Transcript Introduction - American College of Cardiology Puerto Rico

Guidelines Applied to Practice
(GAP)
American College of Cardiology,
Puerto Rico Chapter
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
American College of Cardiology Puerto Rico
Chapter
February 6, 2006
Eduardo J. Viruet M.D., F.A.C.C.
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• 68-year-old man with history of
dyslipidemia, arterial hypertension and
Diabetes Mellitus II
• Chest discomfort associated to strenuous
physical activity
• LDL levels = 170 mg/dl
What is the adequate initial therapy?
What preventive measures should be taken ?
Pharmacotherapy for Chronic
Stable Angina Pectoris
• Pharmacotherapy to Prevent MI
and Death
• Pharmacotherapy to Reduce
Ischemia and Relieve Symptoms
Pharmacotherapy for Chronic
Stable Angina Pectoris
Therapy to Prevent MI and Death
• Aspirin
• Beta Blockers
• Statins
• ACE inhibitors
Pharmacotherapy for Chronic
Stable Angina Pectoris
Therapy to Reduce Ischemia and
Relieve Symptoms
• Nitrates
• Beta Blockers
• Calcium channel Blockers
Pharmacotherapy for Chronic
Stable Angina Pectoris
ABCDE Formula
– ASA and antianginal
– Beta-blockers and blood
pressure
– Cholesterol and cigarettes
– Diet and diabetes mellitus
– Education and exercise
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.
I IIa IIb III
•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 Recommendations
Goal: <140/90 mm Hg or <130/80 if
diabetes or chronic kidney disease
I IIa IIb III
I IIa IIb III
Blood pressure 120/80 mm Hg or greater:
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 greater (or 130/80 or
greater 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
Physical Activity Recommendations
I IIa IIb III
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
I IIa IIb III
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
I IIa IIb III
Advise medically supervised programs for high-risk
patients (e.g. recent acute coronary syndrome or
revascularization, HF)
Lipid Management Goal
I IIa IIb III
LDL-C should be less than 100 mg/dL
I IIa IIb III
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 Goals: NCEP
Risk Category
High risk:
CHD or CHD risk equivalents
(10-year risk >20%)
and
Very high risk:
ACS or established CHD
plus: multiple major risk
factors (especially diabetes) or
severe and poorly controlled
risk factors
Consider
Drug Therapy
LDL-C and non-HDLC Goal
Initiate TLC
<100 mg/dL
if TG > 200 mg/dL,
non-HDL-C should
be < 130 mg/dL
100 mg/dL
>100 mg/dL
(<100 mg/dL: consider drug
options)
<70 mg/dL,
non-HDL-C < 100
mg/dL
All patients
>100 mg/dL
(<100 mg/dL: consider drug
options)
ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol,
TLC=Therapeutic lifestyle changes
Grundy, S. et al. Circulation 2004;110:227-39.
Lipid Management Recommendations
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 according to the following schedule:
I IIa IIb III
If baseline LDL-C > 100 mg/dL, initiate LDL-lowering
drug therapy
I IIa IIb III
I IIa IIb III
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
When LDL lowering medications are used, obtain at least a 30-40% reduction in LDL-C
levels.
Lipid Management Recommendations
I IIa IIb III
If TG are 200-499 mg/dL, non-HDL-C should be < 130
mg/dL
I IIa IIb III
Further reduction of non-HDL to < 100 mg/dL is
reasonable
I IIa IIb III
Therapeutic options to reduce non-HDL-C:
More intense LDL-C lowering therapy I (B) or
Niacin (after LDL-C lowering therapy) IIa (B) or
Fibrate (after LDL-C lowering therapy) IIa (B)
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
Weight Management Recommendations
I IIa IIb III
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 an appropriate balance of physical activity,
caloric intake, and formal behavioral programs when indicated.
I IIa IIb III
I IIa IIb III
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.
*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.
Diabetes Mellitus Recommendations
Goal: Hb A1c < 7%
I IIa IIb III
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (<7%).
I IIa IIb III
Vigorous modification of other risk factors (e.g.,
physical activity, weight management, blood
pressure control, and cholesterol management as
recommended).
