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Post Myocardial Infarction Pharmacotherapy © Continuing Medical Implementation …...bridging the care gap Post MI Pharmacologic Intervention • • • • • ASA & Anti-platelet agents Anti-coagulation - blockers ACE inhibitors Dyslipidemic therapy – Statins – Fibrates © Continuing Medical Implementation …...bridging the care gap ASA & Anti-platelet agents Rationale: • Ruptured plaque – – – – platelet activation & aggregation thrombus core downstream and upstream propagation cyclical patency and re-occlusion v.s. persistent thrombus formation © Continuing Medical Implementation …...bridging the care gap Mechanism of Anti-platelet Activity • Class I - ASA, NSAIDs & sulfinpyrazone – block CO (cyclo-oxygenase) • Class II - Dypyridamole – inhibits phosphodiesterase-mediated breakdown of cyclic AMP – prevents platelet aggregation • Class III - thienopyridines (ticlopidine&clopidogrel) – block binding of ADP to platelet receptor P2Y12 therby inhibiting adenylyl cyclase • Class IV - antibody, peptide & small molecule IIb/IIIA receptor inhibitors © Continuing Medical Implementation …...bridging the care gap Antiplatelet Trialists’ Collaboration: Summary • Meta-analysis of 145 trials included about 70,000 high-risk patients • Anti-platelet drugs reduced risk of composite outcome of ischemic stroke, MI, or vascular death by 27% in high-risk patients • The relative odds reduction was consistent: – Over a wide range of clinical manifestations (ischemic cerebrovascular, coronary, and atherosclerotic peripheral arterial disease) – Across subsets of patients at varying risks within specific clinical disorders Antiplatelet Trialists’ Collaboration. BMJ 1994; 308: 81–106. © Continuing Medical Implementation …...bridging the care gap Patients with stroke, MI, or vascular death (%) Anti-platelet Trialists’ Collaboration: Results 25 22% odds reduction 20 29% odds reduction Antiplatelet therapy Control 25% odds reduction 27% odds reduction 15 32% odds reduction 10 5 0 Prior Acute stroke/TIA MI Prior MI Other All high risk high risk Category of trial Anti-platelet Trialists’ Collaboration. BMJ 1994; 308: 81–106. © Continuing Medical Implementation …...bridging the care gap ASA: Efficacy ASA Relativerisk reduction 25% ASA reduces the risk of stroke, MI, or vascular death by 25% relative to placebo Antiplatelet Trialists’ Collaboration. BMJ 1994; 308: 81–106. © Continuing Medical Implementation …...bridging the care gap Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events © Continuing Medical Implementation …...bridging the care gap CURE – Design (3) Day 0 Clopidogrel 300 mg loading dose Day 1 Patients with ACS (unstable angina or NQMI without ST elevation) Clopidogrel 75 mg od 12 months + standard therapy† (n=6259) R Placebo loading dose Day 1 Placebo 1 tab od † 12 months + standard therapy (n=6303) R=Randomization, occurred within 24 hours of symptom onset † Standard therapy always included ASA, and could also include heparin, heparin, LMWH, GP IIb/ IIb/IIIa inhibitors post-randomization, beta-blockers, ACE-inhibitors, lipid-lowering agents, and/or other therapies or interventions (e.g. PTCA, CABG) at physician’s discretion. LMWH, lowlow-molecularmolecular-weight heparin; GP, glycoprotein; glycoprotein; PTCA, percutaneous transluminal coronary angioplasty; CABG, coronary artery bypass graft CURE Study Investigators. Eur Heart J 2000;21:2033– 2000;21:2033 © Continuing Medical Implementation …...bridging the care gap –2041 The CURE Investigators. N Eng J Med 2001;345:4942001;345:494-502 CURE – Main Efficacy Results Primary endpoint (2) % of patients with recurrent ischemic event* 14 Benefits were seen within hours and continued to increase over the 12 months 12 10 8 20% RRR p=0.00009 n=12,562 6 4 Standard therapy‡ Clopidogrel + standard therapy‡ 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Months of follow-up ‡including ASA Medical Implementation The CURE Investigators. N Eng J Medthe 2001;345:494-502 2001;345:494 © Continuing …...bridging care gap Data on file *cardiovascular