Transcript Lipid Management - Home - KSU Faculty Member websites

Basma Y. Kentab
Why Is It Necessary??
Aggressive comprehensive risk factor management:
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Improves survival,
Reduces recurrent events and
Reduces need for interventional procedures,
Improves the quality of life
AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other
Atherosclerotic Vascular Disease: 2006 Update
Secondary Prevention Definition
Therapy to reduce recurrent cardiovascular events and
decrease cardiovascular mortality in patients with
established atherosclerotic vascular disease
Secondary Prevention Patient Population
Established coronary and other atherosclerotic
vascular disease, including:
• Peripheral arterial disease,
• Atherosclerotic aortic disease
• Carotid artery disease
Components of Secondary Prevention
Cigarette smoking cessation
Blood pressure control
Lipid management to goal
Physical activity
Weight management to goal
Diabetes management to goal
Antiplatelet agents / anticoagulants
Renin angiotensin aldosterone system blockers
Beta blockers
Influenza vaccination
Cigarette Smoking Recommendations
Goal: Complete Cessation and No Exposure to
Environmental Tobacco Smoke
•Ask about tobacco use status at every visit.
•Advise every tobacco user to quit.
•Assess the tobacco user’s willingness to quit.
•Assist by counseling and developing a plan for
quitting.
•Arrange follow-up, referral to special programs, or
pharmacotherapy (including nicotine replacement
and bupropion)
•Urge avoidance of exposure to environmental
tobacco smoke at work and home.
Blood Pressure Control
Goal: <140/90 mm Hg or <130/80 if diabetes or
chronic kidney disease
Blood pressure ≥ 120/80 mm Hg :
Initiate or maintain lifestyle modification: weight control,
increased physical activity, alcohol moderation, sodium
reduction, and increased consumption of fresh fruits vegetables
and low fat dairy products
Blood pressure ≥ 140/90 mm Hg (or ≥ 130/80 for
chronic kidney disease or diabetes)
As tolerated, add blood pressure medication, treating initially
with beta blockers and/or ACE inhibitors with addition of other
drugs such as thiazides as needed to achieve goal blood
pressure
Lipid Management
Lipid Management Goal
 LDL-C should be less than 100 mg/dL
 Further reduction to LDL-C to < 70 mg/dL is
reasonable
 If TG >200 mg/dL, non-HDL-C should be < 130
mg/dL*
*Non-HDL-C = total cholesterol minus HDL-C
Lipid Management
For All Patients
Start dietary therapy (<7% of total calories as saturated fat and
<200 mg/d cholesterol)
 Adding plant stanol/sterols (2 gm/day) and fiber (>10 mg/day)
will further lower LDL
 Promote daily physical activity and weight management.
 Encourage increased consumption of omega-3 fatty acids in
fish or 1 g/day omega-3 fatty acids in capsule form for risk
reduction.
Lipid Management
 Assess fasting lipid profile in all patients, and within 24 hours
of hospitalization for those with an acute event.
 For patients hospitalized, initiate lipid-lowering medication as
recommended below prior to discharge:
• If baseline LDL-C > 100 mg/dL, initiate LDL-lowering
drug therapy
• If on-treatment LDL-C > 100 mg/dL, intensify LDLlowering drug therapy (may require LDL lowering drug
combination)
• If baseline is LDL-C 70 to 100 mg/dL, it is reasonable
to treat to LDL < 70 mg/dL
Lipid Management
• If TG are 200-499 mg/dL, non-HDL-C should be < 130
mg/dL
• Further reduction of non-HDL to < 100 mg/dL is
reasonable
• Therapeutic options to reduce non-HDL-C:
- More intense LDL-C lowering therapy or
- Niacin (after LDL-C lowering therapy)
- Fibrate (after LDL-C lowering therapy)
• If TG are > 500 mg/dL, therapeutic options to prevent
pancreatitis are fibrate or niacin before LDL lowering
therapy; and treat LDL-C to goal after TG-lowering
therapy. Achieve non-HDL-C < 130 mg/dL, if possible
Physical Activity Recommendations
Goal: 30 minutes 7 days/week, minimum 5 days/week
 Assess risk with a physical activity history and/or an
exercise test, to guide prescription
 Encourage 30 to 60 minutes of moderate intensity
aerobic activity such as brisk walking, on most,
preferably all, days of the week, supplemented by an
increase in daily lifestyle activities
 Advise medically supervised programs for high-risk
patients (e.g. recent acute coronary syndrome or
revascularization, HF)
Weight Management Recommendations
Goal: BMI 18.5 to 24.9 kg/m2
Waist Circumference: Men: < 40 inches Women: < 35 inches
 Assess BMI and/or waist circumference on each visit and
consistently encourage weight maintenance/reduction through
appropriate balance of physical activity, caloric intake, and formal
behavioral programs
 If waist circumference (measured at the iliac crest) >35 inches
in women and >40 inches in men initiate lifestyle changes and
consider treatment strategies for metabolic syndrome as
indicated.
