the abc’s of the aha/acc ischemic heart disease guidelines roger s. blumenthal, md
DESCRIPTION
THE ABC’S OF THE AHA/ACC Ischemic Heart Disease GUIDELINES Roger S. Blumenthal, MD Professor of Medicine Director, The Johns Hopkins Ciccarone Center For The Prevention of Heart Disease. DEFINITION. - PowerPoint PPT PresentationTRANSCRIPT
THE ABC’S OF THETHE ABC’S OF THEAHA/ACC Ischemic Heart AHA/ACC Ischemic Heart
Disease GUIDELINES Disease GUIDELINES
Roger S. Blumenthal, MD Professor of Medicine
Director, The Johns Hopkins Ciccarone Center For The Prevention of Heart Disease
DEFINITIONDEFINITION
PRIMARY Prevention: Modification of risk factors or prevent their development to prevent or delay the onset of CHD.
SECONDARY Prevention: Initiation of Rx to reduce recurrent CHD events in patients with CHD.
PRIMARY AND A HALF Prevention*: As individuals with subclinical CHD are identified, the distinction between primary and secondary prevention becomes blurred.
*Celermajer DS. JACC 2005;45:1994-6
CHD=Coronary heart disease
ASPIRIN RECOMMENDATIONS ASPIRIN RECOMMENDATIONS
CABG=Coronary artery bypass graft, CHD=Coronary heart disease
*To be administered within the first 48 hours after surgery in order to reduce the risk of saphenous vein graft failure. Doses >162 mg/day may be continued for up to one year.
Aspirin (75-325 mg daily) in those with known CHD or carotid artery or leg artery narrowings due to plaque.
Aspirin (100-325 mg daily) in those that have undergone CABG surgery*.
SECONDARY PREVENTION
CLOPIDOGREL EVIDENCE: SECONDARY PREVENTIONCLOPIDOGREL EVIDENCE: SECONDARY PREVENTION
CLOPIDOGREL IN UNSTABLE ANGINA TO PREVENT RECURRENT EVENTS (CURE) TRIAL
The CURE Trial Investigators. NEJM. 2001;345:494-502
DAP=Dual antiplatelet therapy, NSTE-ACS=Non ST-segment elevation acute coronary syndrome
3 6 90 12
RA
TE
OF
DE
AT
H,
MY
OC
AR
DIA
L IN
FA
RC
TIO
N, O
R S
TR
OK
E
P<0.001
MONTHS OF FOLLOW UP
ASPIRIN + CLOPIDOGREL
ASPIRIN + PLACEBO
12,562 patients with a NSTE-ACS randomized to daily aspirin (75-325 mg) or clopidogrel (300 mg load, 75 mg thereafter) plus aspirin for 9 months
ACE INHIBITOR RECOMMENDATIONSACE INHIBITOR RECOMMENDATIONS
SECONDARY PREVENTION
*Defined by previous MI or angiographically significant CAD.
ACE=Angiotensin converting enzyme, CAD=Coronary artery disease, CKD=Chronic kidney disease, CV=Cardiovascular, DM=Diabetes mellitus, EF=Ejection fraction, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction, SBP=Systolic blood pressure
An ACE inhibitor in those following a MI, regardless of EF or in those with CAD* along with hypertension (SBP >120 mmHg), LVSD (EF <0.40), heart failure, DM, or CKD.
Optional use of an ACE inhibitor in those with low risk CAD*, well controlled CV risk factors, a normal EF, and successful revascularization.
