EvidenceNOW SW Learning Collaborative. Kyle Knierim, MD January 2017

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1 EvidenceNOW SW Learning Collaborative Kyle Knierim, MD January 2017

2 What is cardiovascular disease? Why are we even talking about cardiovascular disease? What can we do to prevent and treat cardiovascular disease? What can your practice do to improve systems of care for cardiovascular disease treatment and prevention?

3 Cardiovascular disease refers to a group of conditions affecting the heart (coronary heart disease and congestive heart failure) and blood vessels (stroke). CVD is the #1 killer in Colorado Preventing and treating CVD starts with healthy lifestyle choices Prevention and treating CVD also includes the ABCS: Aspirin use, Blood pressure control, Cholesterol control, and quitting Smoking That last question? It s up to you. That s why you re here!

4 Cardiovascular disease refers to a group of conditions affecting the heart (coronary heart disease and congestive heart failure) and blood vessels (stroke). Coronary Heart Disease Two Types Of Stroke

6 Heart Disease causes 1 in every 4 deaths in the US 1 Heart disease is the leading cause of death for both men and women 1 Americans have 735,000 heart attacks every year 2 1. CDC, NCHS. Underlying Cause of Death on CDC WONDER Online Database. Accessed via Access date: Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics 2015 update: a report from the American Heart Association. Circulation. 2015;131:e

8 CDPHE. Cardiovascular Disease Burden and Disparities in Colorado. Facts for Action: Chronic Diseases and Related Risk Factors in Colorado Source data taken from Colorado Behavioral Risk Factor Surveillance System.

9 Stroke is the fifth leading cause of death in the U.S. A stroke happens every 40 seconds and every 4 minutes someone dies from stroke. Up to 80 percent of strokes can be prevented. Stroke is the leading cause of adult disability in the U.S.

10 Heart Disease and Stroke Statistics 2015 Update. AHA/ASA.

11 That s $320,000,000,000 EVERY YEAR! Heart Disease and Stroke Statistics 2015 Update. AHA/ASA.

13 Two buckets: Non-modifiable things that won t change Modifiable things that can change (with effort)

14 NON-Modifiable risk factors to reduce your risk of cardiovascular disease Family History Age Ethnicity Gender Diabetes* Socioeconomic Status*

15 Modifiable risk factors to reduce your risk high blood pressure high cholesterol diabetes obesity physical inactivity of cardiovascular disease diets high in saturated fats, cholesterol, and sodium low fruit and vegetable consumption tobacco use exposure to secondhand smoke excessive alcohol use

16 Diet and exercise have a serious impact on CVD First line therapy for high blood pressure, high cholesterol, weight loss Saves lives in people who already had a heart attack* *Leon AS, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease. Circulation. Jan

17 High intake of fruits, vegetables, and whole grains Lower intake of red meat Substitution of lower-fat or fat-free dairy products for higher-fat dairy foods Use of oils such as olive and canola, nuts, and margarines with flaxseed and/or rapeseed oil

18 Lyon Diet Heart Study 1 Mediterranean diet vs. typical US diet after first MI People eating Mediterranean diet had a 50% to 70% lower risk of recurrent heart disease measured by cardiac deaths and nonfatal heart attacks, unstable angina, stroke, heart failure, and pulmonary or peripheral embolism. International cohort study 2 Significantly reduced risk of CVD with an increased intake of vegetables, fruit, soy protein, and alcohol. CVD risk increased with a higher intake of meat.

19 All healthy adults age years need Moderate-intensity aerobic physical activity for a minimum of 30 min on five days each week OR Vigorous-intensity aerobic activity for a minimum of 20 min on three days each week. Moderate-intensity aerobic activity can be accumulated toward the 30-min minimum from bouts lasting 10 or more minutes Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. Aug ;116(9):

20 Those meeting basic activity guidelines had a 14% lower risk of CHD compared to individuals who had no leisurely time physical activity. People meeting the advanced guideline had a 20% lower risk As levels of physical activity increases, CVD risk decreases Even with activity below recommended levels people still saw CHD risk reduction benefits -- Something is better then nothing when it comes to exercise

Aspirin: Increase low-dose aspirin therapy according to recognized prevention guidelines Blood pressure: Prevent and control high blood pressure Cholesterol: Prevent and control high blood

21 Aspirin: Increase low-dose aspirin therapy according to recognized prevention guidelines Blood pressure: Prevent and control high blood pressure Cholesterol: Prevent and control high blood cholesterol Smoking: Increase tobacco screening, counseling services, and use of smoking cessation products CDC. Strategies for States to Address the ABCS of Heart Disease and Stroke Prevention Available from:

22 How does Aspirin prevent heart attacks and strokes? COX-1 inhibitor: Blocks the formation of thromboxane A2 in platelets Stops them from activating and clumping together

23 Aspirin prevents platelets from clumping in the middle of arteries

24 Clear cut for patients with known coronary artery disease: Long-term single antiplatelet therapy with aspirin 75 to 100 mg daily or clopidogrel 75 mg daily is recommended over no antiplatelet therapy Dual antiplatelet therapy (usually aspirin + another medication) is recommended in the first year after an acute coronary syndrome event. Suggested regimens vary based on the type of ACS intervention performed. Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e637S-668S.