death, MI, or stroke Primary Outcome in Key Subgroups Patient characteristics Overall 2N % events Standard Clopidogrel + therapy‡ standard therapy‡ 12 562 11.4 9.3 ST deviation + ST deviation - 6275 6287 14.3 8.6 11.5 7.0 Entry enzymes elevated + Entry enzymes elevated - 3176 9386 13.0 10.9 10.9 8.8 Diabetes + Diabetes - 2840 9722 16.7 9.9 14.2 7.9 Risk Low Intermediate High 4187 4185 4184 6.7 9.4 18.0 5.1 6.5 16.3 Rev after randomization + 4577 Rev after randomization - 7985 13.9 10.0 11.5 8.1 History of rev + History of rev - 14.4 10.7 8.4 9.5 2246 10 316 RR (95% CI) - without condition Rev, revascularization 0.4 0.6 0.8 1.0 1.2 © Continuing Medical Implementation …...bridging the care gap ‡including ASA The CURE Investigators. N Eng J Med 2001;345:494-502 + with condition Unresolved Questions • Use in all comers with UAP/NSTEMI? • With IIB/IIA inhibitors? • How long to use – With PCI? – Without PCI? • Cost efficacy? • Peri-CABG discontinuation? © Continuing Medical Implementation …...bridging the care gap Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis.Anand SS; Yusuf S JAMA 1999 Dec 1;282(21):2058-67 • • • • 44 Trials-23,397 patients oral anticoagulation for at least three months acute MI, unstable angina, CABG high intensity (INR 2.8-4.8) and moderate intensity (INR 2-3) • Odds Ratio – death: 22 & 18% – MI: 42 & 52% – CVA: 63 & 53% • Bleeding: 6 & 2.4 X • No difference in death, MI or CVA v.s. ASA © Continuing Medical Implementation …...bridging the care gap Anti-coagulation • • • • • • Indication post MI: LV thrombus or aneurysm LVEF < 30% CHF History of thrombo-embolism Chronic atrial fibrillation-continue indefinitely © Continuing Medical Implementation …...bridging the care gap LV thrombus or aneurysm • Up to 40% large Q-anterior MIs – less in smaller MIs – less post-thrombolysis • Odds ratio 0.14 for embolization with anticoagulation for 6 months v.s no anticoagulation – Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis.Vaitkus PT; Barnathan ES J Am Coll Cardiol 1993 Oct;22(4):1004-9. © Continuing Medical Implementation …...bridging the care gap SELECTED RANDOMIZED TRIALS OF - BLOCKER THERAPY ADMINISTERED DURING AND AFTER AMI - Blockers Agent # Patients Duration RRR of Death P Value During MI •ISIS I Atenolol 16027 7 days 0.85 < 0.04 •MIAMI Metoprolol 5778 15 days 0.87 0.29 •TIMI IIB Metoprolol 1434 6 days 1.0 0.98 After MI •Norwegian Timolol 1884 33 months 0.61 < 0.001 •BHAT Propranolol 3837 25 months 0.72 < 0.005 © Continuing Medical Implementation …...bridging the care gap ACC/AHA Guidelines Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after myocardial infarction. Lancet 2000; 356: 639 - 644 • Paula A Rochon, Jack V Tu, Geoffrey M Anderson, Jerry H Gurwitz, Jocalyn P Clark, Paula Lau, John Paul Szalai, Kathy Sykora, C David Naylor • 13 623 patients aged 66 years or older discharged from hospital post myocardial infarction • No ß-blocker therapy vs received low, standard, or high doses. • Of 8232 patients with no previous history of heart failure – ß-blocker therapy was associated with a 43% reduction in subsequent admission for heart failure © Continuing Medical Implementation …...bridging the care gap Rate of heart failure and 1-year survival for older people receiving low-dose ß-blocker therapy after myocardial infarction. Lancet 2000; 356: 639 - 644 • Of 4681(57%) patients prescribed ß-blockers – Risk of admission was greater in the highdose than in the low-dose group !!!!! – Iin the cohort, 2326 (17·1%) died by 1 year – Adjusted risk ratio 0·57 [95% CI 0·48-0·69] compared with patients not dispensed this therapy • Compared with those not dispensed ß-blocker therapy, the adjusted risk ratio for mortality was lower for all three doses – low 0·40 [0·34-0·47] – standard 0·36 [0·31-0·42] – high 0·43 [0·33-0·56] © Continuing Medical Implementation …...bridging the care gap CAPRICORN CAPRICORN CArvedilol Post-infaRct survIval COntRol in LV dysfunctioN NOT AN APPROVED INDICATION FOR COREG © Continuing Medical Implementation …...bridging the care gap Inclusion Criteria • Confirmed