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

Goal

Complete 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

<140/90

Or

<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 < 100

If 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?