Transcript Valvular Heart Disease

Cardiovascular Risk Factors
Gregory Hill, DO
Interim CV Fellowship Program Director
OSU Division of Cardiovascular Disease
September 28,2006
Cardiovascular Risk Factors
• Format for this lecture
– KNOW COLD
for current test
– IMPORTANT CLINICAL INFO
know for boards, tests and clinical practice
Cardiovascular Risk Factors (CVRF)
• What is the significant of CVRF?
Ischemic Heart Disease

Single Largest Cause of Death since 1900 (except 1918)

12,200,000 people in the US have had an MI, angina
pectoris, or both

1,433,000 Americans hospitalized for IHD in 1996
- 225,000 died before hospital

1,100,000 Americans will have a new or repeat IHD
event this year

Nearly 2,600 Americans die of CVD each day, an
average of 1 death every 34 seconds
WHO – 2000, NCHS 2000, AHA - 2000 Heart and Stroke Statistical
Update, National Health and Nutrition Examination Survey III
Cardiovascular Risk
Rank of Age Related Death Rate in U.S. (2000)
Total CV Disease # 2
Coronary HD # 2
Heart Disease and Stroke Statistics, AHA 2004
Cardiovascular Risk Factors (CVRF)
• A 35 yo white male presents to the ER with a dull
substernal chest pain
– What is the etiology of his chest pain?
– Are you going to discharge him from the ER or
admit him?
– Do we have enough information to make a
decision on treatment?
Cardiovascular Risk Factors (CVRF)
• A 60 yo black female wants to know what is her
risk for having a heart attack
– What is her risk?
– Do you need to start her on a cholesterol
lowering medication?
Cardiovascular Risk Factors (CVRF)
What is the significant of CVRF?
1.
A number of diseases have been identified as independent predictors
for CAD and CV events and are refer to as CVRF
2.
By controlling these CVRF, MI, death, CV events and prognosis can
improve
3.
Guidelines have been established to guide us as to how to treat these
conditions to better care for our pts
One of the oldest studies of CVRF and CV disease was first initiated in
1948 and is still on-going. Much of our knowledge today is attributed to
the Framingham Heart Study. Thus, CVRF are frequently referred to as
Framingham Risk Factors.
Background
• Guidelines for the management of CVRF have been developed
based on hundreds of clinical trials, from panels of expert
opinions and recommendation from the various colleges of
medicine
• Guidelines do not represent the final answer but are a work in
progress, provide a sound scientific basis to care for your pt and
need to be individualize for each patient
– eliminates treating pts based on personal experience of a few dozen,
to universal expert experience from treating thousands of pts
supported by Evidenced Based Medicine (EBM)
Recommendations from EBM
EBM Resources
ATP III Adult Treatment Panel III from the National Cholesterol Education
Program
NJC 7
7th Report from the National Joint Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood Pressure
CV Risk Assessment
• What diseases have been identified as independent
Risk Factors?
• Who is at high risk for developing CAD or a CV
events?
CV Risk Assessment
• What diseases have been identified as independent
Risk Factors?
•
•
•
•
•
•
Dyslipidemia
Hypertension
Tobacco Use
Diabetes
Age (men 45 years; women 55 years)
Family History of premature CAD
 CHD in male first degree relative <55 years
 CHD in female first degree relative <65 years
CV Risk Assessment
• Who is at high risk for developing CAD or a CV
event?
Estimate the 10 yr risk Assessment via
the Framingham Risk Score
CV Risk Assessment
• Who is at high risk for developing CAD or a CV
event?
Simplified 10 yr risk Assessment:
 >20% Risk – High CAD or its Equivalent
 10-20% Risk – Intermediate 2 or more RF
 <10% Risk – Low 0-1 RF
CV Risk Assessment
• Who is at high risk for developing CAD or a CV
event?
High Risk Group: >20% CAD or its Equivalent
CAD – MI, Abn Stress Test, Cath, Cardiac CT
CAD Equivalents