DAYS OF FOLLOW-UP
CV
DE
AT
H, M
I, O
R S
TR
OK
E (
%)
22% RRR, P<0.001
0.00
0.05
0.10
0.15
0.20
0 500 1000 1500
ACE INHIBITOR EVIDENCE: SECONDARY PREVENTIONACE INHIBITOR EVIDENCE: SECONDARY PREVENTION
PLACEBO
RAMIPRIL
HOPE Investigators. NEJM 2000;342:145-153
HEART OUTCOMES PREVENTION AND EVALUATION (HOPE) STUDY
ACE-I=Angiotensin converting enzyme inhibitors, DM=Diabetes mellitus, CV=Cardiovascular, HF=Heart failure, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction
9,297 patients with DM or vascular disease plus one additional CV risk factor, but without HF or known LVSD randomized to ramipril (10 mg) or placebo for 5 years
ACE-I reduce CV events in high-risk individuals
YEARS
PR
OB
AB
ILIT
Y O
F E
VE
NT
0
0.05
0.15
0.2
0.25
0.3
0 1 2 3
0.35
0.4
4
ACE-I
Placebo
OR: 0.74 (0.66–0.83)OR: 0.74 (0.66–0.83)0.1
Flather MD, et al. Lancet. 2000;355:1575–1581
ACE INHIBITOR EVIDENCE: SECONDARY PREVENTIONACE INHIBITOR EVIDENCE: SECONDARY PREVENTION
ACE-I=Angiotensin converting enzyme inhibitors, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction, OR=Odds ratio
ACE-I provide substantial benefit in post-MI LVSD
Radionuclide
EF 40%
SAVEClinical and/or radiographic signs of HF
AIREEchocardiogram
EF 35%
TRACE
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
Usual Diastolic BP (mm Hg)Usual Systolic BP (mm Hg)
Isch
emic
Hea
rt D
isea
se M
orta
lity
50-59
60-69
70-79
80-89Age at Risk (Y)
40-49
256
128
64
32
16
8
4
2
1
0120 140 160 180
50-59
60-69
70-79
80-89
Age at Risk (Y)
40-49
256
128
64
32
16
8
4
2
1
080 90 100 11070
BLOOD PRESSURE: LOWER IS BETTERBLOOD PRESSURE: LOWER IS BETTER
Isch
emic
Hea
rt D
isea
se M
orta
lity
Ischemic Heart Disease Mortality
BP=Blood pressure
BLOOD PRESSURE RECOMMENDATIONSBLOOD PRESSURE RECOMMENDATIONS
Initiation or maintenance of lifestyle modification in those with a BP >120/80 mmHg.
ACE=Angiotensin converting enzyme, BP=Blood pressure, CKD=Chronic kidney disease, DM=Diabetes mellitus
*A BP >130/80 mmHg should be used for individuals with CKD or DM
Use of an ACE inhibitor and/or b-blocker in those with a BP >140/90 mmHg*. Other drugs (i.e., thiazide diuretics) should be added in order to achieve the desired BP.
SECONDARY PREVENTION
Nissen S et al. JAMA 2004;292:2217-26.
BLOOD PRESSURE EVIDENCE: SECONDARY PREVENTIONBLOOD PRESSURE EVIDENCE: SECONDARY PREVENTION
COMPARISON OF AMLODIPINE VS ENALAPRIL TO LIMIT OCCURRENCES OF THROMBOSIS (CAMELOT) TRIAL
*Includes CV death, MI, cardiac arrest, coronary revascularization, hospitalization for HF or angina pectoris, stroke, TIA, development of PAD
CV
eve
nt r
ate*
0
0.25
0.20
0.10
0.05
6 12 18 24
0.15
0
Placebo
AmlodipineEnalapril
Months
Follow-up BP (mmHg)
125/77124/77130/78
BP=Blood pressure, CAD=Coronary artery disease, CV=Cardiovascular, DBP=Diastolic blood pressure, HF=Heart failure, MI=Myocardial infarction, PAD=Peripheral arterial disease, TIA=Transient ischemic attack
1,991 patients with CAD and a DBP <100 mmHg randomized to amloidipine (10 mg), enalapril (20 mg), or placebo for 2 years
A BP <130/80 mmHg is associated with fewer CV events
A -blocker in all patients following a MI.
A beta-blocker in all patients with LVSD.
*Relative contraindications include asthma, chronic obstructive pulmonary disease, insulin dependent diabetes mellitus, severe peripheral arterial disease, and a PR interval >0.24 seconds.
CV=Cardiovascular, DM=Diabetes mellitus, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction
-BLOCKER RECOMMENDATIONS*-BLOCKER RECOMMENDATIONS*
SECONDARY PREVENTION
A -blocker in those with other forms of CV disease or DM, unless contraindicated.
SECONDARY PREVENTION
CHOLESTEROL MANAGEMENT GUIDELINESCHOLESTEROL MANAGEMENT GUIDELINES
Restriction of saturated fat (<7% of total calories) and cholesterol (<200 mg/day) in all patients.
Promotion of daily physical activity and weight management in all patients.
Increase in -3 fatty acid consumption in all patients.
LDL-C=Low density lipoprotein cholesterol
SECONDARY PREVENTION
CHOLESTEROL MANAGEMENT GUIDELINES (CONTINUED)CHOLESTEROL MANAGEMENT GUIDELINES (CONTINUED)
Initiation or intensification of LDL-C lowering drug therapy in those with a baseline or on-treatment LDL-C level >100 mg/dl.
LDL-C=Low density lipoprotein cholesterol
Initiation of LDL-C lowering drug therapy in those with a baseline LDL-C level <100 mg/dl based on clinical judgment.
