Not Again! Secondary Prevention of Future Cardiovascular Events J. Clay Hays, Jr., MD, FACC.
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Transcript of Not Again! Secondary Prevention of Future Cardiovascular Events J. Clay Hays, Jr., MD, FACC.
![Page 1: Not Again! Secondary Prevention of Future Cardiovascular Events J. Clay Hays, Jr., MD, FACC.](https://reader036.fdocuments.in/reader036/viewer/2022062511/55166cb55503469d698b561e/html5/thumbnails/1.jpg)
Not Again!
Secondary Prevention of Future Cardiovascular Events
J. Clay Hays, Jr., MD, FACC
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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
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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
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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?
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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
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What do you do?
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ASCVD
• Coronary Artery Disease
• Peripheral Arterial Disease
• Carotid Arterial Disease
• Atherosclerotic Aortic Disease
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Benefits of Aggressive Risk Factor Reduction
• Improves survival
• Reduces recurrent events
• Reduces need for further intervention
• Improves quality of life
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Smoking
Goal
Complete Cessation
No exposure to environmental tobacco smoke
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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)
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Blood Pressure Control
Goal
<140/90
Or
<130/80 if diabetic or chronic kidney disease
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Recommendations
For all patients
• Weight control• Increased activity• Alcohol moderation
• Sodium reduction• Increased fruit intake• Increased veggies• Low fat dairy
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Recommendations
For hypertensive patients
• Initially treat with B blockers and/or ACEI
• Add other drugs such as thiazides prn to achieve goal
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Lipid Management
Goal
LDL-C < 100
If Triglycerides are >200,
non-HDL-C should be < 130
(Total cholesterol – HDL)
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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)
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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
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Physical Activity
Goal
30 minutes, 7 days per week
(Minimum 5 days per week)
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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)
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Weight Management
Goal
BMI: 18.5 to 24.9kg/m2
Waist circumference: Men <40 inches,
Women < 35 inches
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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)
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Diabetes Management
Goal
HbA1C <7%
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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
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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
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Warfarin
• INR 2.0-3.0
• Paroxysmal atrial fib
• Chronic atrial fib or flutter
• Post MI patient with LV thrombus
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ACE Inhibitors
• LV dysfunction <40%
• Hypertension
• Diabetes
• Chronic Kidney disease
• Optional for patients with normal LV function and good control of other risk factors
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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
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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)
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Beta blockers
• All patients with MI, Acute coronary syndrome, or LV dysfunction
• Continue indefinitely
• Consider in other forms of vascular disease
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Influenza Vaccination
• All patients with any form of ASCVD
• Have you had yours?
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Questions?