acute myocardial infarction within 3–21 days (mean, 10 d) • LV ejection fraction 40% • All appropriate treatments for MI including aspirin, thrombolysis, and percutaneous interventions • Receiving an ACE inhibitor for 48 hours • Patients were usually hospitalized, but may have been recently discharged © Continuing Medical Implementation The CAPRICORN Investigators, Lancet 2001 …...bridging the care gap NOT AN APPROVED INDICATION FOR COREG Study Plan Uptitration Maintenance Downtitration Carvedilol (n=975) (N=1959) Placebo (n=984) Initiation with 6.25 mg or 3.125 mg bid Uptitration to maximum tolerated dosage over 2–4 weeks. Target, 25 mg bid Normally 3–5 days but up to 21 days postpost-MI Time to 633 events Optimum therapy at investigator’s discretion Mean follow up: 1.3 years © Continuing Medical Implementation The CAPRICORN Investigators, Lancet 2001 …...bridging the care gap NOT AN APPROVED INDICATION FOR COREG 0.95 0.9 0.85 0.8 Carvedilol 0.75 Placebo 0.7 Proportion Event Free 1 All-Cause Mortality 0 0.5 1 1.5 2 2.5 Years © Continuing Medical Implementation The CAPRICORN Investigators, Lancet 2001 …...bridging the care gap NOT AN APPROVED INDICATION FOR COREG All-Cause Mortality or Recurrent MI Proportion Event Free 1 0.9 Carvedilol 0.8 Placebo 0.7 0 0.5 1 1.5 2 2.5 Years © Continuing Medical Implementation The CAPRICORN Investigators, Lancet 2001 …...bridging the care gap NOT AN APPROVED INDICATION FOR COREG CAPRICORN: Summary • In patients with LV dysfunction following an acute MI, carvedilol treatment was associated with – 23% lower risk of all-cause mortality – 8% lower risk of mortality or CV hospitalizations – 26% lower risk of sudden death – 14% lower risk of HF hospitalization – 41% lower risk of nonfatal myocardial infarction – 29% lower risk of mortality plus MI • Carvedilol was well tolerated, and target doses for treatment were reached in the majority of patients © Continuing Medical Implementation The CAPRICORN Investigators, Lancet 2001 …...bridging the care gap NOT AN APPROVED INDICATION FOR COREG ACE inhibitors © Continuing Medical Implementation …...bridging the care gap SELECTED RANDOMIZED TRIALS OFACE INHIBITOR THERAPY ADMINISTERED DURING AND AFTER AMI Trial Agent # Patients Duration RRR of Death P Value During MI & 4-6 weeks after ISIS – 4 Captopril 58050 35 days 0.93 0.02 GIZZI – 3 Lisinopril 19394 42 days 0.88 0.03 Consensus II Enalaprilat 6090 41-180 days 1.11 0.26 Post MI LV Dysfunction SAVE Captopril 2231 42 mo. 0.81 0.02 AIRE Ramipril 2006 15 mo. 0.73 0.002 TRACE Trandolapril 1749 24-50 mo. 0.78 < 0.001 ACC/AHA Guidelines Heart Outcomes Prevention Evaluation Study A large, simple, randomized trial of Ramipril and vitamin E in patients at high risk for cardiovascular events Final Key Inclusion/Exclusion Criteria Inclusion Criteria Patients (age 55) at high risk for cardiovascular events because of: • any evidence of vascular disease (CHD, stroke, PVD) • diabetes + one other coronary risk factor Exclusion Criteria Heart failure or low EF On ACE-I or Vitamin E Nov. 20, 1999 Final Primary Adjudicated Events Ramipril vs Placebo 1/2 Ramipril Plac (%) (%) RR No. Rand. 1 Outcome MI,Stroke,CVDth CV Death* MI* Stroke* Non-CV Death 4645 4652 14.1 6.1 9.9 3.4 4.3 10.4 17.7 8.1 12.2 4.9 4.1 12.2 Mortality *not mutually exclusive Nov. 20, 1999 0.78 0.75 0.80 0.69 1.03 0.84 95% CI p 0.70-0.86 0.000002 0.64-0.87 0.0002 0.71-0.91 0.0005 0.56-0.84 0.0003 0.84-1.25 0.78 0.75-0.95 0.0058 Primary Outcome Ramipril vs Placebo Final K ap lan -M eier R ates 0.2 Ram ipril Placebo 0.15 0.1 0.05 0 0 500 1000 1500 D ays of F ollow-up Nov. 20, 1999 RR=0.78 (0.70-0.86) © Continuing Medical Implementation P=0.000002 …...bridging the care gap Final Prespecified Subgroups Ramipril vs Placebo No. Of Pts. Placebo Rate CVD+ 8160 18.7 CVD- 1137 10.1 Diabetes+ 3578 19.8 Diabetes- 5719 16.5 0.6 Nov. 20, 1999 © Continuing Medical Implementation 0.8 1.0 1.2 RR (95% CI) …...bridging the care gap Final Other Subgroups of Prior Stated Interest: Ramipril vs Placebo (1/2) Age<65 Age 65+ Male Female Hypertension+ HypertensionCAD+ CADNov. 