Download Top 5 Ways to Prevent a Second Cardiac Event

Top 5 Ways to Prevent a Second Cardiac Event …they work well to prevent a first one, too!
John P. Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Sco< & White Heart and Vascular InsBtute …But first, a word from our sponsor!
1. Avoid Tobacco Products and Sidestream
Smoke
Smoking Cessation Algorithm
Prevent Relapse
Ask and document pt s
tobacco use status
•  Congratulate successes
•  Encourage to remain tobacco-free
•  Discuss benefits experienced by patient
•  Address weight gain, negative mood, and lack of support
Recent Quitter
Current User (<6 months)
Advise: Provide a strong, personalized
message to quit using tobacco
Increase Motivation
Assess* readiness to quit in next 30 days
Ready
Not Ready
Assist
•  Negotiate a plan
•  STAR**
•  Discuss pharmacotherapy
•  Social support
•  Provide educational materials
Arrange follow-up to check plan or adjust meds
•  Call right before and after quit date
•  Weekly follow-up x 2 weeks, then monthly x 6 months
•  Ask about difficulties (withdrawal, depressed mood)
•  Build upon successes
•  Seek commitment to stay tobacco-free
•  Relevance to patients personal situation
•  Risks: short and long term, environmental
•  Rewards: potential benefits of quitting
•  Roadblocks: identify barriers and potential solutions
•  Repetition: repeat motivational intervention
•  Reassess readiness to quit
**STAR
Set quit date
Tell family, friends, and coworkers about it
Anticipate challenges: withdrawal, breaks
Remove tobacco from the house, car, and
social life
Treating Tobacco Use and Dependence: A
Clinical Practice Guideline, U.S.
Department of Health and Human Services,
June 2000
2. LIFESTYLE MODIFICATION IS KEY
Exercise Evidence: Mortality Risk
Observational study of self-reported physical activity in 772 men with
established coronary heart disease
Light or moderate exercise is associated with lower risk
Wannamethee SG et al. Circulation 2000;102:1358-1363
3. COMPREHENSIVE CARDIAC
REHABILITATION IS A MUST
Changes in risk factors after rehabilitation
program
Risk factor
Change after rehabilitation
program (%)
p
% body fat
-4.4
0.001
Body mass index
-1.7
0.01
HDL
+10.2
0.001
CRP
-33
0.01
Resting heart rate
-4.5
0.01
Resting systolic
pressure
-2.3
0.049
Depression score
-58
0.001
Anxiety score
-46
0.001
Hostility
-46
0.001
Quality of life
+15.8
0.001
Lavie CJ and Milani RV. Arch Intern Med 2006;
166:1878-1883.
37000
40000
$/YLS
30000
88000
CV Disease Cost-Effectiveness
1. Lovastatin - CV,TC >6.2, men, age 45-54
2. Enalapril - EF<35%
3. Smoking counseling by RN - post MI
4. Smoking counseling by MD - men, age 50-54
5. Cardiac Rehabilitation post MI
6. CABG - severe angina, LM
7. PTCA - severe angina, 1VD
8. Exercise - men age 35
9. Angiography - CAD, p=.9, men age 55
10. CCU - possible MI, p=.2 b
250
1300
2
3
4
9000
0
1
8000
0
10000
10000
22000
20000
0
5
6
7
8
9 10
27th Bethesda Conference.
JACC 27(5):957,1996
Blue Cross/Blue Shield CV Rehab
Criteria
4. PRESCRIBE EVIDENCE BASED MEDICATIONS
ACS Adjunct Medical Therapy
Checklist:
Simple as your ABC s
A- Aspirin /Antiplatelet
ACE-I/ ARB/
Aldosterone Inhibitor
B-Beta-blocker
C-Cholesterol Lowering
Dosing Table for Antiplatelet and Anticoagulant
Therapy Discussed in This Focused Update to
Support PCI in STEMI
Drug
During PCI
Patient received initial
medical treatment (with an
anticoag &/or fibrinolytic
therapy)
Patient did not receive
initial medical treatment
(with an anticoag &/or
fibrinolytic therapy)
Comments
►All patients to receive ASA
(162–325 mg)
Thienopyridines
Clopidogrel†
If 600 mg given orally, then no
additional treatment
A second LD of 300 mg may
be given orally to supplement
a prior LD of 300 mg (Class I,
LOE:C)
LD 300–600 mg orally
MD of 75 mg orally per day
(Class I, LOE: C)
►optimal LD has not been
established ►Dose for
patients >75 years old has
not been established. ►A
recommended duration of
therapy exists for all postPCI patients receiving a
BMS or DES. ►Period of
withdrawal before surgery
should be at least 5 days.
Prasugrel
No data available
LD of 60 mg orally
►There is no clear need for
treatment with prasugrel
before PCI.
13
Drug
During PCI
Patient received initial
medical treatment (with
an anticoag &/or lytic
therapy)
Prasugrel ‡(cont.)
