Practical Strategies to Reduce Cardiovascular Risk in Family Practice

1
Practical Strategies to Reduce Cardiovascular
Risk in Family Practice
Developed by the Office of Family Health
Education Research at the University of Alabama
School of Medicine-Huntsville Regional Medical
Campus, Huntsville, AL. This lecture series is
funded by an unrestricted educational grant from
Wyeth Pharmaceuticals.
2
Learning Objectives

• Understand the evidence-based care guidelines for
  Hypertension, Dyslipidemia, Diabetes, and CVD
  prevention
• Understand the importance of ACE-I, Statins, and
  Aspirin in CVD prevention
• Learn clinical pearls for implementing
  therapeutic regimens in CVD risk reduction

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The Average Joe or Jane (A. J.)
55 yr old f/u visit Asymptomatic Non-smoker Father
had MI at 54 yr age BP 155/80 (previous visit
BP 146/86) Ht 510 Wt 210 Waist
Circumference 42 Chol - 228 U/A - no
protein Trig - 240 Glucose - 108 HDL -
38 LDL - 134
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Does A. J. have CVD Risk ?
55 yr oldf/u visit Asymptomatic Non-smoker Father
had MI at 54 yr age BP 155/80 (previous visit
BP 146/86) Ht 5 10 Wt 210 Waist Circ
42 T Chol - 228 Urinalysis - no protein Trig
- 240 Glucose - 108 mg/dL HDL - 38 LDL - 134
BMI 29
5
Risk Factors for CVD
Dyslipidemia
Obesity
Hypertension
Male
Metabolic Syndrome
CVD
Age
Diabetes
Family History
PhysicalInactivity
Smoking
AtherogenicDiet
Page 3
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
6
Does A. J. have High Blood Pressure ?
Hypertension ?
155/80
7
JNC 7 Definitions
Page 4
From JNC-7.
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Reassessment of Normal Blood Pressure
Evidence
Framingham Heart Disease Study
gt130/85
CVD
gt120/80
Optimal BP
lt120/80
Vasan RS. N Engl J Med. 2001345(18)1291-7
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HOT TRIAL
Lower is Better
Diastolic BP
Systolic BP
CV event RR
CV event RR
Evidence
Adapted from Hansson L et al. Lancet.
19983511755-1762.
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Importance of Systolic Blood Pressure
Evidence
gt130/85
gt120/80
SBP gt 160
MRFITT Arch Int Med, 1992
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Take-Home Lessons from JNC 7

• Optimal BP is 120/80
• CVD risk doubles for every 20/10 increase over
  115/75
• Systolic BP more important than Diastolic BP in
  predicting risk after age 50
• Most patients require 2 or more
  anti-hypertensive drugs to achieve BP goal
• Home BP readings are valid
• Reestablishes the need for aggressive BP
  screening and treatment

Page 4
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Does A. J. have a Lipid Problem ?
A. J. Age 55 Father () MI BP 155/80 510 Wt
210 Waist 42 TC 228 TG 240 LDL 134 HDL 38 Glu
108 U/A (-)
YES

• Is the TC gt 200 ?
• Are the TG gt 200 ?
• Is the HDL lt 40 ?

YES
YES

• Is the LDL at goal ?

LDL Goal is based on CV Risk
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How is CV Risk Expressed ?
Review

• CV Risk
• is the chance of having a
• CV event (MI, Stroke, Cardiac death, or
• progression of CVD) within 10 years
• High Risk 10-year CV risk gt 20
• Moderate Risk 10-year CV risk gt 10
• Low Risk 10-year CV risk lt 10

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Patients with High CV Risk (gt20)
Practice Pearl

• CAD
• TIA, Stroke
• PVD, AAA
• Carotid Artery Disease
• Renal Artery Disease
• Diabetes

LDL goal lt 100 mg/dl
Page 5
15
Patients with2 Risk Factors gt20 CV Risk
Page 5
Also Coronary Equivalent
LDL goal lt 100 mg/dl
Practice Pearl
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CVD Risk Calculator
TC (age 40-49 y) lt160 0/0 160-199
3/3 200-239 5/6 240-279 6/8 ?280 8/10
TC (age 50-59 y) lt160 0/0 160-199
2/2 200-239 3/4 240-279 4/5 ?280 5/7
SMOKER (age 20-39 y) No 0/0 Yes
8/9 (age 40-49 y) No 0/0 Yes 5/7
(age 50-59 y) No 0/0 Yes 3/4
AGE 20-34 -9/-7 35-39 -4/-3 40-44
0/0 45-49 3/3 50-54 6/6 55-59 8/8 60-64
10/10 65-69 11/12 70-74 12/14 75-79 13/16