20, 1999 No. Of Pts. 4169 5128 Placebo Rate 14.1 20.7 6817 2480 18.7 14.8 4355 4942 19.4 16.3 7475 1822 18.5 14.2 © Continuing Medical Implementation 0.6 0.8 1.0 1.2 …...bridging the care gap RR (95% CI) Final Ramipril vs Placebo Patients with Documented normal EF [N= 4759; mean 0.59 (SD 0.11)] N Primary Outcome CV death MI Stroke All HF Revasc. Nov. 20, 1999 Ramipril Placebo RR 95% CI P (%) (%) 2387 2372 14.0 18.9 0.73 (0.63-0.84) 0.00001 5.2 7.5 0.68 (0.54-0.86) 0.0009 10.7 14.1 0.75 (0.64-0.88) 0.0005 2.9 4.3 0.67 (0.50-0.91) 0.0104 8.3 10.5 0.78 (0.65-0.94) 0.0082 19.9 24.0 0.80 (0.71-0.91) 0.0004 © Continuing Medical Implementation …...bridging the care gap Final Conclusions: Ramipril vs Placebo There is overwhelming evidence that Ramipril prevents: – CV death, strokes and MI – Heart Failure, Revascularization – Development of diabetes – Diabetic microvascular complications and Nephropathy These benefits are consistently observed in a very broad range of high risk patients and in addition to other effective therapies The Nov. 20, 1999only adverse event is a 5% excess of cough © Continuing Medical Implementation …...bridging the care gap Statins Post MI © Continuing Medical Implementation …...bridging the care gap Major Statin Trials Trial Statin Cholesterol at baseline Control % ARR NNT 6.7 5.6 5.4 21.5 17.2 13.7 8.0 3.9 2.7 13 26 37 7.0 5.7 8.4 3.6 2.6 1.4 38 71 Secondary Prevention 4S Simva LIPID Prava CARE Prava Primary Prevention WOSCOPS Prava AFCAPS Lova Total MI or CV Death © Continuing Medical Implementation …...bridging the care gap ACUTE MI GUIDELINES 11/96 Drug Rx Peri MI: Meta-Analyses Number RR Death p value Beta blocker during MI 28,970 .87 (.77-.98) 0.02 Beta blocker post MI 24,298 .77 (.70-.84) <0.001 ACEI during MI 100,963 .94 (.89-.98) 0.006 ACEI post MI if LV dysfxn 5,986 .78 (.70-.86) <0.001 Nitrates during MI 81,908 .94 (.90-.99) 0.03 Ca++ blockers 20,342 1.04 (.95-1.14) 0.41 Magnesium 61,860 1.02 (.96-1.08) >0.05 Lidocaine 9,155 1.38 (.98-1.95) >0.05 Class I Antiarrhythmics 6,300 1.21 (1.01-1.44) 0.04 NEJM 335:1662, 1996 Cardiac Rehabilitation Programs • Definition – “the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status”.1 • May include multifactorial secondary prevention – defined as “the sum total of all interventions, both physiological and behavioral, designed to favorably modify an individual’s lifestyle, and enhance adherence and compliance with long-term behaviors compatible with minimizing disease progression”.1 © Continuing Medical Implementation …...bridging the care gap Benefits • 20% reduction in mortality after a threeyear follow-up.16 • Improvement in exercise tolerance, blood lipid levels, and psychosocial well-being.2 • A significantly lower incidence of rehospitalization and visits to the emergency department at three and 12 months compared with controls.29 © Continuing Medical Implementation …...bridging the care gap Needs • • Only 10-20% of appropriate patients in US currently participate in formal Rehab Secondary prevention population 1999 in Ontario A. Post event (3o prevention)-95,699 B. Pre-event- 332,362 • High risk primary prevention population 2,140,529 © Continuing Medical Implementation …...bridging the care gap System requirements • Assuming – 40% participation from secondary prevention A) group – 20% participation from secondary prevention B) group • Systematic capacity required June 2002 100,000 © Continuing Medical Implementation …...bridging the care gap CCN Network Model • Coordinating sites – Regional hub in population areas of > 500,000 • In-patient sites – All hospitals with in-patient cardiac services • Out-patient sites – Hospital or community based provider – Phase 2&3 care • Maintenance sites – Hospital or community based provider – Phase 4 care © Continuing Medical Implementation …...bridging the care gap Guide for Comprehensive Cardiovascular Risk Reduction Patients with Coronary and Other Vascular Disease Patient: _______________________________ Diagnosis: _____________________________ Rx () Risk Recommendations Intervention