25 American College of Chest Physicians (ACCP): For persons aged 50 years or older consider low-dose aspirin 75 to 100 mg daily is recommended over no aspirin therapy United States Preventive Services Task Force (USPSTF): For men (45-79) and women (55-79) if potential reduction in risk of myocardial infarction outweighs potential harm to due gastrointestinal hemorrhage Ann Intern Med 2009 Mar 17;150(6):396 Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e637S-668S.

26 American Heart Association (AHA): Persons with 10-year risk of cerebrovascular disease > 10% for cardiovascular prophylaxis (including but not limited to stroke) Persons with chronic kidney disease Women If BP is controlled and benefit for ischemic stroke and myocardial infarction prevention likely to outweigh risk of gastrointestinal bleeding and hemorrhagic stroke at dose 81 mg once daily or 100 mg every other day in women 65 years With diabetes mellitus unless contraindicated AHA 2011 evidence-based guidelines for cardiovascular disease prevention in women. Circulation 2011 Mar 22;123(11):1243 AHA 2014 guidelines for primary prevention of stroke Stroke 2014 Dec;45(12):3754

27 A 2011 meta-analysis of nine primary prevention trials found that aspirin reduced the risk for total cardiovascular events and nonfatal heart attack, BUT did not reduce the risk of death from CHD, stroke, cardiovascular mortality, or death from any cause. In 2006 a meta-analysis was done on more than 40,000 men and 50,000 women, and there was a significant reduction in cardiovascular events in both groups with lowdose aspirin. Elwood P. Aspirin Revisited: Evaluating Aspirin's Role in Primary Prevention. Medscape Education Cardiology Accessed 7/5/15.

28 Aspirin: Increase low-dose aspirin therapy according to recognized prevention guidelines Blood pressure: Prevent and control high blood pressure Cholesterol: Prevent and control high blood cholesterol Smoking: Increase tobacco screening, counseling services, and use of smoking cessation products` CDC. Strategies for States to Address the ABCS of Heart Disease and Stroke Prevention Available from:

Systolic Diastolic Interpretation <130 <85 Normal 130-139 85-89 High

29 Systolic Diastolic Interpretation <130 <85 Normal High Normal Hypertension Stage Hypertension Stage II

31 Patient seated in calm environment with arm rested on support at level of heart Cuff size appropriate so bladder inside cuff encircles 80% of arm Use average of at least 2 measurements Measurement error Small number of readings Effects of recent activities Expense & Inconvenience White coat effect Proper Technique Common Issues

32 Home Blood Pressure Monitoring (HBPM) is better at predicting a person s risk of dying from heart disease or stroke than blood pressure measured in the doctor s office.

Two types: Primary (essential) 90-95% of patients have this type No identifiable underlying cause. Commonly treated with drugs in addition to lifestyle changes (e.g., exercise, proper nutrition, weight reduction, stress reduction).

33 Two types: Primary (essential) 90-95% of patients have this type No identifiable underlying cause. Commonly treated with drugs in addition to lifestyle changes (e.g., exercise, proper nutrition, weight reduction, stress reduction). Secondary Caused by an identifiable underlying condition (i.e. renal artery disease, thyroid disease, pregnancy) Treat the underlying cause

34 Risk factor for: Dying early Coronary artery disease (CAD) Heart failure Chronic kidney disease Stroke Transient ischemic attack (TIA) Peripheral arterial disease (PAD) Mild cognitive impairment (MCI) Hypertension at age 50 years associated with about 5-year reduction in life expectancy 1 Difference of 10 mm Hg in systolic BP associated with increased risk of all-cause and cardiovascular-related mortality and morbidity 2 1. BMJ 2012 Mar 20;344:e Lancet 2002 Dec 14;360(9349):1903

35 Ages Diabetes Chronic kidney disease Ages 60+ without diabetes or chronic kidney disease

36 Always appropriate to include diet and exercise changes If diet and exercise changes will/do not work or if the initial BP >160/ use medications Approach Angiotensin Converting Enzyme Inhibitors Calcium Channel Blockers Diuretics Angiotensin Receptor Blockers Common Medications

37 Aspirin: Increase low-dose aspirin therapy according to recognized prevention guidelines Blood pressure: Prevent and control high blood pressure Cholesterol: Prevent and control high blood cholesterol Smoking: Increase tobacco screening, counseling services, and use of smoking cessation products` CDC. Strategies for States to Address the ABCS of Heart Disease and Stroke Prevention Available from:

Cholesterol Cholesterol is a waxy fat carried through the bloodstream by lipoproteins HDL High density lipoproteins Good cholesterol LDL Low density Lipoprotein Bad

38 Cholesterol Cholesterol is a waxy fat carried through the bloodstream by lipoproteins HDL High density lipoproteins Good cholesterol LDL Low density Lipoprotein Bad Cholesterol Good cholesterol (HDL) is stable and carries bad cholesterol (LDL) from the arteries. Bad cholesterol (LDL) sticks to artery walls and contributes to plaque build up

40 Diet and Exercise!!!!! Both for prevention and for treatment once it is high Diet is a bit confusing now because lowering the amount of cholesterol in your food does not seem to lower cholesterol your blood Statin medications

41 Clinical ASCVD LDL-C 190 mg/dl Diabetes Type 1 or 2 Age y 7.5% estimated 10-y ASCVD risk and age y Stone NJ, et al. Circulation. 2013: published online before print November 12, 2013.

