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Prevention of a “Broken Heart”

Prevention of a “Broken Heart”. Prevention of a “Broken Heart”. February 16 2005 Mario L Maiese DO FACC FACOI Associate Professor UMDNJSOM S outh J ersey H eart G roup www.sjhg.org Email @ maiese1@comcast.net. Hidden Overlap of Atherothrombotic Disease.

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Prevention of a “Broken Heart”

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  1. Prevention of a “Broken Heart”

  2. Prevention of a “Broken Heart” February 16 2005 Mario L Maiese DO FACC FACOI Associate Professor UMDNJSOM South Jersey Heart Group www.sjhg.org Email @ maiese1@comcast.net

  3. Hidden Overlap of Atherothrombotic Disease CoronaryArteryDisease CerebrovascularDisease 40% 15% 16% 9% 11% 3% 6% 38% overlap (³ 2 vascular beds) Peripheral Arterial Disease Patients with one manifestationoften have coexistent disease in other vascular beds Ness J, Aronow WS. JAGS. 1999;47(10):1255-56.

  4. Dyslipidemia: Identify high-risk patients and determine benefits of treatment. Strategy and recommendations for obtaining safe optimal aggressive treatment goals.

  5. Atherothrombosis: A Progressive Process PlaqueRupture/Fissure &Thrombosis Occlusive AtheroscleroticPlaque Unstable Angina FattyStreak FibrousPlaque Normal MI Coronary Death Stroke Effort Angina Claudication Clinically Silent Critical Leg Ischemia Increasing Age Courtesy of P Ganz.

  6. Thrombotic occlusion Final Result Normal blush

  7. “To a man with a hammer every nail looks like it needs driving”. …Mark Twain

  8. “If prevention is your goal focus on the donut, not the hole”.

  9. Lesion growth

  10. Mechanism of Plaque Disruption in Atherothrombosis

  11. It is this "hidden disease" – the presence of vulnerable plaques throughout the coronary tree – that is the target of long-term treatment with high-dose statins, aspirin, ACE inhibitors.

  12. ABCs of CVD Risk Management CVD=cardiovascular disease; ACE=angiotensin converting enzyme; ARB=angiotensin receptor blocker; BP=blood pressure; EF=ejection fraction; MI=myocardial infarction. Braunstein JB et al. Cardiol Rev. 2001;9:96-105.

  13. ABCs of CVD Risk Management Braunstein JB et al. Cardiol Rev. 2001;9:96-105.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. * Circulation July 13 2004; 110: 227-239.

  14. ABCs of CVD Risk Management BMI=body mass index; HbA1c=glycosylated hemoglobin;CAD=coronary artery disease. Braunstein JB et al. Cardiol Rev. 2001;9:96-105. *JAMA Nov 2004;2442-2490.

  15. PRIMARY GOAL: LDL-C SECONDARY GOAL: Non HDL-C JAMA 2001; 285: 2486-2497. Cholesterol Management…per NCEP III Guidelines

  16. Non-HDL-C • Provides a measure of all the cholesterol in atherogenic particles including LDL-C, Apo B, LP(a) and TG-rich particles in VLDL,VLDL remnants and intermediately dense lipoproteins. • Introduced as the secondary target of therapy in patients with high TG (> 200mg/dL) per NCEP ATP III. JAMA 2001; 285: 2486-2497.

  17. NCEP III Non HDL-C Goal • Non-HDL-C = TC - HDL-C • Goal Non-HDL-C is 30mg > LDL-C goal Must be remembered that LDL-C and non HDL-C goals are surrogates for the number 1 lipid risk factor which is Apo B (a marker of atherogenic lipoproteins).