Smoking: Goal-Complete cessation Lipid Management: Primary goal * LDL 2.5 mmol/l Secondary goal * HDL 1.2 mmol/l(men)/ 1.1mmol/l (women) TG 2.0 mmol/l Canadian Working Group on Hypercholesterolemia and other Dyslipidemias Blood pressure control: Goal 135/85 mm Hg 2001 CHS www.chs.md Guidelines revised Jan 2002 Diabetes 1998 CDA www.diabetes.ca Physical activity: Minimum goal 30 minutes 3 to 4 times/week HR guided Obesity/weight management: Ideal body weight Antiplatelet agents/ anticoagulants: ACE inhibitors Post-MI/LV Dysfunction: ACE inhibitors Vascular disease Beta-blockers: Post-MI Beta-blockers: CHF Homocyst(e)ine Estrogens: © Continuing Medical Implementation 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. Consider drug Rx in all patients* with LDL 2.8 mmol/L Assess fasting lipid profile. In post -MI patients, lipid profile may take 4 to 6 weeks to stabilize. Baseline lipid profile < 24 after acute event. 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 with any of CAD, TIA, CVA, PVD/bruits, DM (Age 30) or for patients with very high 10 year risk of CV event ( 30% or 4 risk factors). Target initial therapy with the medication dose required to achieve target LDL 2.5 mmol/l. For 3 risk factors (10 yr CV risk 20-30%) LDL target is 3.0 mmol/l. For 2 risk factors (10 yr CV risk 10-20%) LDL target is 4.0 mmol/l. For 1 risk factor (10 yr CV risk 10%) LDL target is 5.0 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 lifestyle modification in all patients with blood pressure 140 systolic or 90 diastolic. Add Rx individualized to patient requirements and characteristics (i.e., age, race, need for drugs with specific benefits) if BP is not less than 140 systolic or 90 diastolic in three visitswithout target organ (TOD) damage or 5 visits with no TOD. Initiate Rx immediately if BP > 180/105. No age distinction in initial therapy ( avoid -blocker or -blocker as initial Rx HTN 60yr) Initial Rx: LDD(low dose diuretic)/-blocker/ACE-I/ long-acting DHP-CCB( - blocker not 1st line) Isolated systolic HTN: LDD/long-acting DHP-CCB Type 2 diabetes with micro-albuminuria, proteinuria or nephropathy ARBs alternate1st line Rx Initiate diet, weight loss, education. Consider drug therapy for FBS 7.0 mmol/L Aggressive BP control. Target130/80 (125/75 if micro-albuminuria: 30-300 mg/day; macro-albuminuria 300mg/day or albumin/creatinine ratio > 2 mg/mmol-male or 2.8 mg/mmol-female) Assess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30-40 minutes of moderate intensity activity 3 or 4 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) Maximum benefit 5 to 6 hours per week. Advise 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. 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 (CURE Trial: duration of therapy 9-12 months) 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. Consider ACE inhibitors in all patients 55 yrs with evidence of vascular disease or diabetes and one other risk factor: HOPE Trial-Ramipril 2.5 to 10 mg OD 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 Add 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. Rx Folic acid 2.5 mg, B6 25 mg, B12 250 mcg for homocyst(e)ine level 10 mmol/L 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. …...bridging the care gap We can’t do it alone © Continuing Medical Implementation …...bridging the care gap Conclusions • Multidisciplinary intervention indicated in all post MI patients • Patient education is key to empowerment and motivation • Diet, lifestyle,exercise form core component of 2o prevention strategy • In hospital timeframes limits educational opportunity © Continuing Medical Implementation …...bridging the care gap Conclusions • Optimization of 2o prevention pharmacotherapy provides opportunity to recapture lost morbidity and mortality benefit • Long term follow-up is necessary to ensure compliance • Cardiac rehabilitation (formal or informal) creates the framework for optimal prevention • Resources are currently inadequate to meet the demonstrated need © Continuing Medical Implementation …...bridging the care gap