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Global CVD Management Vascular Health Integration Joel Niznick MD FRCPC Continuing Medical Implementation ® …...bridging the care gap CHD Depression CBVD Special populations PVD GerioVascular Disease CKD PATIENT Women’s Health Thrombosis Obesity Smoking HTN DM Metabolic LIPID Syndrome Continuing Medical Implementation ® …...bridging the care gap Depression PATIENT CHD Special populations GerioVascular Disease CBVD PVD Vascular Medicine Integration Women’s Health Smoking CKD Thrombosis DM Obesity Metabolic Syndrome Continuing Medical Implementation ® LIPID HTN …...bridging the care gap Depression PATIENT CHD Special populations GerioVascular Disease CBVD PVD Vascular Medicine Training Program Women’s Health Smoking CKD Thrombosis DM Obesity Metabolic Syndrome Continuing Medical Implementation ® LIPID HTN …...bridging the care gap Depression PATIENT CHD Special populations GerioVascular Disease CBVD PVD Vascular Medicine Specialist Women’s Health Smoking CKD Thrombosis DM Obesity Metabolic Syndrome Continuing Medical Implementation ® LIPID HTN …...bridging the care gap Depression PATIENT CHD Special populations GerioVascular Disease CBVD PVD Vascular Medicine Program Women’s Health Smoking CKD Thrombosis DM Obesity Metabolic Syndrome Continuing Medical Implementation ® LIPID HTN …...bridging the care gap Vascular Health Integration • • • • • • • • • • Continuing Medical Implementation ® Medicine Cardiology Neurology Endocrinology Nephrology Thrombosis Geriatrics Vascular Surgery Women's Health Psychiatry …...bridging the care gap Vascular Health Institute • • • • • • • • • • Medicine Cardiology Neurology Endocrinology Nephrology Thrombosis Geriatrics Vascular Surgery Women's Health Psychiatry Continuing Medical Implementation ® • • • • • • • • • Physician Nurse Pharmacist Nutritionist Physiotherapist Kinesiologist Social Worker Epidemiologist Educator …...bridging the care gap PLATINUM Program Program to Limit Atherosclerosis, Thrombosis, Ischaemia and Nephropathy through Universal Management Continuing Medical Implementation ® …...bridging the care gap PLATINUM Program PLATINUM HOP to ITT LOT to ITT EMERALD DELIVER GOLD DIAMOND AMETHYST SILVER Continuing Medical Implementation ® …...bridging the care gap PLATINUM Program DELIVER PLATINUM HOP to ITT LOT to ITT GOLD Continuing Medical Implementation ® EMERALD DIAMOND AMETHYST SILVER …...bridging the care gap PLATINUM Program • • • • DELIVER – Diet, Exercise and Lifestyle to Implement Vascular Event Reduction EMERALD – Evaluation of Metabolic Syndrome for Reduction of Atherosclerosis, Lipids and Diabetes DIAMOND – Diabetes Atherosclerosis Management for Outcome and Nephropathy Delay AMETHYST – Atherosclerosis Management for Effective Treatment of Hypertension and Systemic TOD Continuing Medical Implementation ® • • • • GOLD – Glucose Optimization for Longevity in Diabetics SILVER – Smoking Intervention for Longevity through Vascular Event Reduction LOT to ITT – Lipid Optimization Tool to Implement Treatment Targets HOP to ITT – Hypertension Optimization Program to Implement Treatment Targets …...bridging the care gap Evidence Based Implementation Tools CME CMI A New Paradigm Continuing Medical Implementation® CMI Continuing Medical Implementation ® …...bridging the care gap www.cvtoolbox.com Continuing Medical Implementation ® …...bridging the care gap www.cvtoolbox.com