6,300
.87 (.77-.98)
.77 (.70-.84)
.94 (.89-.98)
.78 (.70-.86)
.94 (.90-.99)
1.04 (.95-1.14)
1.02 (.96-1.08)
1.38 (.98-1.95)
1.21 (1.01-1.44)
0.02
<0.001
0.006
<0.001
0.03
0.41
>0.05
>0.05
0.04
NEJM 335:1662, 1996
© Continuing Medical Implementation …...bridging the care gap
Cardiac Rehabilitation ProgramsCardiac Rehabilitation Programs
• Definition– “the enhancement and maintenance of cardiovascular
health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status”.1
• May include multifactorial secondary prevention– defined as “the sum total of all interventions, both
physiological and behavioral, designed to favorably modify an individual’s lifestyle, and enhance adherence and compliance with long-term behaviors compatible with minimizing disease progression”.1
© Continuing Medical Implementation …...bridging the care gap
BenefitsBenefits
• 20% reduction in mortality after a three-year follow-up.16
• Improvement in exercise tolerance, blood lipid levels, and psychosocial well-being.2
• A significantly lower incidence of re-hospitalization and visits to the emergency department at three and 12 months compared with controls.29
© Continuing Medical Implementation …...bridging the care gap
NeedsNeeds
• Only 10-20% of appropriate patients in US currently participate in formal Rehab
• Secondary prevention population 1999 in Ontario
A. Post event (3o prevention)-95,699
B. Pre-event- 332,362
• High risk primary prevention population 2,140,529
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System requirementsSystem requirements
• Assuming – 40% participation from secondary prevention
A) group– 20% participation from secondary prevention
B) group
• Systematic capacity required June 2002 100,000
© Continuing Medical Implementation …...bridging the care gap
CCN Network ModelCCN Network Model
• Coordinating sites– Regional hub in population areas of > 500,000
• In-patient sites– All hospitals with in-patient cardiac services
• Out-patient sites– Hospital or community based provider– Phase 2&3 care
• Maintenance sites– Hospital or community based provider– Phase 4 care
© Continuing Medical Implementation …...bridging the care gap
Guide for Comprehensive Cardiovascular Risk Reduction
Guide for Comprehensive Cardiovascular Risk Reduction
Patients with Coronary and Other Vascular Disease Patient: _______________________________ Diagnosis: _____________________________ Rx () Risk
Intervention Recommendations
Smoking: Goal-Complete cessation
Strongly encourage patient and family to stop smoking. Provide counselling, nicotine replacement, and formal cessation programs as appropriate.
Lipid Management:
Start hypolipidemic diet in all patients: 30% fat,7%saturated fat, 200mg/day cholesterol. 10 % LDL achievable with diet. Consider drug Rx in all patients* with LDL 2.8 mmol/L Assess fasting lipid profile. In post -MI patients, lipid profile may take 4 to 6 weeks to stabilize. Baseline lipid profile < 24 after acute event. Add drug therapy according to the following guide:
LIPID Profile
1st Line Therapy 2nd Line Therapy
LDL Statin Resin
LDL & TG Statin Niacin or Fibrate
LDL & TG Fibrate or Niacin Combination Therapy
TG & HDL Fibrate or Niacin Combination Therapy
Primary goal * LDL 2.5 mmol/l
Secondary goal *
HDL 1.2 mmol/l(men)/ 1.1mmol/l (women)
TG 2.0 mmol/l
Canadian Working Group on Hypercholesterolemia and other Dyslipidemias
* Primary goal: For patients with any of CAD, TIA, CVA, PVD/bruits, DM (Age 30) or for patients with very high 10 year risk of CV event ( 30% or 4 risk factors). Target initial therapy with the medication dose required to achieve target LDL 2.5 mmol/l. For 3 risk factors (10 yr CV risk 20-30%) LDL target is 3.0 mmol/l. For 2 risk factors (10 yr CV risk
10-20%) LDL target is 4.0 mmol/l. For 1 risk factor (10 yr CV risk 10%) LDL target is 5.0 mmol/l. Initiate lipid lowering early in high-risk patients (in conjunction with dietary modification). For specific medications and dosing strategy see Lipid Optimization Tool
Blood pressure control: Goal
135/85 mm Hg
2001 CHS www.chs.md
Guidelines revised Jan 2002
Initiate lifestyle modification in all patients with blood pressure 140 systolic or 90 diastolic. Add Rx individualized to patient requirements and characteristics (i.e., age, race, need for drugs with
specific benefits) if BP is not less than 140 systolic or 90 diastolic in three visitswithout target organ (TOD) damage or 5 visits with no TOD. Initiate Rx immediately if BP > 180/105.