SBP Treatment No Yes lt120 0/0
0/0 120-129 0/1 1/3 130-139 1/2
2/4 140-159 1/3 2/5 ?160 2/4
3/6
HDL ?60 -1/-1 50-59 0/0 40-49 1/1
lt40 2/2

Total points lt0 0 1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 ?17 18 19 20 21
22 23 24 ?25 10-y CHD risk () lt1 1 1
1 1 1 2 2 3 4 5 6 8 10 12
16 20 25 ?30 lt1 1
1 1 1 2 2 3 4 5 6 8
11 14 17 22 27 ?30
Men Women
CHD MI or coronary death
See Quick Reference guide
Adapted from NCEP ATP III JAMA.
20012852486-2497 (Framingham Point Scores).
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LDL
NCEP-ATP III Primary Goals
10-year CAD Risk
0
10
20
0-1 RF
160
Low Risk
A.J.
134
CADDiabetes Atherosclerotic disease
or gt 2 Risk Factors
LDL
130
Moderate Risk
16
? 2 RFs
100
High Risk
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
18
NCEP-ATP III
LDL
"Therapeutic Option"
News Flash
10-year CAD Risk
10
20
0
0-1 RF
160
Low Risk
CADDiabetes Atherosclerotic Disease or
gt 2 Risk Factors
130
LDL
Moderate Moderate High
? 2 RFs
16
100
Very High Risk
High Risk
70
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
19
Very High Risk
NCEP ATP III
CVD
Page 5

• Multiple Major Risk Factors (e.g., DM)
• Severe Poorly Controlled Risk Factors
• (e.g., Continued Smoking)
• Metabolic Syndrome
• (especially Triglycerides gt 200 and
• Non-HDL gt 130 and HDL lt 40)
• Acute Coronary Syndromes

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Does A. J. have a Non-HDL Problem ?
A. J. Age 55 Father () MI BP 155/80 510 Wt
210 Waist 42 TC 228 TG 240 LDL 134 HDL 38 Glu
108 U/A (-)
YES

• Is the TC gt 200 ?
• Are the TG gt 200 ?
• Is the HDL lt 40 ?
• Is the LDL at goal ?

YES
YES
NO

• Is the Non-HDL at goal ?
• Is the Triglyceride at goal ?

Page 6
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Why worry about Triglycerides ?
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TG ?123 mg/dL TG ?123 mg/dL
4
Mean annual CHD mortality rate/1,000
2
0
Evidence
?220
gt220
?220
gt220
Cholesterol (mg/dL)
Fasting TG and Risk for CHD Death Paris
Prospective Study Adapted from Fontbonne A et al.
Diabetologia. 198932300-304.
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What is Non-HDL ?
Practice Pearls
Non-HDL TC - HDL
When should Non-HDL be considered ?
Patients with TG ? 200
Page 6
What is the Non-HDL goal ?
Non-HDL goal LDL goal 30
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
23
Non-HDL
NCEP-ATP III Primary Goals
10-year CAD Risk
0
10
20
0-1 RF
A.J.
190
Low Risk
CADDiabetes Atherosclerotic disease or gt
2 RFs
Non-HDL
160
Moderate Moderate high
? 2 RFs
130-
High Risk
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA. 20012852486.
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Is Glucose a Risk Factor for A. J.?
A. J. Age 55 Father MI BP 155/80 510 Wt
210 Waist 42 BMI 29 TC 228 TG 240 LDL 134 HDL
38 Glu 108 U/A (-)

• Age gt 45Test for DM
• Especially if BMI gt 25
• If normal, repeat at 3-yr intervals
• Age lt 45Test for DM
• If BMI gt 25
• and
• one additional risk factor

Practice Pearl
Page 7
2004 ADA recommendation
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Diabetes Screening
Practice Pearl

• Fasting Glucose is the most
• efficient screening test for
• DM (NOT Hgb A1c)

