a1 wright treating cv risk factors

8/7/2019 A1 Wright Treating CV Risk Factors

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Partners in Healthcare Education, LLC

Treating Cardiovascular Risk

Factors in Medically Complex

Patients

1

Wendy L. Wright, MS, RN, ARNP, FNP, FAANP

Owner Wright & Associates Family Healthcare

Partner Partners in Healthcare Education

Disclosures

Grants: Novartis, DaiichiGrants: Novartis, Daiichi--SankyoSankyo

Speaker Bureau: OrthoSpeaker Bureau: Ortho--McNeil, Abbott,McNeil, Abbott,Novartis, GSK,Novartis, GSK, SanofiSanofi--Pasteur, DSI, Takeda,Pasteur, DSI, Takeda,

Wright, 20102

Upon completion of this lecture, the participantwill be able to:

Discuss the epidemiological impact of CAD in 2011

List the maor risk factors im actin a ressive

Objectives

3

CAD

Identify treatment options for the medicallycomplex patient at risk of cardiovascular disease

The Problem:

Cardiovascular Disease is Deadly!

4www.Hypertensiononline.org

500,000

600,000

700,000

800,000

900,000

Deaths

Alzheimer

CLRD

Cancer

CVD and Other Causes of Death

CVD and other major causes of death: both sexes.(United States: 2006). Source: NCHS and NHLBI.

0

100,000

200,000

300,000

400,000

All Ages


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Bob47-year-old Caucasian Sales Executive

Presents for a physical examination

No complaints at present and feels well PMH

7

-

Obesity since young adulthood

Bipolar disorder

Smoker

Family HistoryFather died age 62 - MI

Bob Social History

Tobacco use: 1- 2 pack daily; 25 years

Alcohol: 1 2 beers nightly Exercise: none Married, 2 children in high school

8

a es execu ve w o rave s o meaway from home)

MedicationsMultivitamin 1 po dailyASA 81 mg 1 po daily Lithium 300 mg 1 pill two times daily

BobPhysical Examination

Height: 5 8

Weight: 287 lbs

BMI: 43.9

9

Waist circumference: 46

BP: 138/90 (2 readings)

Pulse: 86 bpm and regular

EKG: Left axis deviation

No conduction abnormalities or ischemic changes

BobLaboratory Parameters

FBS: 106 mg/dL (60 99)

BUN: 16 mg/dL (9 21)

Creatinine: 1.0 mg/dL (0.8- 1.4)

10

.

HDL: 34 mg/dL (> 40)

Triglycerides: 156 mg/dL (


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Interrelation Between Atherosclerosisand Insulin Resistance

Hypertension

Obesity

Hyperinsulinemia

13

Diabetes

Hypertriglyceridemia

Small, dense LDL

Low HDL

Hypercoagulability

InsulinInsulinResistanceResistance

InsulinInsulinResistanceResistance

AtherosclerosisAtherosclerosisAtherosclerosisAtherosclerosis

Slide source: Lipidsonline.org

Insulin Resistance Primarily, the plasma glucose level regulates

the physiologic control of insulin secretion

When an individual develops insulin resistance,the normal amount of insulin is not able to

14

To compensate, insulin secretion is increaseduntil the plasma glucose levels return to normal

Eventually, the pancreas may NOT be able tocompensate

Clinicia ns Manual on Insulin Resistance. H E Lebovitz Science Press 2002 London,UKhttp://care.diabetesjournals.org/cgi/content/full/27/2/602

Causes of Insulin Resistance

Adiposity and Physical Conditioning

25% each.50% of IR patients

15

Genetic Factors..50% of IR Patients

First World Congress on Insulin Resistant Syndrome; 2003, Nov20-23, Los Angeles, California, USAhttp://care.diabetesjournals.org/cgi/content/full/27/2/602

Insulin Resistance

47 million people in the USA have

the insulin resistance syndrome.