Patient did not
receive initial
medical treatment
(with an anticoag
&/or lytic
therapy)
MD of 10 mg
orally per day
(Class I, LOE:
B)
Comments
►All patients to receive ASA
(162–325 mg)
►MD of 5 mg orally per day
in special circumstances.
►Special dosing for patients
<60 kg or >75 years of age.
►There is a recommended
duration of therapy for all
post-PCI patients receiving
a DES.
►Contraindicated for use in
patients with prior history
of TIA or stroke.
14
EFFECT OF MED DISCONTINUATION POST-MI
ARCH IMED SEPT 25, 2006
5. GET A FLU SHOT
Influenza Vaccination Evidence
Effectiveness of Influenza Vaccination during the Influenza Seasons
Vaccinated
Subjects
(N=77,738)
Unvaccinated
Subjects
(N=62,317)
Adjusted Odds
Ratio
P value
Pneumonia or influenza
495 (0.6)
581 (0.9)
0.68
(0.60–0.78)
<0.001
Cardiac disease
888 (1.1)
1026 (1.6)
0.81
(0.73–0.89)
<0.001
Ischemic heart disease
457 (0.6)
535 (0.9)
0.80
(0.70–0.91)
0.001
Heart failure
466 (0.6)
538 (0.9)
0.81
(0.70–0.92)
0.002
398 (0.5)
427 (0.7)
0.84
(0.72–0.97)
0.018
Death
943 (1.2)
1361 (2.2)
0.52
(0.47–0.57)
<0.001
Hospitalization or death
2387 (3.1)
2910 (4.7)
0.65
(0.62–0.70)
<0.001
Hospitalization
Cerebrovascular disease
Community cohort of 140,055 subjects in the 1998–1999 season of which 55.5 % were immunized.
Nichol et al. N Engl J Med 2003;348:1322-32.
Evolution of Medical Care
100%
??%
Reduction in Mortality
???
64%
20%
55%
25%
40%
20%
25%
25%
Beta blocker
ASA
Beta blocker
Statin
ASA
Beta blocker
ACEI
Statin
ASA
Beta blocker
ACEI
Statin
ASA
Beta blocker
0%
1970
1980
1990
2000
2010
DNR!!
Do Not Recline!!
DNR!!
Systolic Heart Failure
J.P. Erwin, III, MD, FACC
Associate Professor of Medicine
Texas A&M College of Medicine
Scott and White Heart and Vascular
Institute
Questions that we must pose:
•  Why do we need to improve outcomes?
•  What proven therapies do we have
available to us?
•  What system changes can we perform to
ensure success with failure ?
156.4
65.5
69.4
Heart Failure
Hypertensive
Disease
Stroke
34.8
Coronary
Heart
Disease
Billions of Dollars
180
160
140
120
100
80
60
40
20
0
Estimated direct and indirect costs (in billions of dollars) of
major cardiovascular diseases and stroke
(United States: 2008). Source: NHLBI.
Discharges in Thousands
700
600
500
400
300
200
100
0
79
80
85
90
95
00
05
Years
Male
Female
Hospital discharges for heart failure by sex
(United States: 1979-2005). Source: NHDS, NCHS and NHLBI.
Note: Hospital discharges include people discharged alive, dead
and status unknown.
The Joint Commission
What proven therapies do we
have available to us?
CHF
Treatment
Selected patients
• Prevention. Control of risk factors
• Life style
All • Treat etiologic cause / aggravating factors
• Drug therapy
• Personal care. Team work
• Revascularization if ischemia causes HF
• ICD (Implantable Cardiac Defibrillator)
• Ventricular resyncronization
• Ventricular assist devices
• Heart transplant
• Artificial heart
• Neoangiogenesis, Gene therapy
CHF Class
Therapy
Therapy
Diuretic
ACE-I (ARB)
Beta-Blocker
I
+*
+
II
+*
+
+
+
Statins
Digoxin
Eplerenone§
Spironolactone
+
+
Hydralazine/NTG
III
+
+
+
IV
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Nitrates**
§Any post MI pt with CHF
* - if signs of fluid overload-retake dietary hx
** - can use at any point if angina
Levy, W. C. et al. Circulation 2006;113:1424-1433
Who needs a bi-ventricular
pacemaker? ….Defibrillator?
Cardiac Resynchronization Therapy
(CRT)
Delayed ventricular activation
Sinus
node
AV
node
Conduction
block
•  Delayed lateral wall
contraction
•  Disorganized ventricular
contraction
•  Decreased pumping
efficiency
CARDIAC
RESYCHRONIZATION (CRT)
Indication for dilated cardiomyopathy in medically
refractory NYHA class III or IV patients with:
•  QRS > 130 ms,
• LVEDD > 55 mm and
• EF < 35%
…..Debrillator?
