Management of Hyperlipidemia and Hypertension

1
Management of Hyperlipidemia and Hypertension

• Carol H. Wysham, MD
• Rockwood Clinic, PS
• Spokane, Washington
• Assistant Clinical Professor of Medicine
• University of Washington

2
Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
Self-Management Support
ClinicalInformationSystems
DeliverySystem Design
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
3
Major Clinical Complications of Hypertension and
Hyperlipidemia
Ischemic stroke
Vascular Dementia
Myocardial infarction
Congestive Heart Failure
Chronic Kidney Disease

• Peripheral arterial
• disease

Adapted from Drouet L. Cerebrovasc Dis 2002
13(suppl 1) 16.
4
Leading Causes of Death for All Males and Females
(US 2000)
5
Traditional CVD risk factors

• Family history
• Older age
• Male gender
• Smoking
• Physical inactivity
• Overweight/obesity
• Total-C/LDL-C/HDL-C/TG
• BP
• Glucose

Adapted from Stampfer MJ et al. Circulation.
2004109(suppl)IV3-IV5.
6
Mechanisms Contributing to the Development of
Vascular Disease
Oxidative Stress
Endothelial Dysfunction andSmooth Muscle
Activation
?NO ? D Local Mediators ? ?Tissue ACE, AII
PAI-1, PlateletAggregation, Tissue Factor
EndothelinCatecholamines
VCAM/ICAMCytokines
ProteolysisInflammation
Growth Factors,Cytokines, Matrix
Vasoconstriction
Thrombosis
Inflammation
Plaque Rupture
Vascular Lesionand Remodeling
Clinical Sequelae
Adapted from Dzau VJ. Hypertension.
20013710471052.
7
Selected emerging biomarkers
Lipids Lp(a) apoA/apoB Particle size/density
Inflammation CRP SAA IL-6 IL-18
TNF Adhesion mols Lp-PLA2 CD40L CSF
Hemostasis/Thrombosis Homocysteine tPA/PAI-1
TAFI Fibrinogen D-dimer
CSF colony stimulating factor
MPO myeloperoxidase
Adapted from Stampfer MJ et al. Circulation.
2004109(suppl)IV3-IV5.
TAFI thrombin activatable fibrinolysis inhibitor
8
CRP Lipids Additive CV Risk

• CRP and CV Risk
• Strong epidemiologic association with risk
• Predicts CV risk even in those without classic
  risk factors
• Intervention Trials
• High CRP predicts higher risk
• Lowering of CRP (in statin trials) associated
  with signficantly greater risk reduction

Ridker PM, Circulation 103 1813, 2001 Ridker PM.
N Engl J Med 200535220-8.
9
Traditional CVD risk factors

• Family history
• Older age
• Male gender
• Smoking
• Physical inactivity
• Overweight/obesity
• Total-C/LDL-C/HDL-C/TG
• BP
• Glucose