Continuing Medical Implementation ® …...bridging the care gap www.cvtoolbox.com Continuing Medical Implementation ® …...bridging the care gap Guide for Comprehensive Cardiovascular Risk Reduction Patients with Coronary, Other Vascular Disease or DM Patient: _______________________________ Diagnosis: _____________________________ Rx () Intervention Recommendations SMOKING Goal-Complete cessation LIPID MANAGEMENT Primary goal * LDL 2.5 (1.8) mmol/L Secondary goal * TC/HDL 4 Tertiary goal * Metabolic Syndrome TG 1.7 mmol/L HDL 1.0mmol/L(men)/ 1.3mmol/L (women) CWG on Hypercholesterolemia and other Dyslipidemias * NCEP ATP III Revision 2004 HYPERTENSION Goal 135/85 mm Hg 2005 CHS www.hypertension.ca Earlier Dx is key Rx: BP control supersedes pleiotropic benefit DIABETES 2003 CDA Guidelines released Dec 2003 PHYSICAL ACTIVITY Minimum goal 30 minutes 3 to 5 times/week HR guided OBESITY/WEIGHT MANAGEMENT ANTIPLATELET AGENTS/ ANTICOAGULANTS: ACE INHIBITORS Post-MI/LV Dysfunction: ACE INHIBITORS § Vascular disease/Diabetes BETA-BLOCKERS: POST-MI BETA-BLOCKERS CHF † HOMOCYST(E)INE Target 10 mmol/L ESTROGENS Strongly encourage patient and family to stop smoking. Provide counselling, nicotine replacement, and formal cessation programs as appropriate. Start hypolipidemic diet in all patients: 30% fat,7%saturated fat, 200mg/day cholesterol. 10 % LDL achievable with diet. Assess fasting lipid profile. Baseline lipid profile < 24 hrs. after acute event. In post -MI patients, lipid profile may take 4 to 6 weeks to stabilize. Add drug therapy according to the following guide: LIPID Profile 1st Line Therapy 2nd Line Therapy Statin Resin LDL Statin Niacin or Fibrate LDL & TG Fibrate or Niacin Combination Therapy LDL & TG Fibrate or Niacin Combination Therapy TG & HDL * Primary goal: For patients CHD Risk equivalent: any of CAD, TIA, CVA, AAA, PVD/bruits, DM with one additional categorical risk factor or for patients with very high 10-year risk for hard CV events ( 20%). Target initial therapy with the medication dose required to achieve target LDL 2.5 (1.8) mmol/L. For 10 yr CV risk for hard endpoints 10-20%, LDL target is 3.5 mmol/L. For 10 yr CV risk for hard endpoints 10%, LDL target is 4.5 mmol/L. Initiate lipid lowering early in high-risk patients (in conjunction with dietary modification). For specific medications and dosing strategy see Lipid Optimization Tool Initiate DASH diet, exercise, smoking cessation, alcohol reduction & lifestyle modification in all pts. Initiate Rx immediately if hypertensive urgency Dx HTN on second visit if : target organ damage, DM, chronic kidney disease (CKD) or BP > 180/110 Dx HTN on 3rd visit if BP 160-179/100-109 Validate hypertension with: 1) Office BP, ambulatory BP or home/self BP. Initial Rx for systolic/diastolic HTN in absence of compelling indication: Low dose thiazide; -blocker if age < 60 yr; ACE-I § in non-black pts; long-acting CCB and ARB. ISH: LDD/ DHP-CCB/ARB Consider Rx ASA (once BP controlled) and statin in HTN patients for cardiovascular protection CHF&HTN-Rx -blocker †; ACE-I (ARB if ACE-I intolerant)&aldosterone antagonist(Class III/IV HF) CKD or Type 2 DM § with micro-albuminuria, proteinuria or nephropathy ACE-I/ARB are 1st line Rx Dx DM: FBG 7.0 mmol/L or 2 hr PCG 11.1 mmol/L.