AHA Secondary Prevention Guidelines The Foundation of “Get with the Guidelines” Timothy A. Denton, M.D., F.A.C.C. Heart Institute of the High Desert Victorville, CA Southern California Chairman, “Get with the Guidelines”
State Standings Ranked by CV indicators, mammog, immune, etc Jencks et al. JAMA 2000;284:1670
AHA/ACC Scientific Statement AHA/ACC Guidelines for Secondary Prevention in Patients with Coronary and Other Vascular Disease: 2001 Update Sidney C Smith, Steven N Blair, Robert O Bonow, Lawrence M Brass, Manuel D Cerqueira, Kathleen Dracup, Valentin Fuster, Antonio Gotto, Scott M Grundy, Nancy Houston Miller, Alice Jacobs, Daniel Jones, Ronald M Krauss, Lori Mosca, Ira Ockene, Richard C Pasternack, Thomas Pearson, Marc A Pfeffer, Rodman D Starke, Kathryn A Taubert Circulation 2001;104:1577-1579 www.americanheart.org www.acc.org
To Which Patients dothe Guidelines apply? • Coronary artery disease • Carotid disease • Peripheral vascular disease • Abdominal aortic aneurysm • Diabetics
The Guidelines
AHA Secondary Prevention Guidelines2001 Antiplatelet / anticoagulant therapy • Intervention recommendations: • Start and continue indefinitely aspirin 75–325 mg/d if not contraindicated. • Consider clopidogrel 75 mg/d or warfarin if aspirin contraindicated. • Manage warfarin to INR=2.0 to 3.0 in post-MI patients when clinically indicated or for those unable to take aspirin or clopidogrel.
AHA Secondary Prevention Guidelines2001 Beta blockers • Start in all patients post MI and post ACS • Continue indefinitely • Observe usual contraindications. • Use as needed to manage CHF, angina, rhythm, or blood pressure in all other patients.
AHA Secondary Prevention Guidelines2001 ACE inhibitors • Treat all patients indefinitely post MI • Consider use in all patients with coronary or other vascular disease • Early use in anterior MI, previous MI, Killip Class II (S3 gallop, rales, radiographic CHF)
Benefits in HOPE • 9,541 subjects randomized to ramipril 10 mg/day or placebo and vitamin E 400 Units/day or placebo for 5 years • Terminated early at 4.5 years • All patient subgroups had benefit with ACEI. • Primary endpoint (MI, stroke, or death from cardiovascular causes) was significantly reduced by 22% with ramipril. • Risk reduction with ramipril was evident at 1 year and statistically significant at 2 years. • Vitamin E arm showed no benefit. HOPE Study Investigators. N Engl J Med 2000;342:145–160.
AHA Secondary Prevention Guidelines2001 Lipid management • LDL-cholesterol goal < 100 mg/dl • Statins as first line therapy for LDL lowering • If LDL low but HDL < 40 mg/dl, consider fibrate or niacin as first line therapy (especially in diabetes) • If TG’s are high, do not use a resin • TG 200-499, use fibrate/niacin after statins • TG >500, use fibrate/niacin before statins • Omega-3 FA’s for high TG’s
Placebo Simvastatin 5 (3) 20 (4) 35 (5) 46 (5) 54 (7) HPS—Simvastatin: Major Vascular Events by Year 30 25 Logrank p<0.0001 20 Proportion with event (%) 15 10 5 0 0 1 2 3 4 5 6 Years of follow-up Benefit/1000 (SE): 60 (18) HPS Collaborative Group. Lancet 2002;360:7–22. SIMVASTATIN
Baseline LDL-C (mg/dL) Statin (n=10,269) Placebo (n=10,267) <100 282 (16.4%) 358 (21.0%) 100–129 668 (18.9%) 871 (24.7%) 130 1083 (21.6%) 1356 (26.9%) All patients 2033 (19.8%) 2585 (25.2%) 0.4 0.6 0.8 1.0 1.2 1.4 HPS—Simvastatin: Vascular Events by Baseline LDL-C Event rate ratio (95% CI) Statin better Statin worse 0.76 (0.72–0.81) p<0.0001 www.hpsinfo.org
AHA Secondary Prevention Guidelines2001 Diabetes • Measure Hgb A1c • Appropriate hypoglycemic therapy to achieve near-normal plasma glucose as determined by Hgb A1c < 7.0 • Treatment of other risks (weight, activity, BP, lipids)
Mortality Due to Heart Disease in Men and Women with or without Diabetes (US) 29.9 Diabetes No Diabetes 23.0 19.2 Mortality per 1000 person-years* 11.5 11.0 7.1 6.3 3.6 Men Women Men Women All heart disease Ischemic heart disease *Age-adjusted Adapted from Gu K et al. Diabetes Care 1998;21:1138-1145.