16

Flegal, KM., Carroll MD., et al. Prevalence and Trends in Obesity AmongUS Adults, 1999-2000. JAMA. 2002; 288:1723-1727.Mokdad, AH, Ford ES. Et al. Prevalence of obesity, diabetes and obesity related

health risk factors 2001. JAMA. 2003; 289:76-79.

-Prevalence in men 24%; women 23.8%

Age 60 - 69 years oldPrevalence in men 43.5%; women 42%

Metabolic Syndrome Consensus Definition

Central Obesity > 40 inches male / >35 inches female Raised triglycerides

> 150 mg/dL (or treatment of triglycerides)

Reduced HDL cholesterol

130 mm Hg systolic or > 85 mm Hg diastolic or treatment

toward this goal

Raised fasting plasma glucose level FBS> 99 mg/dL or treatment toward this goal

Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults. National Cholesterol Education Program, National Heart, Lung,and Blood Institute, National Institutes of Health. NIH Publication No 01-3670. May 2001

Regardless of NameMetabolic Syndrome is:

Method to identify those at risk for

Early

Aggressive

18

Patients with Metabolic Syndrome have a 3 Xgreater chance of developing CAD and dyingfrom it

Diabetes Care. 2001; 24:683-689.JAMA. 2002; 288:2709-2716.


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Coronary Artery Disease

19

s ac or:

Obesity


Height: 5 8

Weight: 287 lbs BMI: 43.6

20

Waist circumference: 46 BP: 138/90 (2 readings)


EKG:

Left axis deviation


Definition of Obesity

Obesity is a chronic disease of

multiple etiologies characterized by

21

e presence o excess a pose ssue

Atkinson RL, Hubbard VS. Report on the NIH Workshop on PharmacologicTreatment of Obesity. American Journal of Clinical Nutrition, Vol 60,153-156, Copyright 1994 by The American Society for Clinical Nutrition, Inc

Practical Diagnosis

Waist Circumference

Obtained by taking a measurement between theiliac crest and the bottom of the rib cage aftermild exhalation

22

Waist circumference of > 102 cm (> 40 inches) inmen or 88 cm ( > 35 inches) in women is aimportant component of the metabolic syndromediagnosis

The Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

Disease Risk*BMI Classification (Waist Circumference)

(kg/m2) Men < 40 in >40 in

Women < 35 in >35 in

Determine Obesity Classand Disease Risk

Determine Obesity Classand Disease Risk

-

23

* for type 2 diabetes mellitus, hypertension, and CVD

NHLBI Practical Guide. Oct 2000 Table 2, pg 10

. - .

30.0-34.9 Obesity I High Very High

35.0-39.9 Obesity II Very High Very High

> 40 Obesity III Extremely High Extremely High

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

Source: CDC Behavioral Risk Factor Surveillance System.

24

No Data


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Obesity Trends* Among U.S. AdultsBRFSS, 2009

(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)

Source: CDC Behavioral Risk Factor Surveillance System.

No Data


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Guide for SelectingTreatment

Guide for SelectingTreatment

BODY MASS INDEX (BMI)25-26.9 27-29.9 30-34.9 35-39.9 >40

DIET, PHYSICAL ACTIVITY * *

31

PHARMACOTHERAPY *

SURGERY *

* With ComorbiditiesAlways use as an adjunct to diet and physical activity

NHLBI Practical Guide. Oct 2000 Table 3, pg25

Drugs Approved by FDAfor Treating Obesity

NameApproval

Year UseMechanism of

ActionDEA

Schedule

Dosage/Monthly

Cost

Orlistat Lon - 120 mg

32

enca term pase n or one ~ $120

Phentermine(Adipex,lonamin)

1973 Short-termNorepinephrine

reuptake inhibitor IV15-37.5

mg/d

~ $40

FDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placebo

2020

4040

6060 MenMen WomenWomen

ngein

ngein

orsum(

%)

orsum(

%)

Change in Weight and CHD Risk FactorChange in Weight and CHD Risk FactorClustering: Framingham Offspring StudyClustering: Framingham Offspring Study

Risk factors: Low HDL-C High cholesterol High systolic BP High TG High glucose

33

LossLoss

2.25 kg2.25 kg

GainGain

2.25 kg2.25 kg

00

--2020

--4040

--6060

ChCh

riskfact

riskfact

LossLoss

2.25 kg2.25 kgGainGain

2.25 kg2.25 kg

Weight Change Over 16Weight Change Over 16--Year Follow UpYear Follow Up

Adapted from: Wilson PW, et al.Adapted from: Wilson PW, et al. Arch Intern Med.Arch Intern Med. 1999;159:11041999;159:1104 --11091109

Thoughts to Ponder

Lithium..