CHOLESTEROL MANAGEMENT GUIDELINES (CONTINUED)CHOLESTEROL MANAGEMENT GUIDELINES (CONTINUED)
As set forth by the Adult Treatment Panel III (ATP III) National Cholesterol Education Program (NCEP)
Obtain a fasting lipid profile in all patients. For those with a myocardial infarction, a fasting lipid profile should be obtained within 24 hrs of admission.
Start therapeutic lifestyle changes in all patients, including:
• Reduced intakes of saturated fats (<7% of total calories) and cholesterol (<200 mg/day)
• Addition of plant stanols/sterols (2 g/day) and viscous fiber (10-25 g/day) to enhance LDL-C lowering
• Weight reduction
• Increased physical activity
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486.
RECOMMENDATIONSGOALS
Risk Category LDL-C Goal Initiate TLCConsider
Drug Therapy
High risk: CHD or CHD risk equivalents (10-year risk >20%)
<100 mg/dL (optional goal:
<70 mg/dL)100 mg/dL
>100 mg/dL (<100 mg/dL: consider drug
options)
Moderately high risk: 2+ risk factors* (10-year risk 10% to 20%)
<130 mg/dL (optional goal: <100 mg/dL)
130 mg/dL>130 mg/dL
(100-129 mg/dL: consider drug options)
Moderate risk: 2+ risk factors* (10 year risk <10%)
<130 mg/dL 130 mg/dL >160 mg/dL
Lower risk: 0-1 risk factor*
<160 mg/dL 160 mg/dL>190 mg/dL
(160-189 mg/dL: LDL-lowering drug optional)
Grundy, S. et al. Circulation 2004;110:227-39.
ATP III LDL-C GOALS AND CUT-POINTS FOR DRUG THERAPYATP III LDL-C GOALS AND CUT-POINTS FOR DRUG THERAPY
ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol, TLC=Therapeutic lifestyle changes
*Risk factors for cardiovascular disease include: cigarettes smoking, hypertension (blood pressure >140/90 mmHg or on antihypertensive medication, HDL-C <40 mg/dl (>60 mg/dl is a negative risk factor), family history of premature CHD, age >45 years in men or >55 years in women.
PRIMARY THERAPIES TO LOWER LDL-CPRIMARY THERAPIES TO LOWER LDL-C
Class Drug(s)
3-Hydroxy-3-Methylglutaryl Coenzyme A (HMG-CoA) reductase inhibitors [Statins]
Atorvastatin (Lipitor)
Fluvastatin (Lescol XL)
Lovastatin (generic and Mevacor)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
Bile acid sequestrants Cholestyramine (generic and Questran)
Colesevelam (Welchol)
Colestipol (Colestid)
Cholesterol absorption inhibitor Ezetimibe (Zetia)
Dietary Adjuncts Soluble fiber
Soy protein
Stanol esters
Follow-up (months)
3 6 9 12 15 18 21 24 27 30
30
25
20
15
10
5
0
P =0.005
Rec
urr
ent
MI o
r C
ard
iac
Dea
th
16% RRR
PRAVASTATIN OR ATORVASTATIN EVALUATION AND INFECTION THERAPY (PROVE-IT)—TIMI 22 STUDY
Atorvastatin
Pravastatin
ACS=Acute coronary syndrome, CV=Cardiovascular, MI=Myocardial infarction, RRR=Relative risk reduction
Cannon CP et al. NEJM 2004;350:1495-1504
HMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTIONHMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTION
4,162 patients with an ACS randomized to atorvastatin (80 mg) or pravastatin (40 mg) for 24 months
Acute intensive therapy significantly reduces the event rate
SCANDINAVIAN SIMVASTATIN SURVIVAL STUDY (4S)
Mo
rtal
ity
(%)
Placebo
11.5
Simvastatin
12
8
4
0
8.2
P<0.001
30% RRR
4S Group. Lancet 1994;344:1383–1389
MI=Myocardial infarction, RRR=Relative risk reduction
4,444 patients with angina pectoris or previous MI randomized to simvastatin (20-40 mg) or placebo for 5.4 years
HMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTIONHMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTION
Statins provide significant benefit in those with average LDL-C levels
Baseline
LDL-C (mg/dL)Statin
(n = 10,269)Placebo
(n = 10,267)
<100 282 (16.4%) 358 (21.0%)
100–129 668 (18.9%) 871 (24.7%)
130 1083 (21.6%) 1356 (26.9%)
All patients 2033 (19.8%) 2585 (25.2%)
Event Rate Ratio (95% CI)
Statin Better Statin Worse
0.4 0.6 0.8 1.0 1.2 1.4
0.76 (0.72–0.81)P<0.0001
HEART PROTECTION STUDY (HPS)
HMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTIONHMG-COA REDUCTASE INHIBITOR: SECONDARY PREVENTION
20,536 patients with CAD, other occlusive arterial disease, or DM randomized to simvastatin (40 mg) or placebo for 5.5 years
CAD=Coronary artery disease, CI=Confidence interval, DM=Diabetes mellitus,
HPS Collaborative Group. Lancet 2002;360:7-22
Statins provide significant benefit across a broad range of LDL-C levels
Complete cessation
No environmental tobacco smoke exposure
CIGARETTE SMOKING CESSATION GUIDELINESCIGARETTE SMOKING CESSATION GUIDELINES
Ask about tobacco use at every visit.