Adapted from Stampfer MJ et al. Circulation.
2004109(suppl)IV3-IV5.
10
Hyperlipidemia
11
Atherogenic Particles
VLDL
Chylomicron
Chylomicron
0.95
VLDL
VLDL
VLDL Remnants
IDL
1.006
Chylomicron Remnants
Density,g/mL
1.02
LDL
1.06
HDL2
Lp(a)
1.10
HDL3
1.20
5
10
20
40
60
80
1000
Diameter, nm
Reprinted from Segrest JP et al. The amphipathic
alpha helix a multifunctional structural motif
in plasma apolipoproteins. Adv Protein Chem.
199445303369, with permission from Elsevier
Science.
12
LDL-C Distribution in U.S. Adults Data from
NHANES III, 19881994
without CHD and with ?2 RF
Number of US Adults (millions)
with CHD
LDL-C (mg/dl)
Jacobson TA et al. Arch Intern Med.
2000160(9)1361-9.
13
Epidemiologic Evidence for a Relationship
between LDL-C and CHD Risk
CHDRiskCurvilinearorLog-Linear
100
LDL-C (mg/dL)
14
TNT Extending and confirming benefit of LDL-C
lowering beyond current guidelines
30
4S
Statin
Placebo
25
20
Event()
15
LIPID
LIPID
CARE
CARE
10
HPS
HPS
TNT (10 mg atorvastatin)
5
TNT (80 mg atorvastatin)
0
210
190
170
150
130
110
90
70
0
LDL-C (mg/dL)
Ave 30 reduction in risk
LaRosa JC et al. N Engl J Med. 20053521425-35.
15
Evidence for a Log-Linear Relationship between
LDL-C and CHD Risk (2001)
Epidemiology
CHDRiskCurvilinearorLog-Linear
Clinical Trials
100
LDL-C (mg/dL)
16
HPS Vascular events by baseline LDL-C levels
(N20,536)
Placebo (n10,267)
Statin (n10,269)
Baseline LDL-C (mg/dL)
Statin better
Placebo better
358 (21.0)
282 (16.4)
lt100 (n 3421)
871 (24.7)
668 (18.9)
100 lt130
1356 (26.9)
1083 (21.6)
?130
2585 (25.2)
2033 (19.8)
All patients
24 reduction 2P lt 0.00001
Rate ratio
HPS Collaborative Group. www.hpsinfo.org
17
PROVE IT-TIMI 22 Primary endpoint and achieved
LDL-C levels
Lower better
Higher better
gt80100 Referent gt6080 0.80 (95 CI,
0.591.07) gt4060 0.67 (95 CI,
0.500.92) 40 0.61 (95 CI, 0.400.91)
Achieved LDL-C (mg/dL)
0
1
2
Adjusted hazard ratio
All-cause mortality, MI, revascularization,
unstable angina, strokeSignificantly lower than
referent
Wiviott SD et al. J Am Coll Cardiol.
2005461411-16.
18
TNT Treatment effects on primary outcome
Treating to New Targets
N 10,001 with stable coronary disease
0.15
Atorvastatin 10 mg (n 5006)
22 Risk reductionHR 0.78 (0.690.89) P lt 0.001
0.10
Major CV events ()
0.05
Atorvastatin 80 mg (n 4995)
0.00
6
5
4
2
1
3
0
Follow-up (years)
CHD death, MI, resuscitation after cardiac
arrest, fatal/nonfatal stroke
LaRosa JC et al. N Engl J Med. 20053521425-35.
19
Updated NCEP ATP III Risk Categories, LDL-C
Goals, Treatment Cutpoints
20
ADA-Recommended LDL-C Goals in Adults With
Diabetes
21
Global Risk Assessment Cumulative point scale
for estimating 10-year CHD risk in men and women
(Framingham point scores)
Systolic Blood Pressure Treatment No Yes
?120 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
Smoker (age 50-59 y) No 0/0 Yes
3/4 (age 60-69 y) No 0/0 Yes 1/2 (age
70-79 y) No 0/0 Yes 1/1
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
HDL-C ?60 -1/-1 50-59 0/0 40-49
1/1 ?40 2/2
TC (age 7079 y) ?160 0/0 160-199
0/1 200-239 0/1 240-279 1/2 ?280 1/2
Total points ?0 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 () ?1 1 1
1 1 1 2 2 3 4 5 6 8 10 12 16
20 25 ?30 ?1 1
1 1 1 2 2 3 4 5 6 8
11 14 17 22 27 ?30
CHD MI or coronary death
Adapted from NCEP ATP III. Circulation.
20021063143-3421.
22
NCEP ATP III Dietary Recommendations
Nutrient Recommended Intake
Saturated fat Polyunsaturated fat Monounsaturated
fat Total fat Carbohydrate Fiber Protein Cholester
ol Total calories
? 7 of total calories Up to 10 of total
calories Up to 20 of total calories 2535 of
total calories 5060 of total calories 2030
g/d 15 of total calories ? 200 mg/d Balance
energy intake and expenditure to maintain
desirable body weight/ prevent weight gain
NCEP ATP III. JAMA. 20012852486-2497.
23
CHD Patients Did Not Achieve LDL-C Goal on Diet
Lipid Measurement
200
-7
-18
177
164
145
150
LDL-C (mg/dL)
Target level
100
50
0
Baseline
NCEP Step II Diet
lt 20 Fat Diet
N 126
Aquilani R et al. Eur Heart J. 1999201020-1029.
24
The Nurses Health Study Moderate-to-Vigorous
Activity Decreases CHD Risk in Diabetic Women
1.2
1.0
0.8
Relative Risk
0.6
0.4
0.2
0.0
lt 1
11.9
23.9
46.9
gt 7
Average Activity/Week (h)
P value for trend .003
Hu FB et al. Ann Intern Med. 200113496-105.
25
Possible Benefits From Other Therapies
Therapy Result