DM
Symptomatic Carotid disease (CVA,TIA)
PVD (Aneurysm, Abn Test – ABIs)
CV Risk Assessment
• Who is at high risk for developing CAD or a CV
event?
Simplified 10 yr risk Assessment:
 >20% Risk – High CAD or its Equivalent
Easily addressed, treat aggressively to prevent
progression
 10-20% Risk – Intermediate 2 or more RF
 <10% Risk – Low 0-1 RF
Easily addressed, do not need Chol meds, just
treat underlying condition
CV Risk Assessment
• Who is at high risk for developing CAD or a CV
event?
Simplified 10 yr risk Assessment:
 >20% Risk – High CAD or its Equivalent
 10-20% Risk – Intermediate 2 or more RF
This group is very important to address for
primary prevention and deciding when to start /
adjust chol meds
 <10% Risk – Low 0-1 RF
In ATP III, diabetes is regarded as a
CHD risk equivalent.
In ATP III, diabetes is regarded as a
CHD risk equivalent.
High mortality in DM with established CHD
– High mortality with acute MI
– High mortality post acute MI
Importance of Cholesterol
Viewing a patient’s cholesterol
VLDL3: Most dense
VLDL subclass.
Atherogenic
IDL: An
intermediate in
VLDL catabolism.
Atherogenic
Pattern A:
Predominance of
large, buoyant LDL
“Low/Ideal Risk”
B
B
B
HDL2:
Subclasses of
larger, buoyant
HDL. “Highly
protective”
HDL3:
Subclasses of
smaller, dense
HDL. “Least
protective”
B
IDL Remnants
DECREASING DENSITY
Pattern B:
Predominance
of dense LDL.
“Highest Risk”
B
VLDL-C
B
Buoyant LDL
B
Dense
LDL
TG-RICH LIPOPROTEINS
B
B
B B
B
B
A
HDL2
B
LDL-C
B
B B
A
A
HDL-C
INCREASING SIZE
Total LDL: The end product of
VLDL catabolism.
Lp(a): Consists of LDL plus a protein called apo(a).
“Heart attack” cholesterol.
10X Greater risk than LDL alone
A
HDL3 A
Total VLDL:
Main carrier of
triglycerides.
Elevated levels
shown to
contribute to
increased risk
for CAD.
Total HDL
B = All Lipoproteins containing an ApoB 100
A = All Lipoproteins containing an ApoAI &/or AII
Importance of Cholesterol
Fasting Lipid Profile
• Total Cholesterol
• HDL – Good
• LDL – Bad
• Triglycerides
Importance of Cholesterol (LDL)
LDL given by most labs is a calculated
value and not directly measured
Friedewald formula
LDL-C = TC - HDL-C – Tg / 5
Valid for Tg < 400 mg / dL
For Tg levels above 400, direct LDL level will need to be obtained
Importance of Cholesterol (LDL)
Log-Linear Relationship Between
LDL-C Levels and Relative Risk for CHD
3.7
2.9
Relative Risk 2.2
for Coronary
Heart Disease 1.7
(Log Scale) 1.3
1.0
40
70
100
130
160
190
LDL-Cholesterol (mg/dL)
Grund y, S. et al., Circul ation 2004;110:227-39.
LDL is the Primary Target for Therapy
The benefits of treating Cholesterol
ATP III Recommendations for treating
Dyslipidemia (LDL)
1.
Determine what is the pts cholesterol levels
2.
Does the pt have CAD or its equivalent? (PVD, DM)
3.
Determine the presence of major risk factors
4.
Determine the risk
>20% Risk – CAD or its Equivalent
10-20% Risk – 2 or more RF
<10% Risk – 0-1 RF
ATP III Recommendations for treating
Dyslipidemia (LDL)
Major Risk Factors (Exclusive of LDL
Cholesterol) That Modify LDL Goals
• Cigarette smoking
• Hypertension (BP 140/90 mmHg or on anti-hypertensive
medication)
• Low HDL cholesterol (<40 mg/dL)†
• Family history of premature CHD
– CHD in male first degree relative < 55 years
– CHD in female first degree relative < 65 years
• Age (men  45 years; women  55 years)
HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence
removes one risk factor from the total count.
†
ATP III Recommendations for treating
Dyslipidemia (LDL)
Treatment of dyslipidemia is based on the Risk
Category which determines:
• LDL goal of therapy
• The level for therapeutic lifestyle changes (TLC)
• The level for drug consideration
ATP III Recommendations for treating
Dyslipidemia (LDL)
ATP III Recommendations for treating
Dyslipidemia (LDL)
ATP III Recommendations for treating
Dyslipidemia (LDL)
Categories of Lipid Lowering Medications