What do you need to consider?

Thyroid

Kidne function

Worsening insulin resistance?

Must avoid certain medications:

NSAIDs

HCTZ

34

Lithium

Lithium is cleared completely through therenal system

Drugs and conditions that influence renal

serum lithium concentrations

Such drugs include: thiazide diuretics,NSAIDs, ACE inhibitors, Calcium channelblockers (diltiazem and verapamil), Caffeine

35

Thiazides and Lithium

In fact, concomitant use of diuretics has longbeen associated with the development oflithium toxicity

Thiazide diuretics are thought to be theworst because they act distally on the renaltubule (same location as lithium is cleared)causing an increase in the re-absorption oflithium

36


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Think of All theAntihypertensives

Most antihypertensives nowhave HCTZ in them

occur

37

Other Drugs Can Lower LithiumLevels

Osmotic diuretics enhance lithiumexcretion and are often used forlithium toxicit

Caffeine and theophylline alsodecrease lithium levels andtherefore need to be monitored ifused concomitantly

38

Coronary Artery Disease

39

Risk Factor:

Diabetes


FBS: 106 mg/dL (60 99) BUN: 16 mg/dL (9- 21)

Creatinine: 1.0 mg/dL (0.8-1.1)

40

T. Cholesterol: 220 mg/dL (< 200)

HDL: 34 mg/dL (> 40)



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Screening for Diabetes

According to the ADA, screening shouldbegin on all individuals 45 years of age andolder1

Repeated q 3 years if normal

If at risk, can begin screening at an earlier

43

age i.e. obese, sedentary lifestyle

**American College of Endocrinology1: Begin screening at age 25 years, in at risk

individuals

www.diabetes.org accessed on 2-2-2008

www.aace.com accessed on 2-2-2008

A1C

Recommendations:

A1C may be used for screening >6.5% - consistent with diabetes

. - .

Last 6 weeks of blood sugars is driving factorin the A1C

www.diabetes.org

44

What Is Good Control? A1C

AACE: < 6.5%

ADA: < 7.0% ***

45

AACE: < 110 mg/dL

ADA: 70 130 mg/dL

2 hour postprandial: AACE:


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Intensive

glycemic control

Intensive

management of

comorbid

AACE: Managing Diabetes

Lifestyle

intervention

American Association of Clinical Endocrinologists

49

conditions*

A1C 6.5% Glucose (mg/dL)

Preprandial110 Postprandial 140

Lipid modifying BP lowering ASA for prevention of

vascular events

Optimal nutrition Physical activity Smoking cessation Weight control

AACE. Endocr Pract. 2002;8(suppl 1):40-65.*Dyslipidemia, hypertension, early renal disease

BetaBeta--cellcell

dysfunctiondysfunction

Major Targeted Sites of Oral Drug Classes

Pancreas

Muscleand fatLiver

Sulfonylureas

Meglitinides

DPP-4 inhibitors

Incretin Memetics

50

GlucoseGlucose

absorptionabsorption

Hepatic glucoseHepatic glucose

overproductionoverproductionInsulinInsulin

resistanceresistance

DPP-4=dipeptidyl peptidase-4; TZDs=thiazolidinediones.DeFronzo RA. Ann Intern Med. 1999;131:281303.Buse JB et al. In: Williams Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders; 2003:14271483.