No age distinction in initial therapy ( avoid -blocker or -blocker as initial Rx HTN 60yr) Initial Rx: LDD(low dose diuretic)/-blocker/ACE-I/ long-acting DHP-CCB( - blocker not 1st line) Isolated systolic HTN: LDD/long-acting DHP-CCB Type 2 diabetes with micro-albuminuria, proteinuria or nephropathy ARBs alternate1st line Rx
Diabetes
1998 CDA
www.diabetes.ca
Initiate diet, weight loss, education. Consider drug therapy for FBS 7.0 mmol/L Aggressive BP control. Target130/80 (125/75 if micro-albuminuria: 30-300 mg/day; macro-albuminuria 300mg/day or albumin/creatinine ratio > 2 mg/mmol-male or 2.8 mg/mmol-female)
Physical activity: Minimum goal
30 minutes 3 to 4 times/week HR guided
Assess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30-40 minutes of moderate intensity activity 3 or 4 times weekly
(walking, jogging, cycling or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, using stairs, gardening, household work)
Maximum benefit 5 to 6 hours per week. Advise medically supervised programs for moderate to high-risk patients.
Obesity/weight management:
Ideal body weight
Start intensive diet and appropriate physical activity intervention, as outlined above, in patients 120% of ideal weight for height. Particularly emphasise need for weight loss in patients with hypertension, elevated triglycerides or elevated glucose levels.
Antiplatelet agents/ anticoagulants:
Start aspirin 80-325 mg per day if not contraindicated. Consider clopidogrel 75mg OD post MI, post CABG, CVA, PVD in ASA intolerant or allergic patients (CAPRIE Trial). Consider clopidogrel 75mg OD + ASA for ACS: unstable angina/non-ST elevation MI (CURE Trial: duration of therapy 9-12 months) Consider warfarin for post MI patients not able to take aspirin (maintain INR 2-3).
ACE inhibitors Post-MI/LV Dysfunction:
Start early post-MI in stable high risk patients (anterior MI, previous MI, Killip class II (S3 gallop, rales, radiographic CHF). Continue indefinitely for all with LV dysfunction (EF40%) or symptoms of CHF. Use as needed to manage HPT or symptoms in all other patients.
ACE inhibitors Vascular disease
Consider ACE inhibitors in all patients 55 yrs with evidence of vascular disease or diabetes and one other risk factor: HOPE Trial-Ramipril 2.5 to 10 mg OD
Beta-blockers: Post-MI
Start acutely or within a few days of event in all post-MI patients (unless contra-indication). Continue indefinitely if residual ischemia, heart failure LV dysfunction or severe co-morbidity. Continue indefinitely in low risk patients (IIa). Rx as needed to manage angina, arrhythmia or HPT.
Beta-blockers: CHF
Rx Add Beta-blocker to ACE-inhibitor/diuretic/+/- digoxin in stable Class II-IV CHF/LVEF 40% Bisoprolol 1.25 10 mg OD, carvedilol 3.125 mg BID 25 mg BID (50 mg BID if weight > 85 kg) or metoprolol 12.5 mg 75-100 mg BID
Homocyst(e)ine Check in patients with premature CAD/CVD/PVD; Family history premature atherosclerosis or manifest atherosclerosis & no identifiable risk factors. Rx Folic acid 2.5 mg, B6 25 mg, B12 250 mcg for homocyst(e)ine level 10 mmol/L
Estrogens: HRT not recommended for 10 prevention. Use established preventative strategies. Consider HRT or SERMS for non-cardiac indications. Individualize recommendations consistent with other health risks (VTE, endometrial or breast CA). HRT not indicated in 20 prevention. D/C HRT in ACS, MI, PTCA,CABG,CHF,Sx.
© Continuing Medical Implementation …...bridging the care gap
We can’t do it aloneWe can’t do it alone
© Continuing Medical Implementation …...bridging the care gap
ConclusionsConclusions
• Multidisciplinary intervention indicated in all post MI patients
• Patient education is key to empowerment and motivation
• Diet, lifestyle,exercise form core component of 2o prevention strategy
• In hospital timeframes limits educational opportunity
© Continuing Medical Implementation …...bridging the care gap
ConclusionsConclusions
• Optimization of 2o prevention pharmacotherapy provides opportunity to recapture lost morbidity and mortality benefit
• Long term follow-up is necessary to ensure compliance
• Cardiac rehabilitation (formal or informal) creates the framework for optimal prevention
• Resources are currently inadequate to meet the demonstrated need
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