The Medical Knowledge Behind Integrated NCD Prevention

Transcription

1 The Medical Knowledge Behind Integrated NCD Prevention Helsinki, 15 March 2011 Myocardial Infarction Jorma Turtiainen, 1976 Thomas E. Kottke, MD, MSPH Medical Director for Evidence-Based Health Consulting Cardiologist HealthPartners and HealthPartners Medical Group Professor of Medicine University of Minnesota 1

2 Heart disease: 3 states and 3 transitions Apparently Healthy/ No heart disease diagnosis* Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation *includes occult HD Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 2

3 Heart disease: 3 states N=8,335 Apparently Healthy/ No heart disease diagnosis* N=90,024 *includes occult HD Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation N=1,641 Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 3

4 Heart disease: 3 transitions Apparently Healthy/ No heart disease diagnosis* N=325 Out-of-hospital cardiac arrest Acute/emergent syndromes Ambulatory or incidental presentation STEMI=159 NSTEMI=599 UA/other=1270 Heart disease without symptomatic LV dilatation or Heart disease with symptomatic LV dilatation Systolic heart failure=345 *includes occult HD **N per 100,000 adults aged 30-84/deaths without treatment N=253 Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 4

5 Deaths Apparently healthy 600 HD without slvd HD with slvd 400 Cardiac arrest STEMI Prevalence Pools Acute events nstemi Unstable angina Systolic heart failure Ambulatory Total deaths=1,328 Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 5

6 Risk Factors and Treatments of Known Efficacy/Significant Impact I Risk Factors 1. tobacco free 2. ideal blood pressure 3. good nutrition 4. adequate physical activity 5. omega-3 fatty acid consumption (fish) Out-of-Hospital Cardiac Arrest 6. Automated external defibrillators Acute/Emergent Presentation 7. rescue angioplasty during acute coronary syndrome 8. thrombolysis 9. anti-platelet therapy and heparin for acute coronary syndrome 10. IV beta-blockers for acute coronary syndrome 6

7 Risk Factors and Treatments of Known Efficacy/Significant Impact II Ambulatory/Chronic Heart Disease 11. oral beta-blockers after myocardial infarction 12. statins 13. anti-platelet therapy and anti-coagulation 14. omega-3 fatty acid supplementation 15. coronary artery bypass graft surgery/percutaneous intervention 16. pacemakers 17. ACE inhibitors/arbs for left ventricular dysfunction 18. spironolactone or eplerinone for left ventricular dysfunction 19. implantable cardioverter defibrillators/biventricular pacemakers 20. cardiac rehabilitation 21. management of supraventricular arrhythmias 22. management of valvular dysfunction 7

8 Tobacco 8

9 Life Expectency after MI Mulcahy 1977 Wilhelmssen 1975 Salonen % 200% Subsequent life expectancy is doubled by smoking cessation after a heart attack No other single intervention in cardiology is this effective 9

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11 Major Findings and Recommendations of the Panel 5.There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-toperson contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact). i?rid=hstat2.chapter

12 Major Findings and Recommendations of the Panel 6. Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation: Provision of practical counseling (problem-solving/skills training) Provision of social support as part of treatment (intra-treatment social support) i?rid=hstat2.chapter

13 Major Findings and Recommendations of the Panel 7. Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking. Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates: Bupropion SR (Zyban) Nicotine Nasal Spray Nicotine Gum Nicotine Patch Nicotine Inhaler i?rid=hstat2.chapter

14 Major Findings and Recommendations of the Panel 7. (Continued) Two second-line pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective Clonidine Nortriptyline Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged. i?rid=hstat2.chapter

15 Varenicline (Chantix) Partial nicotine agonist About twice as effective as Zyban* Not tested in patients with psychiatric disease. Ask about psychiatric history. If positive, don t use or use with caution i?rid=hstat2.chapter

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18 Courtesy of People for Ethical Treatment of Animals 18

19 the rats resisted to the daily loading into the exposure tubes and continued to struggle inside the tubes right after the beginning of the exposure. By and large, the rats of the sidestream groups reacted more vigorously than those of the mainstream group. the rats of the sidestream groups continued to show shaggy fur and some pronounced respiratory symptoms characterized by whistling and rattling sounds. 1 rat of the mainstream group, 9 rats of the puffed and 11 of the nonpuffed sidestream group died spontaneously. The rats of the sham and the cage control groups increased their body weight during the 21 days of exposure The sidestream groups showed a decrease to approx. 80 percent of their initial body weight. 19