• Soluble fiber in diet (28 g/d) (oat bran,
  fruit, and vegetables)
• Soy protein (2030 g/d)
• Stanol esters (1.54 g/d) (inhibit cholesterol
  absorption)
• Fish oils (39 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

Avoid trans-fats
Jones PJ. Curr Atheroscler Rep.
19991230-235. Lichtenstein AH. Curr Atheroscler
Rep. 19991210-214. Rambjor GS et al. Lipids.
199631S45-S49. Ripsin CM et al. JAMA.
19922673317-3325.
26
Effects of Drug Classes on Serum Lipids
Drug Class TC LDL
HDL TG

Resins ? 20 ? 1020 ? 35
Variable Nicotinic acid ? 25 ? 1015 ?
1535 ? 2050 Fibrates ? 15
Variable ? 615 ? 2050 Statins ?
1560 ? 2060 ? 315 ?
1040 Chol Abs Inh ? 15 ? 18 ? 1
?8
Adapted from Gotto AM Jr. Management of lipid
and lipoprotein disorders. In Gotto AM Jr,
Pownall HJ, eds. Manual of lipid disorders.
Baltimore Williams Wilkins 1992 Rubins HB,
et al. N Engl J Med. 1999341410-418.
27
Therapy of Hyperlipidemia

• Diet and Exercise
• Prudent alcohol intake
• Avoid offending medications
• Medications
• Statins
• Bile Acid Sequestrants
• Cholesterol absorption inhibitor
• Niacin
• Fibrates
• Fish oil
• Thiazolidinediones

LDL-C
Triglycerides/HDL-C
28
Atherogenic Particles
VLDL
Chylomicron
Chylomicron
0.95
VLDL
VLDL
VLDL Remnants
IDL
1.006
Chylomicron Remnants
Density,g/mL
1.02
LDL
Non HDL-C Total Cholesterol HDL-C
1.06
HDL2
Lp(a)
1.10
HDL3
1.20
5
10
20
40
60
80
1000
Diameter, nm
Reprinted from Segrest JP et al. The amphipathic
alpha helix a multifunctional structural motif
in plasma apolipoproteins. Adv Protein Chem.
199445303369, with permission from Elsevier
Science.
29
Targets for Therapy
Option for high risk patient LDL-C lt 70 mg/dl
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
30
Management of Diabetic Dyslipidemia

• Primary target of therapy LDL-C
• Diabetes CHD risk equivalent
• Therefore, goal for persons with diabetes lt100
  mg/dL (lt 70 mg/dl in very high risk patient)
• After LDL-C goal is met, if TG ?200 mg/dL
  nonHDL-C (lt130 mg/dl) becomes secondary target

