Reducing risk in heart disease

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1 Reducing risk in heart disease An expert guide to clinical practice for secondary prevention of coronary heart disease Prof Patricia Davidson (chair) Prof Nigel Stocks Dr Anu Aggarwal Ms Jill Waddell Ms Rebecca Lee

2 Reducing risk in heart disease An expert guide to clinical practice for secondary prevention of coronary heart disease Endorsed by:

3 Overview Reducing risk Burden of disease Management gaps Lifestyle and medical management Key points

4 Reducing risk Best-practice care for people with coronary heart disease can reduce the incidence of subsequent cardiovascular events and improve quality of life and survival. This requires the application of evidence-based lifestyle, biomedical and psychosocial management recommendations.

5 Burden of disease Leading cause of morbidity and mortality in Australia 3.4 million people or 17% of population have one or more long-term cardiovascular diseases (CVD) (AIHW). CVD contributes greatest proportion of disease burden (total 18%) Majority of burden is due to years of life lost from premature death (78% of CVD burden).

6 Guideline vs Expert Guide

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8 Agree II Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument

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10 Management gaps Management gaps identified: Lifestyle risk factor modification Treatment to target for hypertension and dyslipidaemia Underutilisation of practice systems

11 MJA 2012; 197: doi: /mja

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13 % of encounters with appropriate care Coronary Artery disease 90% Hyperlipidaemia 35%

14 Management gaps Risk factor Community prevalence GP interventions Smoking 17% smoke daily 0.7% of encounters involve smoking advice Poor nutrition Overweight/ obese 51% insufficient fruit intake, 91% insufficient vegie intake 3.4% of encounters involve nutrition/weight advice 60% overweight/obese 3.4% as above Physical inactivity Alcohol 72% physically inactive 1.2% of encounters involve physical activity advice 10% drink at risky/harmful levels 0.4% of encounters involve alcohol advice Britt H, Miller G, Charles J, Henderson J, Bayram C, et al. (2010). General practice activity in Australia : BEACH Bettering the Evaluation And Care of Health. Retrieved from

15 Management gaps Treatment to target for hypertension and dyslipidaemia Hypertension 34% of patients qualified for treatment but weren t treated* Dyslipidaemia 83% of patients qualified for treatment but weren t treated* *Webster R, Heeley E, Peiris D, Bayram C, Cass A, Patel A (2009). Gaps in cardiovascular disease risk management in Australian general practice. Medical Journal of Australia 191:

16 Management gaps Management gaps greater in women than men Measurement Men above target level Women above target level LDL-C 58% 69% TC 57% 76% Receiving treatment 53% 72% Driscoll A, Beauchamp A, Lyubomirsky G, Demos L, McNeil J, Tonkin A (2011). Suboptimal management of cardiovascular risk factors in coronary heart disease patients in primary care occurs particularly in women. Internal medicine journal 41:10;

17 Management gaps Underutilisation of practice systems Practice registers Research suggests practice registers can assist with recall and management of patients with chronic diseases. Models of care E.g. Australian Primary Care Collaboratives

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22 Lifestyle & behavioural risk factor management

23 Smoking GOAL: People with CHD completely stop smoking and avoid second-hand smoke. Brief, repeated, nonjudgmental advice about quitting smoking, provided by health professionals, is effective. If pharmacotherapy is used, aim to combine it with behavioural and psychosocial support.

24 Nutrition GOAL: People with CHD establish and maintain healthy eating which includes: Limiting saturated fatty acid (SFA) intake to <7% and trans-fatty acid (tfa) intake to <1% of total energy intake Consuming 1g eicosapentaenoic acid (EPA) + doxosahexaenoic acid (DHA) and >2g alpha linolenic acid (ALA) daily Limiting salt intake to 4g/day (1550mg sodium) Encourage people with CHD to adopt a healthy eating pattern. Consider referring the patient to a dietitian for support with dietary changes.

25 Alcohol GOAL: People with CHD consume a low-risk amount of alcohol. Advise patients to drink no more than two standard drinks per day. Brief interventions (e.g. advice, counselling) from a GP can be effective for non-dependent drinkers, particularly men.

26 Physical activity GOAL: People with CHD do at least 30 mins of moderate-intensity physical activity on most, if not all, days of the week (i.e. 150 mins/week minimum). This amount can be accumulated in shorter bouts of 10 mins duration and can be built up over time. Incidental physical activity is also important in keeping people moving as often and in as many ways as possible. Encourage patients to sit less and move more throughout the day.

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30 Healthy weight GOAL: Waist measurement: Men <94cm Women <80cm Body mass index (BMI) kg/m 2 BMI = weight (kg)/height (m) 2 Weight loss of 5 10% of original weight can lead to improvements in cardiovascular and metabolic health.

31 Biomedical risk factors/ Medical management

32 BMJ 2005;330:

33 Results 2266 cases were matched to 9064 controls. Drug combinations associated with the greatest reduction in all cause mortality were statins, aspirin, and blockers (83%, CI 77% to 88%); statins, aspirin,blockers, and angiotensin converting enzyme inhibitors (75%, CI 65% to 82%); and statins, aspirin, and angiotensin converting enzyme inhibitors (71%, CI 59% to 79%).

34 Conclusion Combinations of statins, aspirins, and blockers improve survival in high risk patients with cardiovascular disease, although the addition of an angiotensin converting enzyme inhibitor conferred no additional benefit despite the analysis being adjusted for congestive cardiac failure.