20 Which of the following statements is correct:* 1. 3 non-smokers die from other peoples cigarette smoke for every person killed by a drunk driver 2. 1 non-smoker dies from other peoples cigarette smoke for every 10 people killed by drunk drivers 3. 3 people are killed by drunk drivers for every individual who dies from other peoples cigarette smoke. *Based on National Highway Traffic Safety Administration data and studies published in the scientific literature 20

21 Which of the following statements is correct:* 1. 3 non-smokers die from other peoples cigarette smoke for every person killed by a drunk driver 2. 1 non-smoker dies from other peoples cigarette smoke for every 10 people killed by drunk drivers 3. 3 people are killed by drunk drivers for every individual who dies from other peoples cigarette smoke. *Based on National Highway Traffic Safety Administration data and studies published in the scientific literature 21

22 Blood Pressure 22

23 Lifestyle Modification Modification Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption Approximate SBP reduction (range) 5 20 mmhg/10 kg weight loss 8 14 mmhg 2 8 mmhg 4 9 mmhg 2 4 mmhg 23

24 Diet & Dyslipidemia 24

25 Which of the following is true? 1. A Mediterranean diet has been shown to reduce total mortality by 40% 2. A Mediterranean diet has been shown to reduce cardiac events by 50% 3. The cardiac benefits of a Mediterranean diet are offset by an increased risk of cancer. 4. A and B are true 5. A, B and C are true 25

26 Which of the following is true? 1. A Mediterranean diet has been shown to reduce total mortality by 40% 2. A Mediterranean diet has been shown to reduce cardiac events by 50% 3. The cardiac benefits of a Mediterranean diet are offset by an increased risk of cancer. 4. A and B are true 5. A, B and C are true 26

27 Control (n=303) Treatment (n=302) Total Deaths (.58) Cardiac Death (.32) Cancers (.41) All comparisons significant 27

28 Total Cardiac Endpoints (.52) % Control Indo Medit Non-fatal MI (.49) Fatal MI (.71) (NS) Sudden Cardiac Death (.38) 28

29 Omega-3 Fatty Acids 29

30 Sudden Death by N-3 PUFA Levels Among Physicians Healthy at Baseline Albert CM. NEJM 2002;346:

31 N-3 PUFA supplementation and sudden death in individuals with CAD (n=11 324) Control (n=2828) n-3 PUFA (n=2836) Death Cardiac death Sudden death Other deaths RR (all risk ratios except other death significant) GISSI. Lancet 1999;354:

32 Optimum Diet for CHD Prevention 32

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34 Wine (150 ml/d) Fish (114 g 4x/wk) Dark chocolate (100g/d) Fruit and vegetables (400 g/d) Garlic (2.7g/d) Almonds (68 g/d) Combined effect 34

35 Proportion alive 4S: Total Mortality Reduction with Simvastatin in CHD 1.00 Patients simvastatin placebo Log rank p= Years The Scandinavian Simvastatin Survival Study Group. Lancet 1994;344:

36 4S: Cardiovascular Endpoints Number of events Outcomes Placebo (n=2223) Simvastatin (n=2221) Relative risk reduction (%) p-value Total mortality* <0.001 Coronary death <0.001 Major coronary events <0.001 PCTA/CABG <0.001 * primary endpoint The Scandinavian Simvastatin Survival Study Group. Lancet 1994;344:

37 Statin Rx in a Health Plan Arch Int Med

38 Statin Rx in a Health Plan PDC = % days covered Arch Int Med 2009;169(3):260

39 Statin Rx in a Health Plan PDC = % days covered Arch Int Med 2009;169(3):260

40 Thrombolysis reduces STEMI mortality by 18% 40

41 Rescue angioplasty and stenting: 28% mortality reduction over thrombolysis Keely EC et al Lancet 2003;361:

42 RAAS Blockade in Heart Failure 42

43 Probability of survival (%) 1,0 0,9 0,8 0,7 0,6 0,5 0,4 0,3 RALES All-Cause Mortality Standard therapy (ACEI + loop diuretic ± digoxin) Risk reduction 30% 95% CI (18-40%), P<0.001 Spironolactone + standard therapy Pitt et al: NEJM 341:709, 1999 Months 43 CP