LDL-C goal
Non HDL-C goal
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
31
Treatment of Hyperlipidemia
High LDL-C
Therapeutic Lifestyle Change
Drug Therapy
1st Line Statin
2nd Line Resin, Ezetimibe or niacin
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
32
The Majority of Statin LDL-C Efficacy is at
Starting Doses
5
15
Mean Change in LDL-C From Untreated Baseline
25
35
45
10 mg
55
20 mg
40 mg
80 mg
Plt0.001 vs atorvastatin 10 mg and simvastatin 20
mg and 40 mg. P0.026 vs atorvastatin 20 mg.
Jones PH et al. Am J Cardiol. 200392152160.
33
Effects of Hypolipidemic Agents (When Added to
Statin Therapy)
HDL
HDL
HDL
TG
LDL
LDL
LDL
TG
Percent Change
TG
Davignon J et al. Am J Cardiol 199473339-345.
34
Issues of Safety and Tolerability of Niacin and
Fibrates

• Niacin
• Chief complaint is flushing, intolerable in 10
  of patients
• Also conjunctivitis, nasal stuffiness, loose
  stools/diarrhea, acanthosis nigricans,
  ichthyosis, hepatitis
• Fibrates
• Abdominal discomfort, possible gallstones
• Myositis with impaired renal function
• Increased risk of rhabdomyolysis with fibrate or
  niacin statin

Knopp RH. N Engl J Med. 1999341498-511 Jones
PH, Davidson MH. Am J Cardiol. 200595120-122
Bellosta S, et al. Circulation. 2004109(23 Suppl
1)III50-57
35
Treatment of Mixed Hyperlipidemia
High LDL-C and TGs
Therapeutic Lifestyle Change
Drug Therapy
Achieve the LDL-C goal
1
STEP
Achieve the non-HDL-C goal Increase LDL-C
lowering or add fibrate, niacin,fish oil or TZD
2
STEP
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
36
Treatment of Hypertriglyceridemia
High TGs (gt400)
Therapeutic Lifestyle Change
Drug Therapy
Start with fibrate
1
STEP
Add niacin, fish oil or TZD. Address LDL-C once
TG lt 400
2
STEP
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
JAMA 20012852486-2497.
37
What to do With a Statin-Intolerant Patient

• Intensive lifestyle modification
• Different statin at a lower dose
• Low-dose ezetimibe/simvastatin combination
• Ezetimibe monotherapy
• Cholestyramine or colesevelam
• Niacin
• Fish oil

38
Hypertension
39
Hypertension

• Effects more than 50 million individuals in the
  US and more than 1 billion individuals worldwide

• Persons who are normotensive at age 55 have a 90
  lifetime risk for developing HTN.

40
Clinical Impact of Hypertension
Hypertension
The 2nd leading cause of new cases of end stage
renal disease
2-4 fold increase in strokes
Contributes to visual loss in people with diabetes
41
ESRD Incidence Rates by Primary Diagnosis,
19881997
Rate/Million Pop./Year
150
100
Diabetes
Hypertension
50
Other
Glomerulonephritis
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Year
II -8
Adjusted for age, sex, and race
Preliminary
USRDS 1999.
42
Prospective Studies Collaboration CV Mortality
Risk Doubles WithEach 20/10 mm Hg BP Increment
8
7
6
5
CVmortalityrisk
4
3
2
1
0
115/75
135/85
155/95
175/105
SBP/DBP (mm Hg)
CV, cardiovascular DBP, diastolic blood
pressure SBP, systolic blood pressure. Individua
ls aged 40-69 years, starting at BP 115/75 mm
Hg. Lewington S et al. Lancet. 20023601903-1913.
43
Most Patients With Hypertension Have Other Risk
Factors