I IIa IIb III
Coordinate diabetic care with patient’s primary
care physician or endocrinologist. )
HbA1c = Glycosylated hemoglobin
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• 65-year-old woman with history of Diabetes
Mellitus II, and arterial hypertension
• Chest discomfort and fatigue at minimal physical
activity on optimal medical therapy
• Patients also complains of leg swelling, 2 pillows
orthopnea, dyspnea on exercise
What will be the adequate diagnostic test?
Invasive Testing in Chronic
Stable Angina
Recommendations for Coronary Angiography
• Patients with disabling (Canadian
Cardiovascular
Society [CCS] classes III and IV) chronic
stable angina despite medical therapy
• Patients with high-risk criteria on clinical
assessment or noninvasive testing
regardless of anginal severity
Invasive Testing in Chronic
Stable Angina
Recommendations for Coronary Angiography
• Patients with angina who have survived
sudden cardiac death or serious
ventricular arrhythmia
• Patients with angina and symptoms and
signs of congestive heart failure
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• 64 years old male with history of arterial
hypertension and chronic smoking
• Complaining of chest pain with moderate
physical activity
• Baseline EKG shows CLBBB
What will be the adequate diagnostic test?
Cardiac Stress Imaging in Patients
With Chronic Stable Angina
• Abnormal rest ECG or are using digoxin
• LBBB or electronically paced ventricular
rhythm
• Prior revascularization (either PCI or
CABG) pre-excitation
• Wolff-Parkinson-White syndrome
or more than 1 mm of rest ST depression
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• 48 years old male with history of arterial
hypertension and dyslipidemia
• Family history of premature CAD
• Complains of neck and left shoulder pain
with moderate exercise
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• EKG with inverted T waves in anterior
leads
• Exercise stress test with myocardial
perfusion showed stress induced large
anterior ischemic defect
What is the next step of therapy?
High-risk criteria on noninvasive testing
• Severe resting left ventricular dysfunction
(LVEF < 35%)
• High-risk treadmill score (score ≤-11)
• Severe exercise left ventricular dysfunction
(exercise LVEF <35%)
High-risk criteria on noninvasive testing
• Stress-induced large perfusion defect
• Stress-induced multiple perfusion defects
of moderate size
• Large, fixed perfusion defect with LV
dilation or increased lung uptake
(thallium-201)
High-risk criteria on noninvasive testing
• Stress-induced moderate perfusion defect with
LV dilation or increased lung uptake (thallium201)
• Echocardiographic wall motion abnormality
(involving greater than two segments)
developing at low dose of dobutamine (≤10
mg/kg/min) or at a low heart rate (<120
beats/min)
• Stress echocardiographic evidence of extensive
ischemia
Guías de Cardiología Aplicadas a la Práctica
Casos Clínicos
• 68 years old female with history of
Diabetes Mellitus II and dyslipidemia
• History of “heart attack “ in the past
• EKG shows inferior Q waves
• Asymptomatic at this moment
What is the next step of therapy?
Pharmacotherapy to Prevent MI and Death
in Asymptomatic Patients
• Aspirin in the absence of contraindication
in patients with prior MI
• Beta blockers as initial therapy in the
absence of contraindications in patients
with prior MI
Pharmacotherapy to Prevent MI and Death
in Asymptomatic Patients
• Low-density lipoprotein-lowering therapy
in patients with documented CAD and LDL
cholesterol greater than 130 mg/dL, with
a target LDL of less than 100 mg/dL
• ACE inhibitor in patients with CAD1 who
also have diabetes and/or systolic
dysfunction
Guidelines Applied to Practice
(GAP)
American College of Cardiology,
Puerto Rico Chapter
GAP
Casos Clínicos
American College of Cardiology
Puerto Rico Chapter
San Juan Intercontinental; Febrero 6: Eduardo J. Viruet MD
Casa del Médico, Mayaguez; Febrero 7: Francisco Jaume MD
Casa del Médico, Ponce; Febrero 8: Nélida González MD