  18. Modifications to NCEP III • TLC was re-emphasized. • Use of the Framingham CAD risk calculator was recommended. Circulation July 13 2004; 110: 227-239

  19. Coronary Artery Disease Calculator

  20. Modifications to NCEP III

  21. NCEP III Update Based on 5 Clinical Trials Trial Name Statin Therapy Summary

  22. JAMA 2001; 285: 2486-2497.

  23. Safety Analysis of Intensive Tx • Among subjects treated with intensive statin therapy following ACS, there were lower rates of clinical events in those patients who achieved LDL-C < 60 mg/dL (or < 40 mg/dL) compared with those in the > 80-100 mg/dL range. • Lipid levels well below the current guidelines were not associated with worse safety outcomes. • Therefore, there is no need to reduce statin dosage if the LDL-C levels are below target goal. Circulation 2004;110:III-498. Abstract 2340.

  24. “Very High Risk” Patients The updated NCEP III definition of “high risk” requires established CVD plus: • Multiple risk factors (especially diabetes). • Severe and poorly controlled risk factors (especially continued cigarette smoking). • Multiple risk factors for MetS (especially high TG >200 plus non HDL-C > 130mg/dL with low HDL-C [< 40mg/dL]). • Patients with ACS.

  25. The Forgotten Cardiac Risk Factor: Noncompliance With Lipid-Lowering Therapy • Before NCEP ATP III Update. • Will be even more difficult reaching LDL-C goals post update.

  26. The CARDS data strongly demonstrateas the safety and benefits of statin therapy in T2DM regardless of baseline LDL-C. Conclusion:

  27. Comparative Efficacy of Available Statins Available Statins % LDL-C reduction Rosuvastatin 5mg Atorvastatin10mg 33-39% Simvastatin 20mg Lovastatin 40mg Pravastatin 40mg Fluvastatin 80mg Roberts WC. Am J Cardiol. 1997; 80: 106-107. Stein E et al. J Cardiovasc Pharmacol Therapeut. 1997; 2: 7-16.

  28. Even with optimal statin treatment: ----30- 40% reduction in CV events with statins. “There is 50% to 60% risk we’re not addressing”.

  29. Preliminary data suggests that combination therapy is much more efficacious in ↓ CV events (> 75%) - not surprising given that the lipid lowering effect is much greater.

  30. Be aggressive with combination therapies. In insulin resistant patients with abnormalities of the TG/HDL-C axis statin/Zetia/TriCor would solve the overwhelming majority of lipoprotein abnormalities seen in most patients (getting to LDL-C and non-HDL-C goals (apoB surrogate markers).

  31. Efficacy of HDL-C Increasing Compounds • Fibrates reduce major coronary events and increase HDL-C without significant toxicity. • Niacin has a more potent effect on HDL-C levels, but data on CV event reduction are limited. • HDL-C will probably be the “next target” over the next 10 years. J Am Coll Cardiol January 18 2005; 45: 185-197.

  32. AFREGS: Armed Forces Regression Study A combination of 3 drugs aimed at increasing HDL-C (niacin, fibrates and cholestyramine): • Improves cholesterol profiles. • Helps halt angiographic progression of coronary stenosis. • May help prevent CV events. Ann Intern Med January 18 2005; 142: 95-104.

  33. Adverse Effects of Statins • Myalgias (muscle pains), which is seen in 2% to 4% of patients. • Myopathy (10x NL CPK) including rhabdomyolysis (> 10,000 CPK) is very rare: Incidence =0.5-1 in 10,000 patients. • Increased values in liver function tests (LFTs) in ~ 1% of patients, significant elevations > than 3x NL up to 2% or 2.5% with the highest doses of statins.

  34. Adverse Effects of Therapy • Risk usually increases with dose escalation. • Risk is higher in women, older age (> 60), dehydration or those with underlying renal or liver disease. • Risk increases with combination therapy. • Risk is not directly proportional to cholesterol-lowering efficacy.

  35. Management • Listen to the patient first (muscle pain weakness or stiffness). • Negative placebo situation Balance Positive placebo effect • Temporarily stop, reduce the dose or switch (every other day dosing is frequently as effective with reduced side effcts).

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