Sudden Cardiac Death (SCD)
in Heart Failure
High risk in heart failure patients
n  Degree
of SCD risk by class
–  Mortality in NYHA class II is 5 to 15%
»  50 to 80% of the deaths are sudden in nature
–  Mortality in NYHA class III is 20 to 50%
»  Up to half of the deaths are sudden in nature
–  Mortality in NYHA class IV is 30 to 70%
»  5 to 30% of deaths are sudden in nature
Uretsky BF, Sheahan RG. Primary prevention of sudden cardiac death in heart failure: will the solution be shocking? J Am Coll Cardiol.
1997;30:1589-1597
SCD-HeFT
Among patients with NYHA Class II
or Class III CHF and reduced left
ventricular ejection fraction(<35%):
• ICD was associated with a
reduction in all-cause mortality
compared with placebo
• There was no difference between
amiodarone and placebo NEJM 2005
What system changes can we
make to ensure success with
failure ?
Implications for Public Health
*Not FDA approved for HF.
HOPE1,2 (ramipril)
SOLVD3,4 Prevention
(enalapril)
SOLVD1,3 Treatment
(enalapril)
SAVE5 (captopril)
EPHESUS6 (eplerenone)
CAPRICORN7 (carvedilol)
MERIT-HF8 ( metoprolol
succinate)
CIBIS-II9 (bisoprolol)*
RALES10 (spironolactone)
COPERNICUS11 (carvedilol)
Background HF
Therapy
NYH A
Class
ACC/ AH A
Stages
Number Needed
to Treat
for 1 Year to
Save 1 Life (total
mortality)
None (HF pts.
excluded)
—
A
221
± Diuretic, digoxin
I- II
B-C
333
± Diuretic, digoxin
II- III
C
76
l
A-B
86
l-III
B-C
50
l-III
B-C
43
II- IV
C
26
III- IV
C
23
III- IV
C
18
III- IV
C
14
None (HF pts.
excluded)
ACE-I or ARB,
diuretic, β-blocker
ACE-I, aspirin
ACE-I, diuretic,
± digoxin
ACE-I, diuretic,
± digoxin
ACE-I, diuretic,
± digoxin
ACE-I, diuretic,
± digoxin
Otterstad J E, Sle ight P . Eur Heart J . 2001 ;22:1307-1310 . 2 HOP E S tudy Investiga tors. N Engl J Med . 2000 ;342:145-153 . 3 SOLVD Investiga tors. Am J Cardiol. 1990;66 :315-322. 4 SOL VD
Investigators. N Eng l J Med. 1992;327 :685-691. 5 Pfe ffer M A. N Eng l J Med. 1992;327 :669-677. 6 Pi tt B. N Eng l J Med. 2003;348 :1309-1321. 7 The CA PRICORN Investiga tors. Lancet . 2001 ;357:13851390. 8 M ERIT Investiga tors S tudy Group . Lancet . 1999 ;353:2001-2007. 9 CI BI S-I I Investigators. Lance t. 1999;353 :9-13. 1 0 RAL E S Investigators. A m J Cardiol . 1996 ;78:902-907. 1 1 Packer M et al.
1
ß-Adrenergic Blockers
Placebo
15
p=0.0062
Mortality
% 10
Metoprolol XL
5
Risk
Reduction 34%
NYHA II-IV
N=3991
0
0
MERIT-HF!
Lancet 1999; 353: 2001!
3
6
9
12
Months
15
18
21
CHD Patient Treatment Gap:
Community
100%
80%
95%
60%
40%
20%
0%
18%
Physician Awareness
of NCEP Guidelines
Patient Treated to
Goal
Provider awareness does not equal successful implementation
Pearson TA et al. Arch Intern Med 2000;160:459-467.
Healthcare Providers
Optimizing Care
•  Follow the ACC/AHA Heart Failure
Guidelines[1]
•  Review the effects of medical
therapy with your patient using the
Seattle Heart Failure Model (
http://depts.washington.edu/shfm/
app.php?accept=1&enter=Enter)
•  Consider participation in the
American Heart Association s Get
With the Guidelines Program for
Heart Failure
[1] www.acc.org or Circulation. 2005;112:1825-1852
Optimizing Care
•  Standardize hospital admission and
discharge orders
•  Develop standardized treatment
pathways for the outpatient setting
•  Take every opportunity possible to
educate and empower your patient
to take control of his or her disease
–  Ultimately, this will determine success
with failure
Summary
1. CHF is the number one reason for
admission to the hospital in the United
States and costs the country billions in
healthcare dollars
2. There is excellent evidence-based
management that translates to improved
mortality and decreased hospitalization if
followed
3. Educating (Empowering) our patients and
creating systems for care for CHF leads to
improved outcomes.
A Cheerful Heart
is Good
Medicine -Proverbs 17:22
The Seattle Heart Failure Model has been implemented as an interactive program that
employs the Seattle Heart Failure Score to estimate mean, 1-, 2-, and 5-year survival and
the benefit of adding medications and/or devices for an individual patient
Levy, W. C. et al. Circulation 2006;113:1424-1433
Copyright ©2006 American Heart Association