• Test everyone over age 45

• Fasting glucose gt 126 (on 2 occasions)
  or
• Casual glucose gt 200 (with symptoms)

Page 7
2004 ADA recommendation
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Does A. J. have Metabolic Syndrome ?
A. J. Age 55 Father MI BP 155/80 510 Wt
210 Waist 42 TC 228 TG 240 LDL 134 HDL 38 Glu
108 U/A (-)
3 or more of the following

• Waist circumference
• gt 40 (males)
• gt 35 (females)
• Triglycerides gt 150
• Low HDL
• lt 40 (male)
• lt 50 (females)
• BP 130/85
• Fasting glucose 110 / NEW gt 100

Page 8
Update
From ATP III
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Waist Circumference gt 40 is a Risk Factor for CV
Disease
Practice Pearl
Put a cartoon here
From http//a.abcnews.com/media/WNT/images/abc_wnt
_heartrisk_021203_nh.jpg
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Women with Metabolic Syndrome

• Evaluate for Polycystic Ovarian Disease

Practice Pearl
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Why is Metabolic Syndrome so Important ?
Because of

• Atherogenesis People with Metabolic
• Syndrome form plaque faster and at a
• younger age
• Thrombogenesis People with Metabolic
• Syndrome are at higher risk of thrombus
• formation
• Inflammation People with Metabolic
• Syndrome are predisposed to plaque
• rupture

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The Basis of Metabolic Syndrome is Insulin
Resistance
Insulin Resistance
Hyperinsulinemia
Impairedglucosetolerance
HypertriglyceridemiaDecreased HDL
Essentialhypertension
Clinical Diabetes
Accelerated Atherosclerosis
Page 8
?
MI Stroke
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Scott CL. Diagnosis, prevention, and intervention
for the metabolic syndrome. July 3, 200392(2
suppl)35i-42i.
American Journal of Cardiology

• Recommended
• Treatment Goals
• Blood pressure 125/75
• LDL lt100
• Triglyceride lt150
• HDL Men gt40    Women gt50

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What Additional Tests are Indicated for A. J. ?
Billable Codes 401.1 Hypertension

• Microalbumin
• BUN, Creatinine
• EKG (for LVH )

• TSH
• LFT

272.4 Hyperlipidemia
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Microalbumin A Predictor of Outcome
Evidence
RR CVD
Hillege HL. et al. Circulation 2000 102 (suppl)
II-657.
34
Management of CV Risk
STOP

• Therapeutic Lifestyle
• Changes (TLC)
• Pharmacological

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Management of CV Risk Considers TLC First
Patient Education
Page 12
Smoking Cessation
Weight Loss
Exercise
Diet
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Effect of Lifestyle Changes on Blood Pressure
Pre-Hypertension Tx.
SBP Reduction
Modification
Weight reduction
520 mmHg / 22 lb weight loss
Adopt DASH eating plan
814 mmHg
Dietary sodium reduction
28 mmHg
Physical activity
49 mmHg
Moderation of alcohol consumption
24 mmHg
Page 10
From JNC-VII
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Pharmacologic Management
38
JNC 7 Classification/Management of BP
Page 11
NHLBI. Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7) .
39
What are the Compelling Indications ?
ACE-I are the only agents that address all
co-morbidities in JNC-VII
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ACE-I and CV Risk Prevention

• ACE Inhibitors prevent CV Disease
• ACE Inhibitors alter the course of
• disease when appropriately
• prescribed

AAFP Annual Clinical Focus 2003
41
EUROPA Primary Outcome
CV Death, MI, Cardiac Arrest
Placebo
Evidence
Perindopril
n 12 218
Placebo annual event rate 2.4
Fox K, et al. Lancet. 2003362782-788.
42
HOPE/HOPE-TOO Primary Outcome
0.30
MI, Stroke, CV Death
?HOPE Study Ends
0.25
22 event reduction (p lt0.001)
0.20
Ramipril


Hazard
0.15
0.10
ALL RR 0.81, CI (0.74-0.88)
Evidence
CONT RR 0.83, CI (0.75-0.91)
0.05
15 reduction in 1 yr
0.0
Years
1
2
3
4
5
6
7
1
2
3
4
5
6
7