25
26
1
2
1
2
? BP
3
? BP
3
?4
4
21
18
10
Other sources of risk ? TC, ? HDL-C, ? TG, ?
BMI, ? Glucose
Kannel WB. Am J Hypertens. 2000133S-10S.
44
Adjusted Hazard Ratios for First Cardiovascular
Event Based on CRP, BP
9
N15,215 women not on HRT at entry to Womens
Health Study
8
CRPlt3 mg/L CRP³3 mg/L
7
6
Adjusted hazard ratio
5
4
3
2
1
0
lt120/lt75
120-129/75-84
?160/³95
130-139/85-89
140-159/90-94
BP (mm Hg)
Adjusted for age, BMI, smoking status, LDL-C,
HDL-C, and diabetes.CRPC-reactive protein
BPblood pressure HRThormone replacement
therapy.
Blake GJ et al. Circulation. 2003108994-1000.
45
Risk for Death from CVD SBP Total Cholesterol
46
Microvascular Complications Interaction of
Glucose and BP Control (UKPDS)
47
(No Transcript)
48
Relationship of Renal Function and MAP (mm Hg)
95
98
101
104
107
110
113
116
119
0
-2
r 0.69 P lt 0.05
-4
-6
GFR (mL/min/year)
Untreated HTN
-8
-10
-12
130/80
140/90
-14
Summary of studies on nephropathy progression

• Parving HH et al. Br Med J, 1989
• Viberti GC et al. JAMA, 1993
• Klahr S et al. N Eng J Med, 1993
• Hebert L et al. Kidney Int, 1994
• Lebovitz H et al. Kidney Int, 1994

• Moschio G et al. N Engl J Med, 1996
• Bakris GL et al. Kidney Int, 1996
• Bakris GL. Hypertension, 1997
• GISEN Group, Lancet, 1997

Special Report on DM and HTN. Am J Kidney Dis
200036646-661
49
NHANES IBenefits of Lowering BP
In stage 1 HTN and additionalCVD risk factors,
achieving a sustained 12 mmHg-reduction in
SBP over 10 years will prevent
1 death for every 11 patients treated.
Ogden LG et al. Hypertension. 200035539543.
50
Non-pharmacologic interventions and BP reduction
Alcohol reduction
Potassiumsupplement
Exercise
Low-salt diet
0
1
2
BP decrease(mm Hg)
3
4
5
Adapted from Messerli FH et al. In Griffin BP et
al, eds.2004. Manual of Cardiovascular Medicine.
2nd ed. Whelton SP et al. Ann Intern Med.
2002136493-503.Cutler JA et al. Am J Clin
Nutr. 199765(suppl)643S-651S. Xin X et al.
Hypertension. 2001381112-7.Whelton PK et al.
JAMA. 19972771624-32.
SBP
DBP
51
DASH Eating Plan
Study of 3 dietary patterns to compare effect on
BP