Glucose level

Biguanides

TZDs Biguanides

TZDs

Alpha-

glucosidaseinhibitors

Gut

DPP-4 inhibitors

Biguanides

Bile AcidSequestrants

Incretin Memetics

Treatment of Patient Based on AIC

A1C is less than 7.3% A1C is 7.3% - 9.2%

51

Monnier L, Lapinski, H, Colette C. Contributions of fasting and postprandial plasma glucose increments to

the overall diurnal hyperglycemia of type 2 diabetic patients: Variations with increasing levels of HbA(1c).Diabetes Care. 2003;26:881-885.

B -blockadeBlood ressure control

A AspirinACE inhibitionA1C control

Managing diabetes as a CHD risk equivalent:ABCs of coronary prevention

52Adapted from Cohen JD. Lancet. 2001;357:972-3.

C Cholesterol management

Diet

Dont smoke

Decrease diabetes risk

D

Exercise

E

Target Recommendations

A1C


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55

Risk Factor

Dyslipidemia


FBS: 101 mg/dL (60 99)

BUN: 16 mg/dL (9 21) Creatinine: 1.0 mg/dL (0.8-1.1)

56

.

HDL: 34 mg/dL (> 40)



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Risk Level Risk Category

LDL-CGoal

(mg/dL)

LDL-C toConsider Drug

Therapy*

(mg/dL)

ModeratelyHigh Risk

2 Risk Factors;10-Year Risk 10%-20%

High Risk CHD or CHD Risk

NCEP Interim Report:LDL-C Goals and Drug Cut Points for High-Risk Patients


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ASCOT-Lipid Lowering Arm

LDL starting value133 mg/dL

Aggressive LDL lowering.88 mg/dL

67

Major CV events @ 3 years.. 36%

Major vascular events. 27%

Total coronary events. 29%

Lancet2003; 361:1149-1158 68

The HDL Molecules(s)

Industrial Strength

Vacuum2b

69

Dust Buster

2a

3a

3b

3c

Adapted from Berkley Heart Lab70www.lipidsonline.com

Treatment

71

Alternatives

What Does He Need?

Statin?

Bile Acid Sequestrant?

Niacin? Fibrate?

Omega 3?

Any worries?

Kidney function statins?

72


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73

Risk Factor:

Hypertension


Height: 5 8

Weight: 287 lbs

BMI: 43.9


74






FBS: 106 mg/dL (60 99)

BUN: 16 mg/dL (9-21-)


75

T. Cholesterol: 220 mg/dL (< 200)

HDL: 34 mg/dL (> 40)



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JNC 7: Classification and ManagementJNC 7: Classification and Managementof Blood Pressureof Blood Pressure

No antihypertensive

drug indicated

Thiazide-type diuretics

Drug(s) for compelling

indications

Drug(s) for the

Encourage

Yes

Yes

and


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ARB Trials1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

ValHeFTELITE I

ELITE II

LIFE

CHARM

ON TARGET

HF

CV

85

IDNT

RENAAL

IRMA II

OPTIMAAL

VALIANT

VALUE

MARVAL

MI

Renal/CV

Renal

IPreserve

Newer Trials

Combination therapy

ACE/HCTZ, ARB/HCTZ, ACE/CCB\

Triple therapy

86

Becoming norm

Direct Renin Inhibitors and combinationtherapy

Aliskirin + HCTZ, ACE, ARB, CCB

ARB + CCB

What Does He Need? Think:

LVH

Smoker

Prediabetes

Bipolar Disorder

ACE inhibitor

Beta blocker

CCB

DRI

ARB

Thiazide87

Case StudyCase Study

88


Height: 5 8

Weight: 287 lbs

BMI: 43.9

89







FBS: 106 mg/dL (60 99)

BUN: 16 mg/dL (9-21)


90

.

HDL: 34 mg/dL (> 40)



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hs-CRP: 2.7 mg/L (


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Conclusions

Nurse Practitioners and Physician

Assistants are in an excellent position toidentify the individual at risk for CAD

97

Once identified, aggressive treatment formodify obesity, hypertension, dyslipidemiaand diabetes must be employed to reducethe risk of CAD

a1 wright treating cv risk factors

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