35 Lipids GOAL: LDL-C <1.8 mmol/l HDL-C >1.0 mmol/l Triglyceride (TG) <2.0 mmol/l Non-HDL-C <2.5 mmol/l We recommend statin therapy for everyone with CHD (apart from in exceptional circumstances). People with elevated TG may benefit from fish oil supplementation.

36 Blood pressure GOAL: People with CHD achieve and maintain a blood pressure measurement of <130/80 mmhg. This includes people with or without diabetes and/or stroke/tia and/or microalbuminuria (males >2.5 mg/mmol, females >3.5 mg/mmol) If SBP 140 or DBP 90 mmhg on multiple measurements over several occasions, consider diagnosis of hypertension. Consider ambulatory BP monitoring or selfmeasurement to confirm diagnosis.

37 Blood pressure Management of hypertension First line therapy - ACE inhibitors (ACEI) Most people need appropriate drug combinations to reach their blood pressure goals. Combination therapy may also minimise adverse effects. Consider non-adherence with drug therapy as a cause of blood pressure that is difficult to manage.

38 Diabetes GOAL: People with previously undiagnosed type 2 diabetes are identified. In people with diabetes, aim to maintain optimal blood sugar level (BSL) (HbA1c 7%), but be mindful of the potential harmful effects of optimising blood glucose control (particularly weight gain). Everyone with CHD should be screened for diabetes. Acute coronary syndromes (ACS) often unmask glucose intolerance or diabetes. A definitive diagnosis of previously undiagnosed type 2 diabetes should not be made during an acute cardiovascular event.

39 Diabetes Management of type 2 diabetes People with newly diagnosed type 2 diabetes should be routinely offered a trial of lifestyle modification. Pharmacotherapy may also be needed for people with significant hyperglycaemia. Treatment of other risk factors, including dyslipidaemia, hypertension, overweight/obesity and smoking, is particularly important for people with diabetes.

40 Pharmacological management Antiplatelet agents For patients with CHD Everyone with CHD should take mg/day of aspirin unless contraindicated. For patients with ACS We recommend clopidogrel in combination with aspirin for patients with STEMI (undergoing fibrinolysis or coronary stenting) or NSTACS (undergoing coronary stenting) Prasugrel or Ticagrelor can be used as an alternative to clopidogrel for patients with ACS

41 Pharmacological management Anticoagulants Warfarin recommended for high risk patients post-mi New anticoagulants becoming available where warfarin is not appropriate. ACEIs/ARAs ACEIs should be used in all patients with CHD, especially those at high risk of recurrent events. Consider ARAs for people who experience unacceptable side effects with ACEIs. Beta-blockers Beta-blockers should be used in all patients post-mi, especially those at high risk of recurrent events.

42 Pharmacological management Statins Statin therapy for all patients with CHD. Aldosterone antagonists Eplerenone may be used in people post-mi in people with LV systolic dysfunction and symptoms of heart failure. Short-acting Nitrates Short-acting nitrate for all patients plus a written action plan for chest pain.

43 Initiating & sustaining behaviour change Behaviour change is challenging. Support patients and be mindful of individual physical, social, cultural and psychological factors. Multiple attempts may be needed to achieve targets.

44 Secondary prevention/cardiac rehabilitation programs GOAL: Everyone with CHD has access, and is actively referred, to comprehensive ongoing risk factor modification and cardiac rehabilitation services. Contemporary cardiac rehabilitation and secondary prevention programs are cost-effective, safe and beneficial for people of all ages. Improves survival Reduces the need for revascularisation procedures Reduces the need for hospitalisation

45 Warning signs of heart attack GOAL: Everyone with CHD is prescribed a short-acting nitrate, unless contraindicated, and given written information and an action plan to follow in the event they have warning signs of heart attack. Educate patients about the broad range of warning symptoms that may be experienced. Give everyone with CHD a Will you recognise your heart attack action plan and fact sheet (available from the Heart Foundation website).

46 Warning signs of heart attack Communicate the following key messages: Warning signs of heart attack are varied Not everyone will experience chest pain Symptoms can come on suddenly, or come on slowly before getting worse Warning signs experienced in a future cardiac event may be different CHD places people at higher risk of having a heart attack Early treatment is important to reduce heart muscle damage and save lives Act quickly and call Triple Zero (000), even if unsure whether it is a heart attack.

47 Psychological management GOAL: Everyone with CHD is assessed for comorbid depression using a validated tool and treated accordingly. People with depression receive appropriate psychological and medical management. Depression is approximately three times more common in patients after an MI than in the rest of the population. In people with CHD, major depression and elevated depressive symptoms are associated with worse prognosis. Counselling strategies are effective in the management of depression. Aerobic exercise and cardiac rehabilitation can reduce depressive symptoms, in addition to improving cardiovascular fitness.

48 Social support GOAL: Everyone with CHD is assessed for their level of social support. Assess the patient s level of social support. Refer people considered at risk to cardiac rehabilitation services and/or a social worker or psychologist.

49 J Gen Intern Med 26(10): DOI: /s

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52 Key points Establish practice registers to improve recall and management of patients with CHD. Monitor therapy goals and continue to titrate treatment until target is reached. Lifestyle and behavioural change is as important as biomedical management and pharmacotherapy. Educate patients on the Warning Signs of Heart Attack and provide them with a written action plan for chest pain.

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