(Normal: A1C ≤ 6; FG 4-6 mmol/L; 2 hr PCG 5-8 mmol/L.) IFG 6.1-6.9 mmol/L. IGT 2 hr PCG 7.8-11 mmol/L. Target euglycemia ASAP. Initiate dietweight loss (5-10%), diabetes education & exercise program. Target A1C ≤ 7; FG 4-7 mmol/L; 2 hr PCG 5-10 mmol/L. Rx oral hypoglycemic for FBG 7.0 mmol/L & A1C 7-9.Consider initial combination Rx for A1C ≥9 mmol/L. Aggressive BP control. Target 130/80 Rx ACE-inhibitor, ARB, cardio-selective -blocker, thiazide diuretic, long acting CCB. BP target 125/75 for diabetic nephropathy eliminated. Assess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30-40 minutes of moderate intensity activity 3 to 5 times weekly (walking, jogging, cycling or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, using stairs, gardening, household work) Max benefits 5 to 6 hours per week. Medically supervised programs for moderate to high-risk patients. Start intensive diet and appropriate physical activity intervention, as outlined above, in patients 120% of ideal weight for height. Particularly emphasise need for weight loss in patients with hypertension, elevated triglycerides or elevated glucose levels. Ideal body weight BMI < 25. Start aspirin 80-325 mg per day if not contraindicated. Consider clopidogrel 75mg OD post MI, post CABG, CVA, PVD in ASA intolerant or allergic patients (CAPRIE Trial). Consider clopidogrel 75mg OD + ASA for ACS:unstable angina/non-ST elevation MI & post-PCI patients (CURE Trial: duration of therapy 9-12months) Consider warfarin for post MI patients not able to take aspirin (maintain INR 2-3). Start early post-MI in stable high risk patients (anterior MI, previous MI, Killip class II (S3 gallop, rales, radiographic CHF). Continue indefinitely for all with LV dysfunction (EF40%) or symptoms of CHF. Use as needed to manage HPT or symptoms in all other patients. Rx ACE inhibitors in all patients 55 yrs with evidence of vascular disease or DM and one other risk factor: HOPE Trial-Ramipril 2.510 mg QHS or all CAD patients 18 yrs EUROPA Trial-Perindopril 48 mg OD If LVF preserved, patient non diabetic and other risk factors optimized may not need ACE inhibitor (PEACE). Start acutely or within a few days of event in all post-MI patients (unless contra-indication). Continue indefinitely if residual ischemia, heart failure, LV dysfunction or severe co-morbidity. Continue indefinitely in low risk patients (IIa). Rx as needed to manage angina, arrhythmia or HPT. Rx Beta-blocker to ACE-inhibitor/diuretic/+/- digoxin in stable Class II-IV CHF/LVEF 40% Bisoprolol 1.25 10 mg OD, carvedilol 3.125 mg BID 25 mg BID (50 mg BID if weight > 85 kg) or metoprolol 12.5 mg 75-100 mg BID Check in patients with premature CAD/CVD/PVD; family history premature atherosclerosis or manifest atherosclerosis & no identifiable risk factors. Folic acid 2.5 mg, B6 25 mg, B12 250 mcg. HRT not recommended for 10 prevention. Use established preventative strategies. Consider HRT or SERMS for non-cardiac indications. Individualize recommendations consistent with other health risks (VTE, endometrial or breast CA). HRT not indicated in 2 0 prevention. D/C HRT in ACS, MI, PTCA,CABG,CHF,Sx Continuing Medical Implementation ® …...bridging the care gap Lipid Optimization Tool PATIENT: ________________________ Pharmacy: _________________________ Responsible for Lipid Management: Family Physician Cardiologist Endocrinologist Lipid Flow Sheet1-Use the following Table to Guide Intervention: NB: UPPER STRATUM exceeds CWG on Hypercholesterolemia and other Dyslipidemias Recommendations Risk Level 10 year CHD Risk No. Of