ADA Standards of Medical Care for Patients with Diabetes • Glycemic control: HbA1C<7% • Blood pressure control: <130/80 mm Hg • Target lipid levels: • LDL-C <100 mg/dL • HDL-C >45 mg/dL in men, >55 mg/dL in women • TG <150 mg/dL • Smoking cessation ADA. Diabetes Care 2002;25:S33–S49.
But…tight glycemic control has little effect on survival You get more SURVIVAL benefit in diabetics if you start: A Statin An ACE inhibitor ADA. Diabetes Care 2002;25:S33–S49.
AHA Secondary Prevention Guidelines2001 Smoking • Goal is complete cessation • Avoid second hand smoke • Provide: • counseling • tobacco cessation programs • pharmacologic therapy including nicotine replacement and buproprion
Survival Effects of Cigarette Smoking Overall Survival All levels of smoking Doll et al. BMJ 1994;309:901-911
AHA Secondary Prevention Guidelines2001 Physical activity • GOAL • Minimum: 30 minutes 3–4 days/week • Optimal: daily • Intervention recommendations: • Assess risk, preferably with exercise test, to guide prescription. • Encourage minimum of 30–60 minutes of activity (walking, jogging, cycling, or other aerobic activity), preferably daily or at least 3–4 times weekly. • Supplement with increased daily lifestyle activities (walking breaks at work, gardening, household work). • Advise medically supervised programs for moderate- to high-risk patients.
Exercise • 6,213 men • ETT for clinical reasons • 2,534 normal • 3,679 with CAD • Mean f/u 6.2 years • Age 59 + 11 • Peak capacity stronger predictor than cigs, HTN, DM, Chol Myers, NEJM 2002;346:793
AHA Secondary Prevention GuidelinesWeight Management • Goal: BMI 18.5–24.9 kg/m2 • Intervention recommendations: • Calculate BMI and measure waist circumference as part of evaluation. • Start weight management and physical activity as appropriate. • Monitor response of BMI and waist circumference to therapy. • If BMI 25 kg/m2, goal for waist circumference is 40 inches in men, 35 inches in women. Smith SC Jr et al. Circulation 2001;104:1577-1579.
BMI and All-Cause Mortality Calle, NEJM 1999;341:1097
AHA Secondary Prevention Guidelines2001 Blood pressure • General goal: BP < 140/90 • Diabetes: BP < 130/80 (ADA) • Renal failure/heart failure: BP < 130/85 (JNC6) • Lifestyle modification • Dietary management • restrict salt intake • fresh fruits and vegetables
HOT Trial Diastolic blood pressure Systolic blood pressure 70 75 80 85 90 95 100 105 120 130 140 150 160 170 180 190 Lancet 1998;351(9118):1755-62
AHA Secondary Prevention Guidelines2001 Hormone replacement therapy • Do not start HRT for secondary prevention Circulation 2001;104:499 www.americanheart.org
How often do we provide these therapies?
The Guidelines
When to START The Guidelines? • ASAP – When first diagnosed! • Prior to hospital discharge (GWTG) • In the ICU • In the cath lab • On the ward • In the office
Why should you GWTG?
Why should you GWTG?
Why should you GWTG?
The END