In a clear, strong, and personalized manner, advise the patient to stop smoking.
Urge avoidance of exposure to secondhand smoke at work and home.
Assess the patient’s willingness to quit smoking.
Develop a plan for smoking cessation and arrange follow-up.
Provide counseling, pharmacologic therapy, and referral to formal smoking cessation programs as indicated.
RECOMMENDATIONSGOALS
SMOKING CESSATION PHARMACOTHERAPY*SMOKING CESSATION PHARMACOTHERAPY*
Agent CautionSide
EffectsDosage Duration Instructions
Bupropion SR
(Zyban®)
Seizure disorder
Eating disorder
Taking MAO inhibitor
Pregnancy
Insomnia
Dry mouth
150 mg QAM
then
150 mg BID
3 days
Maintenance (8 weeks,
but may be used up to 6
months)
Start 1-2 weeks before quit date.
Take second dose in early afternoon or
decrease to 150 mg QAM for insomnia.
Transdermal
Nicotine
Patch**
Within 2 weeks of a MI
Unstable angina
Arrhythmias
Decompensated heart failure
Skin reaction
Insomnia
21 mg QAM
14 mg QAM
7 mg QAM
or
15 mg QAM
4 weeks
2 weeks
2 weeks
8 weeks
Apply to different hairless site
daily.
Remove before bed for insomnia.
Start at <15 mg for <10 cigs/day
*Pharmacotherapy combined with behavioral support provides the best success rate
**Other nicotine replacement therapy options include: nicotine gum, lozenge, inhaler, nasal spray
JAMA 2006:296:47-55 and JAMA 2006;296:56-63
SMOKING CESSATION PHARMACOTHERAPY: VARENICLINESMOKING CESSATION PHARMACOTHERAPY: VARENICLINE
Two trials compared treatment with varenicline, a nicotine acetylcholine receptor agonist, to treatment with buproprion or placebo.
These trials included a total of almost 700 participants. The mean duration of smoking was 25 years.
Varenicline yielded higher rates of smoking cessation than buproprion or placebo.
Study 1p<0.001 for V vs Bp<0.001 for V vs P
Study 2p<0.001 for V vs Bp<0.001 for V vs P
Calculate BMI* and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy.
BMI 18.5 to 24.9 kg/m2
Women: <35 inchesMen: <40 inches
WEIGHT MANAGEMENT GUIDELINESWEIGHT MANAGEMENT GUIDELINES
Start weight management and physical activity as appropriate.
If BMI and/or waist circumference is above goal, initiate caloric restriction, measures to increase caloric expenditure, and treatment strategies for the metabolic syndrome.
BMI=Body mass index
*BMI is calculated as the weight in kilograms divided by the body surface area in meters2.
Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.
10% weight reduction within the first year of
therapy
RECOMMENDATIONSGOALS
PREVALENCE OF OBESITY IN U.S. ADULTSPREVALENCE OF OBESITY IN U.S. ADULTS
1991 1996
2003
% State Population No Data <10% 10%–14% 15%–19% 20%–24% ≥ 25%
Source: CDC Overweight and Obesity
Mhurchu N et al. Int J Epidemiol 2004;33:751-758
0.5
1.0
2.0
4.0
16 20 24 28 32 36
Body Mass Index (kg/m2)*
Haz
ard
Rat
io
0.5
1.0
2.0
4.0
16 20 24 28 32 36
0.5
1.0
2.0
4.0
16 20 24 28 32 36
HemorrhagicStroke
IschemicStroke
Ischemic HeartDisease
CV RISK INCREASES WITH BODY MASS INDEXCV RISK INCREASES WITH BODY MASS INDEX
CV=Cardiovascular
Body mass index is calculated as the weight in kilograms divided by the body surface area in meters2.