42 ASCVD Statin Benefit Groups Heart healthy lifestyle habits are the foundation of ASCVD prevention. In individuals not receiving cholesterol-lowering drug therapy, recalculate estimated 10-y ASCVD risk every 4-6 y in individuals aged y without clinical ASCVD or diabetes and with LDL C mg/dl. Adults age >21 y and a candidate for statin therapy Yes Clinical ASCVD No Yes Yes Age 75 y High-intensity statin (Moderate-intensity statin if not candidate for high-intensity statin) Age >75 y OR if not candidate for high-intensity statin Moderate-intensity statin Definitions of High- and Moderate-Intensity Statin Therapy High Daily dose lowers LDL-C by approx. 50% Moderate Daily dose lowers LDL-C by approx. 30% to <50% LDL-C 190 mg/dl No Diabetes Type 1 or 2 Age y No Yes Yes High-intensity statin (Moderate-intensity statin if not candidate for high-intensity statin) Moderate-intensity statin Estimated 10-y ASCVD risk 7.5%* High-intensity statin Estimate 10-y ASCVD Risk with Pooled Cohort Equations* 7.5% estimated 10-y ASCVD risk and age y Yes Moderate-to-High Intensity Statin No ASCVD prevention benefit of statin therapy may be less clear in other groups In selected individuals, consider additional factors influencing ASCVD risk and potential ASCVD risk benefits and adverse effects, drug-drug interactions, and patient preferences for statin treatment Stone NJ, et al. Circulation. 2013: published online before print November 12, 2013.

43 statindecisionaid.mayoclinic.org

44 Statins Number Needed to Treat for 5 Years 10-Year Risk of CVD Events 5-Year NNT for CVD Events 5-Year NNT for MI 5-Year NNT for Stroke 5% * 7.5% * 5-Year NNT for Mortality 10% % % Adapted from Statins for prevention of cardiovascular disease. Dynamed. Accessed

45 Aspirin: Increase low-dose aspirin therapy according to recognized prevention guidelines Blood pressure: Prevent and control high blood pressure Cholesterol: Prevent and control high blood cholesterol Smoking: Increase tobacco screening, counseling services, and use of smoking cessation products` CDC. Strategies for States to Address the ABCS of Heart Disease and Stroke Prevention Available from:

Increases the risk of heart disease and heart attack.

disease even for nonsmokers. Photos from: www.4everfitness.co.

46 Increases the risk of heart disease and heart attack. Nicotine raises blood pressure Carbon monoxide reduces the amount of oxygen that blood can carry. Exposure to other people's smoke can increase the risk of heart disease even for nonsmokers. Photos from: humansarefree.com/2012/02/smoking-kills-amazing-experiment-and.html

47 Smoking leads to disease and disability and harms nearly every organ of the body. 1 More than 16 million Americans are living with a disease caused by smoking. Smoking causes cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis.

48 Worldwide, tobacco use causes nearly 6 million deaths per year 1 Cigarette smoking is responsible for one in five deaths annually, or 1,300 deaths every day 2 On average, smokers die 10 years earlier than nonsmokers 3

49 If smoking continues at the current rate among U.S. youth, 5.6 million of today s Americans younger than 18 years of age will die early This represents about one in every 13 Americans aged 17 years or younger who are alive today. Go here for more:

50 Cold turkey - Only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help Medicines About 25% of smokers who use medicines can stay smoke-free for over 6 months Counseling Counseling and other types of emotional support can boost success rates higher than medicines alone

51 Combination of counseling and medication is more effective than either one alone and both should be offered.

52 Everything from 3 minute provider-led counseling to intensive 6 week programs work The more the better

53 Nicotine replacement therapy Patch, Gum, Lozenge, Inhaler, Nasal spray Bupropion Brand names are Zyban, Wellbutrin, or Aplenzin Varenicline Brand name Chantix

55 What is cardiovascular disease? Why are we even talking about cardiovascular disease? What can we do to prevent and treat cardiovascular disease? What can your practice do to improve systems of care for cardiovascular disease treatment and prevention?

56 Cardiovascular disease refers to a group of conditions affecting the heart (coronary heart disease and congestive heart failure) and blood vessels (stroke). CVD is the #1 killer in Colorado Preventing and treating CVD starts with healthy lifestyle choices Prevention and treating CVD also includes the ABCS: Aspirin use, Blood pressure control, Cholesterol control, and quitting Smoking

Steps Against Recurrent Stroke (STARS)

Steps Against Recurrent Stroke (STARS) Take steps against recurrent stroke by making the necessary changes in your life Your Guide to Ischemic What Happened to Me? You had a stroke. The stroke you had