Not Again!

Secondary Prevention of Future Cardiovascular Events

J. Clay Hays, Jr., MD, FACC

56 yr old insurance man

• Presents with chest tightness after playing golf. Trying to walk 18 holes

• Hypertension on diuretics• Not diabetic• Unsure of lipids• Smoker• 82 year old mother with CHF, father died

of stroke at 79 years old

56 year old man

• Heart rate 100 beats/ min• BP 154/92• 5’11’’; 230 lbs; BMI 32• Soft right carotid bruit• Clear lungs• Regular rhythm with soft apical systolic

murmur; soft s4

56 year old man

• Obese• Can’t feel aorta, no bruits• 1+ pedal pulses• EKG sinus, nonspecific st-t wave changes• Trop 10

• What next?

Diagnostics

• 80% circumflex lesion with mild disease elsewhere

• Placed 3.0x 12mm Taxus drug eluting stent

• EF 45% with inferior wall hypokinesis• 30% right carotid lesion by ultrasound• Tchol 205, HDL 27, Trig 425

What do you do?

ASCVD

• Coronary Artery Disease• Peripheral Arterial Disease• Carotid Arterial Disease• Atherosclerotic Aortic Disease

Benefits of Aggressive Risk Factor Reduction

• Improves survival• Reduces recurrent events• Reduces need for further intervention• Improves quality of life

Smoking

GoalComplete Cessation

No exposure to environmental tobacco smoke

Recommendations

• Ask about tobacco use at every visit. I(B)• Advise user to quit. I(B)• Assist with counseling and a plan. I(B)• Arrange for followup, referral, or

pharmacotherapy. I(B)• Avoid exposure at home or work. I(B)

Blood Pressure Control

Goal<140/90Or<130/80 if diabetic or chronic kidney disease

Recommendations

For all patients

• Weight control• Increased activity• Alcohol moderation

• Sodium reduction• Increased fruit intake• Increased veggies• Low fat dairy

Recommendations

For hypertensive patients

• Initially treat with B blockers and/or ACEI• Add other drugs such as thiazides prn to

achieve goal

Lipid Management

Goal

LDL-C < 100If Triglycerides are >200,non-HDL-C should be < 130(Total cholesterol – HDL)

For all patients

• Start diet therapy I(B)• Reduce saturate fat (<7% of total calories)• Reduce trans-fatty acids• Reduce to total cholesterol <200 mg/dl• Add plant sterols (2g/d) and fiber (>10g/d)• Promote daily activity and weight reduction• Omega 3 (1g/d), more if trig are up. II(B)

For lipid management

• Assess fasting lipids within 24 hrs for patients with acute events.

• Initiate medication before discharge according to :

• LDL should be <100 (IA) and <70 is reasonable (IIaA)

• See attached table

Physical Activity

Goal

30 minutes, 7 days per week(Minimum 5 days per week)

Physical Activity

All patients

• Assess risk with physical activity history and/or exercise test to guide prescription

• 30 to 60 mins of moderate intensity I(B)• 2 days/ week of resistance training. IIb (C)• Medical supervision for high risk patients

I(B)

Weight Management

Goal

BMI: 18.5 to 24.9kg/m2

Waist circumference: Men <40 inches,Women < 35 inches

Weight management

• Assess BMI on each visit• Encourage diet and exercise I(B)• Consider treatment strategies for

metabolic syndrome I(B)• Initial goal to reduce 10% from baseline

weight I(B)

Diabetes Management

Goal

HbA1C <7%

Antiplatelet agents

• Aspirin 75 to 162 mg/d in all patients I(A)• For CABG, start ASA within 48 hrs to

reduce chance of graft closure. 162 to 325mg for up to one year

• Clopidogrel 75 mg/d with ASA for up to 1 year after an acute event

Plavix and ASA after PCI

• ASA 325 with Plavix 75 mg/day

• 1 month with bare metal stents• 3 months with Cypher stents• 6 months with Taxus stents

Warfarin

• INR 2.0-3.0• Paroxysmal atrial fib• Chronic atrial fib or flutter• Post MI patient with LV thrombus

ACE Inhibitors

• LV dysfunction <40%• Hypertension• Diabetes• Chronic Kidney disease• Optional for patients with normal LV

function and good control of other risk factors

Angiotensin Receptor Blockers

• Intolerant to ACEI and have CHF or MI with EF <40%

• Intolerant to ACEI• Combined with ACEI in pts with systolic-

dysfunction heart failure

Aldosterone Blockade

• Post MI patients, without renal dysfunction or hyperkalemia, who are on ACEI and B blocker, have EF <40% and have diabetes or CHF. I(A)

Beta blockers

• All patients with MI, Acute coronary syndrome, or LV dysfunction

• Continue indefinitely• Consider in other forms of vascular

disease

Influenza Vaccination

• All patients with any form of ASCVD

• Have you had yours?

Questions?