DIABETES MELLITUS GUIDELINESDIABETES MELLITUS GUIDELINES
Goal HbA1C <7% Intensive lifestyle modification to prevent the development of DM (especially in those with the metabolic syndrome)
Aggressive management of CV risk factors (i.e., tobacco use, hypertension, dyslipidemia, physical inactivity, and overweight and obese states)
Hypoglycemic therapy to achieve normal to near normal fasting plasma glucose as defined by the HbA1C (<7%)
• Weight reduction and exercise• Oral hypoglycemic agents• Insulin therapy
Coordination of diabetic care with the patient’s primary physician and/or endocrinologist.
CV=Cardiovascular, DM=Diabetes mellitus, HbA1C=Glycosylated hemoglobin
RECOMMENDATIONSGOALS
Assess risk, preferably with exercise test, to guide prescription.
Encourage aerobic activity (e.g., walking, jogging, cycling) supplemented by an increase in daily activities (e.g., walking breaks at work, gardening, household work).
Encourage resistance training (e.g., weight machines, free weights) 2 days a week (Class IIb, Level C)
Encourage cardiac rehabilitation for patients with chronic stable angina, recent myocardial infarction, left ventricular systolic dysfunction, or recent coronary artery bypass graft surgery.
Minimum: 30 minutes,5 days per week
Optimal: 30 minutes daily
EXERCISE GUIDELINESEXERCISE GUIDELINES
RECOMMENDATIONSGOALS
EJECTION FRACTION GUIDELINESEJECTION FRACTION GUIDELINES
Echocardiography in those following a STEMI to re-evaluate ventricular function when results are used to guide therapy*.
Echocardiography or radionuclide angiography in those following a NSTE-ACS when results are used to guide therapy*.
*Includes use of an aldosterone antagonist, digitalis, and/or an implantable cardioverter defibrillator
NSTE-ACS=Non-ST-segment elevation acute coronary syndrome, STEMI=ST-segment elevation myocardial infarction
SECONDARY PREVENTION
80706050403020
54-60 >60
50
40
30
20
10
0
<30
31-35
36-45
46-53
Car
diac
Mor
talit
y %
Brodie B et al. Am J Cardiol 1992;69:1113
RELATIONSHIP BETWEEN EF* AND MORTALITYRELATIONSHIP BETWEEN EF* AND MORTALITY
Ejection Fraction (%)
*Post myocardial infarction
EF=Ejection fraction
RR = 0.85, P=0.008
6 12 18 24 30 360
5
10
15
20
25
0
Month
ALDOSTERONE ANTAGONIST: SECONDARY PREVENTIONALDOSTERONE ANTAGONIST: SECONDARY PREVENTION
EPLERENONE POCT-ACUTE MYOCARDIAL INFARCTION HEART FAILURE EFFICACY AND SURVIVAL STUDY (EPHESUS)
EplerenonePlacebo
3,313 patients with evidence of heart failure and LVSD (EF <0.40) after a MI randomized to eplerenone (50 mg) or placebo for 16 months
Pitt B et al. NEJM 2003;348:1309-21
EF=Ejection fraction, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction
Aldosterone inhibition provides significant benefit in patients with post-MI heart failure and LVSD
All
Cau
se M
ort
alit
y (%
)
ICD ALGORITHMICD ALGORITHM
EF < 30%
EPS
Yes
+
NEJM 349:1836,2003
EF 31-40%
No
No ICD.Medical Rx
EF > 40%
–
AT LEAST ONE MONTH FOLLOWING A MYOCARDIAL INFARCTION
EF=Ejection fraction, EPS=Electrophysiology study, ICD=Implantable cardioverter defibrillator, Rx=Treatment, SCD=Sudden cardiac death,
1 Moss AJ. N Engl J Med. 1996;335:1933-19402 Buxton AE. N Engl J Med. 1999;341:1882-18903 Moss AF. N Engl J Med. 2002;346:877-883
1 2 3
54%
75%
55%
73%
31%
61%
27 Months 39 Months 20 Months
% M
ort
alit
y R
edu
ctio
n w
/ IC
D R
xICD: SECONDARY PREVENTION*ICD: SECONDARY PREVENTION*
*Primary prevention of sudden cardiac death
Overall death
Arrhythmic death
EF <35% EF <40% EF <30%
PREVENTION PYRAMID
ACE-1 = angiotensin converting enzyme inhibitor; ASA = aspirin
Secondary
Primary
Primordial
ASAACE-IRehab
β-blockers+Primary
LipidsHypertension
Smoking cessationDiabetes
+Primordial
Physical activityHealthy eatingIdeal weight
Psychosocial factorsFamilial predisposition