44 Cumulative incidence EPHESUS Relative Risk of Total Mortality Placebo Eplerenone RR=0.85 (95% CI, ) P= Pitt et al: N Engl J Med 348:1309, 2003 Months since randomization Placebo 3,313 3,054 2,983 2,830 2,418 1,801 1, Eplerenone 3,319 3,125 3,044 2,806 2,463 1,857 1, CP

45 ICDs and Cardiac Resynchronization 45

46 ICD Trials: SCD-HeFT Bardy GH et al. NEJM 2005;352:

47 NEJM 2005;352:

48 Population expected mortality hazard ratio, 0.63; 95 percent CI, 0.51 to 0.77; P<

49 Cardiac Rehabilitation 49

50 Total Mortality Cardiac Mortality Comprehensive Cardiac Rehab (n = 27) Exercise Cardiac Rehab (n = 19) RR = % CI = 0.74 to 1.02 RR = % CI = 0.59 to 0.98 RR = % CI = 0.65 to 0.99 RR = % CI = 0.56 to

51 Effects of Combination Therapy in Primary Care 51

52 For patients with coronary heart disease, the combination of aspirin, beta blocker and statin appears to reduce events and mortality by: % % % 4. Patients don t live longer, they just feel like they do. 52

53 For patients with coronary heart disease, the combination of aspirin, beta blocker and statin appears to reduce events and mortality by: % % % 4. Patients don t live longer, they just feel like they do. 53

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55 Hippisley-Cox, BMJ 2005;330:

56 Current use of studied drugs Unadjusted odds ratio Adjusted odds ratio None Statins, ASA, BB ACE, ASA, BB Statins, ACE, ASA, BB

57 Putting It All Together Smoke-free - No smoking, no exposure to tobacco smoke Diet - Mediterranean, olive or canola oil, red meat = salmon, white meat = tuna, daily serving of nuts Physical Activity - 10,000 steps/day Pharmacoprophylaxis - lifelong ASA, betablocker, statin. Goal LDL<70. Goal SBP~120. If reduced LV function - Beta-blocker, ACE inhibitor, spironolactone, ICD, consider biventricular pacemaker if QRS is wide 57

58 Based on current estimates, the greatest potential impact of intervention on heart disease mortality in a population would come from: 1. Encouraging patients to buy defibrillators for their homes and cars 2. Reducing door-to-balloon time for patients with ST elevation myocardial infarction 3. Convincing eligible patients to accept an implantable defibrillator 4. Improving risk profiles in individuals who are not known to have heart disease 58

59 Based on current estimates, the greatest potential impact of intervention on heart disease mortality in a population would come from: 1. Encouraging patients to buy defibrillators for their homes and cars 2. Reducing door-to-balloon time for patients with ST elevation myocardial infarction 3. Convincing eligible patients to accept an implantable defibrillator 4. Improving risk profiles in individuals who are not known to have heart disease 59

60 Deaths Prevented or Postponed (DPP) with perfect care Achieved Kottke TE. Am J Prev Med 2009; 36(1):82-88.e5 60

61 Mortality Changes in North Karelian (Finland) Men Ages years: All causes All cardiovascular Coronary heart disease All Cancers Lung cancers 61

62 Increasing Life Expectancy: Finland 85 82, ,8 74, , Personal communication: Pekka Puska Men Women 62

63 Prevention of Chronic Disease Risk Factors Guideline Focus on nutrition, physical activity, avoiding tobacco/tobacco smoke, avoiding risky drinking Documents that intervention does change behavior Recognizes that employers are key members of the health care team Advocates annual assessment when the individual enters labor force Notes that health plans are ideally suited to administer health risk assessment (HRA) and offer intervention programs when indicated hronic_disease_risk_factors primary_prevention_of guideline 23506/chronic_dise ase_risk_factors primary_prevention_of guideline_.html 63

64 Objectives Describe a model of heart disease and heart disease risk that is composed of 3 prevalence pools and 3 event streams. Describe the potential reduction in total mortality in the United States in terms of deaths prevented or postponed (DPP) as a result of perfect care for heart disease and heart disease risk factors. Describe the contribution to total deaths prevented or postponed by a) acute events and b) treatment of individuals before or between events as a result of perfect care. 64

65 The Medical Knowledge Behind Integrated NCD Prevention Helsinki, 15 March 2011 Myocardial Infarction Jorma Turtiainen, 1976 Thomas E. Kottke, MD, MSPH Medical Director for Evidence-Based Health Consulting Cardiologist HealthPartners and HealthPartners Medical Group Professor of Medicine University of Minnesota 65