Risk Factors Targets 2o 3o Count risk factors or use Framingham tables/European SCORECARD to calculate 10-year risk of hard CHD/CVD endpoints. LDL TC/ HDL TG* CAD,PCI,CABG,TIA/CVA,PVD/bruits, DM2,CKD3 High 3 20 Moderate 10-20% 2 Low ≤1 10% 1.8 2.5 3.5 4.5 3 4 5 6 1.5 1.7 2 2 1o Initiation of Lipid Lowering Therapy Immediately Immediately Diet/lifestyle 3 months Diet/lifestyle 6 months 1. Count Risk Factors: Age M 45 F 55 Family Hx CAD Smoking HPT DM2 LVH HDL 0.9 mmol/l 2. Identify Metabolic Syndrome ( 3 parameters):Abdominal obesity: Waist circumference: Male>102 cm(40 in.)/Female >88 cm (34.6 in.)TG* 1.7 mmol/LHDL<1 mmol/L (male)/< 1. 3 mmol/L (female)BP 130/85FBG 6.2-7 mmol/L 3. Identify secondary causes: Diabetes Hypothyroidism Renal disease Liver disease Drugs & Alcohol 4. Record Indication:Risk FactorsCAD:_ angina_ post MI _ post PTCA_ post CABG Cerebrovascular Disease PVD Date 1 2 3 TC TG HDL LDL TC/ HDL ALT CK Medication Rx Next Test Req. Patient Adjustment Sent Called Addition Initial Monitor lipid profile, ALT and CK at baseline, 2 months then every 6 to 12 months Diabetes carries the same CV risk as manifest CAD. DM+CAD impart much higher risk for subsequent CV events. Chronic Kidney Disease Continuing Medical Implementation ® …...bridging the care gap HOP to ITT BP Calendar Condition Treatment threshold if no risk factors, target organ damage or clinical CVD Treatment target& initiation threshold for office BP measurements Treatment target for Ambulatory BP or Home BP measurement Treatment target for Type 2 diabetics ± nephropathy or non-diabetic nephropathy Treatment target for non-diabetic nephropathy with proteinuria Pre-hypertension (JNC-7) Normal BP BP Treatment Targets 160/ or/100 < 140/90 < 135/85 < 130/80 < 125/75 120-139/80-89 < 120/70 VALIDATED HOME BP DEVICES: OMRON: HEM-705CP, HEM-711AC, HEM-712C, HEM-773 and LifeSource: (AND) UA-767 CN, UA-767 Plus, UA-779, UA 787 Sunday Monday Tuesday Wednes- ThursFriday Saturday day day WEEK 1 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Monitor BP 4 times daily, every day for the first week. AM / / / / / / / Noon / / / / / / / PM / / / / / / / BED / / / / / / / Average / / / / / / / WEEK 2 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Monitor BP 4 times daily, two days/week –choosing one weekday and one weekend day. AM / / / / / / / NOON / / / / / / / PM / / / / / / / BED / / / / / / / Average / / / / / / / WEEK 3 Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Sys/Dias Monitor BP 4 times daily, two days/week –choosing one weekday and one weekend day. AM / / / / / / / NOON / / / / / / / PM / / / / / / / BED / / / / / / / Average / / / / / / / Continuing Medical Implementation ® …...bridging the care gap Guide for HF Management Approach Recommendations Symptoms & Signs of HF: Fatigue (low cardiac output), SOB, JVP, rales, S3, edema, radiologic congestion, cardiomegaly. Elevated BNP. CXR to r/o infection, interstitial lung disease & PPH Ejection fraction (obtain echo or LV gated study) 40% = systolic dysfunction 40-55% = mixed systolic and diastolic dysfunction 55% = diastolic dysfunction - treat underlying disorder (HPT/ischaemia/pericardial constriction/restrictive CM (cardiomyopathy)/infiltrative disorders) Ischemic-CM HPT-CM Valvular HD-CM (AS/AR/MR) Metabolic: hyper/hypo thyroidism / hemochromatosis/pheochromocytoma Toxins: Alcohol/ anthracyclines/cocaine/amphetamines Viral CM