- HMG CoA Reductase Inhibitors (Statins)
- Bile Acid Sequestrants
- Nicotinic Acid
- Fibric Acids
HMG CoA Reductase Inhibitors (Statins)
Statin Dose Range
Lovastatin
20–80 mg
Pravastatin
20–40 mg
Simvastatin
20–80 mg
Fluvastatin
20–80 mg
Atorvastatin
10–80 mg
Cerivastatin
10–20 mg
HMG CoA Reductase Inhibitors (Statins)
Demonstrated Therapeutic Benefits
• Reduce major coronary events
• Reduce CHD mortality
• Reduce coronary procedures (PTCA/CABG)
• Reduce stroke
• Reduce total mortality
Hypertension
1. HTN prevalence ~ 50 million people in the United
States.
2. The BP relationship to risk of CVD is continuous,
consistent, and independent of other risk factors.
3. Each increment of 20/10 mmHg doubles the risk of
CVD across the entire BP range starting from 115/75
mmHg.
Average Percent Reduction
Stroke incidence
35–40%
Myocardial infarction
20–25%
Heart failure
50%
NJC 7 Recommendations
BP
SBP*
DBP*
Lifestyle
classification
mmHg
mmHg
modification
Normal
<120
and
<80
Encourage
Prehypertension
120–
139
or 80–
89
Yes
No antihypertensive
drug indicated.
Stage 1
140–
159
or 90–
99
Yes
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB,
or combination.
>160
or
>100
Yes
Hypertension
Stage 2
Hypertension
Initial drug therapy
Without compelling
indication
With compelling
indications
Drug(s) for
compelling
indications. ‡
Drug(s) for the
compelling
indications.‡
Other
antihypertensive
Two-drug combination
drugs (diuretics,
for most† (usually
ACEI, ARB, BB,
thiazide-type diuretic
and ACEI or ARB or BB CCB) as needed.
or CCB).
Metabolic Syndrome
• Comprised of a cluster of metabolic risk factors that when
they occur in an individual put them at increase risk for
CAD or CV events
• Includes risks that are not included in the CVRF
• Main characteristics include obesity, HTN, insulin
resistance and high cholesterol
Metabolic Syndrome
Metabolic Syndrome
Other Markers which may predict
cardiovascular disease
• C-Reactive Protein
• Lipoprotein (a)
• Homocysteine
• Prothrombotic factors
• Proinflammatory factors
• Impaired fasting glucose
• Subclinical atherosclerosis
High Sensitivity c-Reactive Protein (hsCRP)
• One of the acute phase reactant proteins
• Plasma concentration increases with certain inflammatory
states
• The pathophysiologic mechanisms involved with CAD
involves inflammation of the coronary arteries.
• Has been identified as a independent risk factor for CAD
• Although treating underlying CAD is associated at lowering
CRP, it uncertain in the benefit of targeting CRP levels will
have on the progression or prognosis of CAD
Other Markers which may predict
cardiovascular disease
• C-Reactive Protein
• Lipoprotein (a)
• Homocysteine
• Prothrombotic factors
• Proinflammatory factors
• Impaired fasting glucose
• Subclinical atherosclerosis
Total Coronary Artery Plaque
and EBT Coronary Calcium
Fibrotic &
Calcified
20%
66%
Fibrotic
33%
Lipid
Rich
Plaque
Detectable
by IVUS,
Pathology
80%
Examples of Coronary Artery CT Scans
Normal
Condition
Moderate
Calcification
Severe
Calcification
Percent (%) Incidence
Incidence of Identifiable Coronary Calcium by EBT
in a Group of Asymptomatic Men and Women
100
Men (%)
94
Women (%)
80
85
72
100 100
89
67
60
44
35
40
23
21
20
11
11
6
0
20-29
30-39
40-49
50-59
60-69
Age by Decade (years)
Janowitz, et al, AJC 1993
70-79
80-89
Mortality in Asymptomatic Patients
(5 year follow-up)
Absolute Mortality:
[%]
RF-adjusted Survival:
15
15
1.0
Cumulative Survival
Score:
12
12
99
66
33
00
<10
<10
10-100
10-100 100-400
100-400 400-1000
400-1000 >1000
>1000
Score-Groups
Callister et al. , JACC 39: Suppl A-827: 2002
0.99
<10
0.98
10-100
100-400
0.97
400-1000
0.96
n = 10.377
p < 0.001
0.95
>1000
0.94
0
500
1000
1500
Time in Days
Time in days
2000
CAC Risk Prediction in Comparison to
RF in Asymptomatic Subjects
1172 asymptomatic subjects, age 53 ± 11 years, 3.6 years
follow-up: 36 events - 3 deaths, 15 MI, 21 revascularizations