Bosch J. European Society of Cardiology Congress
2003. Aug 30Sep 3, 2003. Vienna, Austria.
43
HOPE/HOPE-TOO New Onset DM
New Diabetes
?HOPE Study Ends
0.12
0.10
34 reduction (plt 0.001)
0.08

Hazard
0.06
0.04
Evidence
ALL RR 0.69, CI (0.57-0.83)
CONT RR 0.70, CI (0.57-0.86)
0.02
0.0
Years
1
2
3
4
5
6
7

Bosch J. European Society of Cardiology Congress
2003. Aug 30Sep 3, 2003. Vienna, Austria.
44
ACC/AHA Guidelines for Management of Chronic
Stable Angina

• ACEIs in all patients with CAD who also have
  diabetes and/or left ventricular systolic
  dysfunction (Level A Evidence)
• ACEIs in patients with CAD or other vascular
  disease (Level B Evidence)

Page 14
Gibbons RJ, et al. Circulation. 2003107149-158.
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ACE-I and Clinical Trials
CHF/ LVD
CVA/ PVD
MI/ CAD
DM/ HTN
Post- revasc
Prevent MI, CVA, CV Death
Page 14
Reduction in nonfatal CV events Reduction
in morbidity and mortality
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AHA/ACC Guidelines for Primary Prevention of
Ischemic Stroke
Control of hypertension in diabetics and
treatment of high-risk patients with the ACE
inhibitor, ramipril, prevents stroke.
Page 9
Goldstein LB, et al. Stroke. 200132280-299.
47
HOPE Primary Outcome
Reduction of Multiple CVD Components with Ramipril
CVDeath
All-Cause Mortality
Nonfatal MI
Composite
Stroke
0
-5
-10
-15
Relative Risk Reduction
16 P0.005
-20
22 Plt0.001
20 Plt0.001
-25
26 Plt0.001
-30
Evidence
-35
32 Plt0.001
Avg. BP decrease 3/2 mm Hg
The HOPE Study Investigators. N Engl J Med.
2000342145-153.
48
New 2004 ADA Guidelines

• Initial drug therapy for those with a BP gt140/90
  mm Hg should be with a drug class demonstrated to
  reduce CVD events in patients with diabetes
  (ACE-Is, ARBs, BBs, diuretics, and CCBs. (A)
• All patients with diabetes hypertension should
  be treated with a regimen that includes either an
  ACE or ARB. (E)
• In patients gt55 years of age, with or without
  hypertension but with another CV risk factor an
  ACE-I should be considered to reduce the risk of
  CV events. (A)

Page 9
if not contraindicted American Diabetes
Association. Diabetes Care. 200426(suppl
1)S33-S50.
49
ACE-I and Clinical Trials
CHF/ LVD
CVA/ PVD
MI/ CAD
DM/ HTN
Post- revasc
Prevent MI, CVA, CV Death
Page 14
Reduction in nonfatal CV events Reduction
in morbidity and mortality
50
ATP III Management of Lipid Disorders
Updated

• Treat LDL to goal, if not possible (at least
  30-40 LDL reduction)
• Monitor Non-HDL cholesterol
• If TG gt200 and Non-HDL not at goal consider
  adding Fibrates or Niacin
• Treat Non-HDL and Triglycerides to goal

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LDL Lowering With Statins
Lower is Better
30
4S
25
4S
20
LIPID
LIPID
Event Rate ()
15
CARE
HPS
CARE
10
HPS
WOSCOPS
AFCAPS
5
WOSCOPS
AFCAPS
0
Evidence
80
90
100
110
120
130
140
150
160
170
180
190
200
LDL-C Achieved (mg/dL)
Adapted from Ballantyne CM. Am J Cardiol.
1998823Q-12Q.
52
Even Lower LDL is Better
NCEP ATP III Update There is no threshold
effect
Evidence
Grudy, S, et al. Circulation. 2004110227-239
53
Statins and LDL Lowering
Page 13
Grudy, S, et al. Circulation. 2004110227-239
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Dont Forget Aspirin
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What have we learned ?

• Current Definitions of Hypertension, Diabetes,
  and Dyslipidemia
• Importance of recognizing Metabolic Syndrome
• The need for aggressive treatment of
  Hypertension, Dyslipidemia and Diabetes
• ACE-I are the only agents that address all
  co-morbidities in JNC-7
• Dont forget Aspirin!

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Questions
?