http//www.nhlbi.nih.gov/health/public/heart/hbp/d
ash/
52
Effect of DASH Diet andReduced Na Intake on SBP
Sacks FM et al. N Engl J Med 3443-10,2001
53
Exercise
30 60 minutes 3 5 times/week BP reduction of
10.5/7.6 mmHg
54
Reduction of CV Death in Hypertension Trials
Difference in SBP between treatment groups
55
JNC 7 Algorithm for the Treatment of
Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (lt140/90 mmHg)
(lt130/80 mmHg for those with diabetes or chronic
kidney disease)
Initial Drug Choices
Without Compelling Indications
With Compelling Indications
Drug(s) for the compelling indications Other
antihypertensive drugs (diuretics, ACEI, ARB, BB,
CCB) as needed.
Stage 2 Hypertension (SBP gt160 or DBP gt100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and ACEI, or ARB, or BB,
or CCB).
Stage 1 Hypertension(SBP 140159 or DBP 9099
mmHg) Thiazide-type diuretics for most. May
consider ACEI, ARB, BB, CCB, or combination.
Compelling Indications Heart failure Post-MI H
igh coronary artery disease risk Diabetes Chroni
c kidney disease Recurrent stroke prevention
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until
goal blood pressure is achieved.Consider
consultation with hypertension specialist.
Reprinted with permission from Chobanian AV et
al. JAMA. 200328925602572.
56
National Kidney Foundation Algorithm for
Achieving Target BP Goals in Hypertensive
Diabetic Patients
Start ACE inhibitor titrate upwards
BP still not at goal (130/80 mm Hg)
Blood pressure gt130/80 mm Hg
If BP still not at goal (130/80 mm Hg)
Add Thiazide Diuretic or long-acting CCB
Baseline pulse ?84
If BP goal achieved, convert to fixed dose
combinations (ACE inhibitor CCB or ACE
inhibitor diuretic)
Add low-dose beta blocker or alpha/beta blocker
Baseline pulse lt84
Add other subgroup of CCB(ie, amlodipine-like
agent if verapamil or diltiazem already being
used and the converse)
BP still not at goal (130/80 mm Hg)
If proteinuria present (gt300 mg per day) non-DHP
preferred.
Refer to a clinical hypertension specialist
Bakris GL, et al. Am J Kidney Dis.
200036(3)646-661.
57
Blood Pressure Effects of Common Antiphyertensive
Classes
Representative effects in monotherapy, by class
58
High-Risk Hypertensive Patients Require Multiple
Agents to Achieve Goal
Achieved Systolic BP
AASK1 (134 mm Hg)
ABCD2,3 (132 mm Hg)
ALLHAT4 (135 mm Hg)
HOT2,5 (141 mm Hg)
IDNT6 (140 mm Hg)
RENAAL7 (140 mm Hg)
UKPDS2,8 (144 mm Hg)
Number of BP Medications
1Wright JT et al. JAMA. 20022882421-2431.
2Bakris GL. J Clin Hypertens. 19991141-147.
3Estacio RO et al. N Engl J Med.
1998338645-652. 4The ALLHAT Officers and
Coordinators. JAMA. 20022882981-2997. 5Hansson
L et al. Lancet. 19983511755-1762. 6Lewis EJ et
al. N Engl J Med. 2001345851-860. 7Bakris GL et
al. Arch Intern Med. 20031631555-1565. 8UK
Prospective Diabetes Study Group. BMJ.
1998317703-713.
59
Guideline Targets Not Achieved in Hypertensive
Patients
Percent of Patients at Goal BP
Black HR et al. Hypertension 2004
60
Why is it So Hard to Get to Target?

• BP is a variable measure
• Poor BP technique
• Overdiagnosis of White Coat Hypertension
• Lack of knowledge of magnitude of BP lowering of
  medications
• Resistance to use of multiple medications
• Nonadherence

61
Measurement of Blood Pressure
62
Proper Measurement of Blood Pressure
63
Assure Proper Fit of Blood Pressure Cuff
64
of Population Meeting ADA Guidelines NHANES

Not reported
Saydah SH et al. JAMA291335-42 Resnick HE,
Foster GL et al. 2006 Diab Care 29531.
65
Self-Measurement of BP

• Provides information on
• Response to antihypertensive therapy
• Timing of drug therapy
• Evaluating white-coat HTN
• Home measurement of gt 125/75 in DM is generally
  considered to be hypertensive.
• Home measurement devices should be checked
  regularly.

66
Ambulatory BP Monitoring

• ABPM is warranted for evaluation of white-coat
  HTN in the absence of target organ injury.
• Ambulatory BP values are usually lower than
  clinic readings.
• Awake, individuals with hypertension have an
  average BP of lt135/85 mmHg and during sleep
  lt120/75 mmHg.
• BP drops by 10 to 20 during the night if not,
  signals possible increased risk for
  cardiovascular events.