Age
TC
RR
DM
Calcium
3.3 (1.3 - 8.4)
4.0 (1.3 - 12.2)
2.6 (1.1 - 6.1) Odds ratio
4.8 (1.6 - 13.9)
14.3 (4.9 - 42.3) RR = 12
Arad et al , Circulation 13: 1951- 3, 1996
Arad et al , J Am Coll Cardiol 36: 1253 - 60, 2000
Relative Risk of Different Risk Factors
for Future Coronary Events
Lipoprotein (a)
Univariate Analysis for
cardiac death, AMI,Rx
Homocystein
Total Cholesterol (TC)
n = 28.263
* n = 4.348
LDL-Cholesterol (LDLC)
TC/HDLC-Ratio
HS-CRP
*
Calcium Score
0
0.5
1
2
3
4
5
6
7
8
9
10
Relative Risk of Future Cardiovascular Events
Ridker PM, Circulation 103: 1813, 2001
O‘Malley PG et al., Am J Cardiol 85: 945, 2001
11
Limitations of CVRF

Even though the CVRF are the cornerstone for identifying
pt with CAD, at best it is approximately 60% accurate

35% of patients with CAD have a total cholesterol <200

Estimate risk (Framingham RF) to predict
the probability of disease == presence of disease
Cardiovascular Risk Factors (CVRF)
A 35 yo white male presents to the ER with a dull
substernal chest pain
• No history of HTN, DM, Chol has been normal, no
family history of CAD, he is a non-smoker
• Symptoms are non-exertional, PE, labs ECG are
normal
Dx and Plan: chest pain is non-cardiac and pt
was discharged to follow up up with his PCP
Cardiovascular Risk Factors (CVRF)
A 60 yo black female wants to know what is her risk
for having a heart attack
– What is her risk?
– Do you need to start her on a cholesterol
lowering medication?
Cardiovascular Risk Factors (CVRF)
A 60 yo black female wants to know what is her risk
for having a heart attack
 Current smoker, history of DM and poorly controlled
HTN, no family history
 FLP: TC=284, LDL=165, HDL=30
CV Risk: >20%
Recom: Low chol, ADA diet, aggressive BP &DM control,
DC smoking, exercise Rx, initiation of statin therapy
Thank you and
Good Luck