Idiopathic Dilated CM Other: Consider etiology Identify triggers Acute-sudden onset Chronic-gradual onset Treatment: General measures Symptomatic therapy Therapy to improve prognosis Consider ACE-I/ARB combination in ACE-I and /or -blocked patients with worsening HF or hospitalization Caution:diabetics/renal disease/elderly/ NSAIDs & COX-2 inhibitors Anti-coagulant anti-platelet Rx Ischaemia, arrhythmia, infection, pulmonary embolism, acute valvular pathology Anemia, thyrotoxicosis, non-compliance, diet, Rx e.g. NSAID’s Correct triggers and precipitants of acute and chronic Heart Failure Low sodium diet D/C smoking Regular exercise/activity Treat lipid abnormalities Treat ischemia Treat and control diabetes Control hypertension Identify & Rx depression Diuretics-titrate to euvolemic state Maintain Ideal Body Weight (dry weight = JVP normal / trace pedal edema) Furosemide 20 - 80 mg OD-BID HCT/Zaroxolyn for refractory congestion Digoxin-for persisting symptoms in NSR (systolic dysfunction) or symptoms and rate control in Afib. Dose: 0.125 mg – 0.25 mg (Lower dose in elderly: 0.0625 mg) ACE Inhibitors-General Guideline: Trandolapril 1 4 mg mg OD‡ Start low and titrate to the target dose *Quinapril 10 mg 40 mg OD used in the clinical trials or the *Cilazapril 0.5 mg 10 mg OD MAXIMUM TOLERATED DOSE: *Fosinopril 5 mg 40 mg OD Captopril 6.25-12.5 mg *Perindopril 4 mg 8 mg OD 50 mg BID-TID *No large scale outcome trials Enalapril 2.5mg 10mg BID† † SoLVD/X-SoLVD § AIRE /AIREX‡TRACE Ramipril 2.5 mg 5mg BID § Consider ISDN 5-40mg QID+Hydralazine 10 Lisinopril 2.5 mg 30-40 mg OD 75mg QID for ACE-I/ARB intolerance VHeFT Angiotensin II receptor antagonists (ARB’s) ACE-Inhibitors remain first line therapy ARB’s indicated in ACE-I intolerant patients (CHARM candesartan 16-32 mg OD) (Val-HeFT /VALIANT valsartan 160 mg BID) Beta-blockers-Add Beta-blocker* to ACE-inhibitor/diuretic/+/- digoxin in stable Class II-IV CHF/LVEF 40% (*No outcome data for other beta-blockers) Bisoprolol* 1.25 10 mg OD (CIBIS II Trial) Carvedilol* 3.125 mg BID 25 mg BID (50 mg BID if weight > 85 kg) Metoprolol* 12.5 mg BID 75 mg BID (MERIT Trial) Aldosterone antagonist (follow K/Cr in 3-7 days/ furosemide to avoid azotemia) Spironolactone 12.5-25 mg OD added to ACE-inhibitor/diuretic/+/- digoxin in stable Class III-IV CHF/LVEF 35%/CR<220/K<5.0 (RALES Trial) ASA if CAD ( dose to ACE inhibitor interaction) Coumadin for Afib, LV thrombus, LVEF 20%, DVT or pulmonary embolism Duration of A/C therapy: Indefinite for Afib/recurring systemic TE or DVT/PE Consider Internal Medicine/Cardiology or Heart Failure Clinic referral for initiation/titration of - blocker. Consider EPS referral for symptomatic sustained or non-sustained ventricular arrhythmia (LVEF 30-40%) or AICD: Prior MI/CAD (LVEF 30% with IVCD 0.12 sec: MADIT II) CHF: (NYHA II-III & LVEF < 35% SCD-HeFT) Cardiac Resynchronization Therapy(CRT):(NYHA Class III-IV with reduced ejection fractions; LVEF < 35%; QRS duration 0.13 with IVCD or LBBB: MIRACLE / MUSTIC) or both CRT/AICD: (NYHA III-IV;QRS 0.12:COMPANION). EECP/Transplant for refractory CHF. Continuing Medical Implementation ® …...bridging the care gap Optimal Management of Atrial Fibrillation OPTIMAL MANAGEMENT of ATRIAL FIBRILLATION* DEFINITIONS. Establish clinical pattern PREVALENCE ETIOLOGY. PROGNOSIS CLINICAL EVALUATION Minimum investigations of AFib: Additional testing of AFib: THERAPEUTIC GOALS