67
Therapeutic Intertia Contributes to Poor Control
of Hypertension

• Population-wide, control of hypertension improved
  from 1970 to 1990 (10 to 29)
• No significant improvement in past 15 years
• Therapeutic Inertia contributes substantially to
  this poor rate of control
• A retrospective cohort study of 7253 patients
  with hyper-tension from VA population in the SE
  US
• Limited to those with 4 or more visits with BP
  recorded in 2003
• Antihypertensive therapy was changed in only 13
  of visits, when BP gt140/90
• By quintiles, those physicians in the top 20, as
  measured by their intensification of therapy, had
  75 of their patients controlled

Okonofua EC, Simpson KN et al Hypertension 2006
47 345-351.
68
ABCs of CV disease prevention
B
BP control/?-blockade
E
Exercise
Adapted from Cohen JD. Lancet. 2001357972-3.
69
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)
plt0.05, plt0.01 compared to men
70
Improvement in Diabetes Processes of Care in the
US, 1988 2002 (NHANES BRFSS)
Saaddine JB, Cadwell, B et al. Ann Int Med
144465, 2006
71
Majority of Americans do not follow a healthy
lifestyle
2000 Behavioral Risk Factor Surveillance System,
N 153,805
100
77.8
76.7
80
59.9
60
Respondents ()
40
24.0
20
0
Smokers
BMI 25 kg/m2
Consumes fruits/vegetables lt5x/day
Infrequentexercise(lt5x/week)
Reeves MJ and Rafferty AP. Arch Intern Med.
2005165854-7.
72
Only 1 in 3 patients adherent to preventive
therapy after 6 months
N 8406 managed-care enrollees receiving
antihypertensive and lipid-lowering medications
50
44.7
40
35.9
Patientsadherent to bothmedications()
30
20
10
0
3
6
Time from initiation of therapy (months)
Chapman RH et al. Arch Intern Med.
20051651147-52.
73
Barriers to Continuing Risk Factor Management in
CHD Patients Outpatient-Initiated
Discontinuation of Lipid-Lowering Medication
Outpatient-initiatedDiscontinuation Rate,
0
8
24
32
48
40
16
Weeks
Andrade SE et al. N Engl J Med 19953321125-1131.
74
Increasing the effectiveness of adherence
interventions may have far greater impact on the
health of the population than any improvement in
specific medical treatments

• WHO Report 2001

75
Issues in Adherence to Prescribed Medical Regimens

• Typical adherence rates
• About 50 for medications
• Much lower for lifestyle prescriptions, other
  behaviorally demanding regimens
• Many patients with medical problems do not seek
  care or drop out of care prematurely
• Simple measures can detect most adherence
  problems, eg
• Asking patients directly
• Watching for appointment nonattendance
• Monitoring for nonresponse to treatment

Haynes RB, et al. JAMA. 20022882880-2883.
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Noncompliance With Antihyperlipidemic
Medications Patient Characteristics

• History of noncompliance
• Inability to cover costs
• Given complex dosing regimen
• Prescribed drug other than statin
• Chronically ill with multiple diseases
• Perceives self as healthy

Avorn J et al. JAMA. 19982791458-1462. Sung JC
et al. Am J Manag Care. 199841421-1430.
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Strategies Shown to Improve Adherence

• Telephone/mail/e-mail contact
• Persuasive communication
• Spousal support
• Signed agreements
• Self-monitoring
• Behavioral skill training
• Education to enhance self-efficacy perceptions

Burke LE et al. Ann Behav Med. 199719239-263.
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Improving Adherence Focus on the Health
Delivery System

• Provide risk factor management through chronic
  disease focused system
• Utilize case management by nurses
• Implement telemedicine (phone follow-up)
  procedures
• Involve pharmacists in collaborative care

ATP III. JAMA. 20012852486-2497.
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Thoughts

• We cant change patients. We address barriers
  and provide strategies to help them make behavior
  changes
• More is not necessarily better small successes
  are good and can be built upon. Patients dont
  need to change everything at one visit
• If you get stuck on something, consider
  focusing on another target
• One size does not fit all
• Patients should be empowered to participate as
  the central member of their healthcare team

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Risk Factor Modification is Like a Game of Golf

• At the tee, use the right club
• You rarely hit a hole in one
• Keep hitting the ball until you hit the target
• Treatment of hypertension is a Par 3 hole

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