 The initial goal of weight loss therapy should be to reduce
body weight by approximately 10 percent from baseline. With
success, further weight loss can be attempted if indicated.
Diabetes Mellitus Recommendations
Goal: Hb A1c < 7%
 Lifestyle and pharmacotherapy to achieve near normal
HbA1C (<7%).
 Vigorous modification of other risk factors (e.g., physical
activity, weight management, blood pressure control, and
cholesterol management as recommended).
 Coordinate diabetic care with patient’s primary care
physician or endocrinologist.
Antiplatelet Agents / Anticoagulation
Recommendations
Aspirin Recommendations
 Start and continue indefinitely aspirin 75 to 162
mg/d in all patients unless contraindicated
 For patients undergoing CABG, aspirin (100 to 325
mg/d) should be started within 48 hours after surgery
to reduce saphenous vein graft closure
 Post-PCI-stented patients should receive 325 mg
per day of aspirin for 1 month for bare metal stent, 3
months for sirolimus-eluting stent and 6 months for
paclitaxel-eluting stent
Clopidogrel Recommendations
 Start and continue clopidogrel 75 mg/d in
combination with aspirin :
– for post ACS or post PCI with stent placement patients for up
to 12 months
–for post PCI-stented patients
• >1 month for bare metal stent,
• >3 months for sirolimus-eluting stent
• >6 months for paclitaxel-eluting stent
Anticoagulation Recommendations
Manage warfarin to international normalized ratio 2.0
to 3.0 for paroxysmal or chronic atrial fibrillation or
flutter, and in post-MI patients when clinically
indicated (e.g., atrial fibrillation, LV thrombus.)
Use of warfarin in conjunction with aspirin and/or
clopidogrel is associated with increased risk of
bleeding and should be monitored closely
Renin-Angiotensin-Aldosterone System
Blockers Recommendations
ACE inhibitor Recommendations
 Use in all patients with LVEF < 40%, and those with
diabetes or chronic kidney disease indefinitely,
unless contraindicated
 Consider for all other patients
 Among lower risk patients with normal LVEF where
cardiovascular risk factors are well controlled and
where revascularization has been performed, their
use may be considered optional
Angiotensen Receptor Blockers
Recommendations
 Use in patients who are intolerant of ACE inhibitors
with HF or post MI with LVEF less than or equal to
40%.
 Consider in other patients who are ACE inhibitor
intolerant.
 Consider use in combination with ACE inhibitors in
systolic dysfunction HF.
Aldosterone Antagonists
Recommendations
 Use in post MI patients, without significant renal
dysfunction or hyperkalemia, who are already
receiving therapeutic doses of an ACE inhibitor and
beta blocker, have an LVEF < 40% and either
diabetes or heart failure
 Contraindications include abnormal renal function
(creatinine >2.5 mg/dL in men or >2.0 mg/dL in
women) and hyperkalemia (K+ >5.0 meq/L)
β-Blockers Recommendations
 Start and continue indefinitely in all post MI, ACS,
LV dysfunction with or without HF symptoms, unless
contraindicated.
 Consider chronic therapy for all other patients with
coronary or other vascular disease or diabetes
unless contraindicated.
Influenza Vaccination
Patients with cardiovascular disease should have
influenza vaccination