Continuing Medical Implementation ® Paroxysmal AF: Persistent AF: Initial or recurrent: Self terminating, lasts >30 seconds and <7 days. Usually < 24hrs- 7 days. Not self-terminating but converts with either DC shock or drugs. Usually lasts >7 days. May be recurrent. Remains after DC shock and drug therapy. Permanent (Chronic) AF: AF occurs in 0.4% of the general population (200,000-250,000) . Prevalence increases with age: < 1% of population < age 60 years and > 6% > age 80 years. Acute causes: Aging, alcohol, MI (if LVF/RVF/RA MI), pericarditis, thromboembolism, myocarditis, hyperthyroidism, cardiac and thoracic surgery, electrocution. Most causes are transient. Treat underlying condition and control rate. Chronic causes: Hypertension, CHD, cardiomyopathy (dilated, hypertrophic, restrictive), sleep apnea, valvular heart disease (mitral>aortic), degenerative (SSS), congenital heart disease. Lone AF: No identifiable etiology (r/o genetic/familial) Non valvular AF: Rate of ischemic stroke is 5% per year. This is 2-7 times the general population. If one considers silent strokes identified on CT scanning or MRI the rate increases to 7% per year. Valvular AF: The rate of ischemic stroke is 25% per year. This rate is 17 times that of the general population. Mortality: Patients with AF have a mortality that is double that of aged matched controls. Mortality is approximately 2% per year, increases progressively with age and is related predominantly to cardiovascular causes. Identify syndrome: PAROXYSMAL, PERSISTENT or PERMANENT. Determine the cause: History, physical Define associated cardiac conditions and extra-cardiac factors. ECG to confirm the rhythm, evidence of LVH, previous MI, pre-excitation, bundle branch block and to measure and follow the QT intervals. CXR for heart size Echo for LVH, LV function, atrial size, cardiomyopathy, valvular disease TSH TMT test for rate control and to r/o coronary ischemia. Holter monitor to assess rate control Cardiac event monitor for symptomatic episodes. TEE may be required especially prior to DC shock to identify atrial thrombi. EPS for documented or suspected PSVT/ consider Aflutter ablation Rate Control Acute vs chronic Digoxin, -blocker, rate limiting CCB, amiodarone Minimize See anticoagulant indications thrombo-embolic risk Restore NSR Acute indications Ischaemia CHF Hypotension Maintain NSR Chronic Relief of symptoms. indications Avoidance of tachycardia induced cardiomyopathy …...bridging the care gap Continuing Medical Implementation ® …...bridging the care gap Implementation Network Family MD Community Patient Care Providers Continuing Medical Implementation ® Specialist …...bridging the care gap How can we amplify the impact of preventative strategies? Interventions-Revascularization-DevicesProcedures 4º Specialist/Cardiologist-Invasive Dx/TxMonitoring/Rehab/Reinforcement 2º & 3º Risk Stratification-Rx Optimization/ Adherence-FD & Specialist 1º & 2º Recognition-Screening-Initial Therapy- Family MD Community Based Awareness/Understanding Primary Care Physician Prevention Awareness Programs/PHN Continuing Medical Implementation ® …...bridging the care gap Network of Networks Continuing Medical Implementation ® …...bridging the care gap Integrated CVD Strategy Public Health Health Care Institutions Community Health Partners Academia Primary Care Community Specialists Continuing Medical Implementation ® …...bridging the care gap