ADULT CARDIOVASCULAR CLINICAL PRACTICE GUIDELINES

Transcription

1 ADULT CARDIOVASCULAR CLINICAL PRACTICE GUIDELINES Risk Intervention Lifestyle Interventions Hypertension Cholesterol Management Recommendations 1. Smoking cessation 2. Maintain ideal weight or weight reduction if needed 3. Maintain normal blood pressure 4. Maintain normal blood glucose level 5. Maintain normal cholesterol level 6. Exercise 40 min 3-4 times a week 7. Heart Healthy Diet See Appendix A Annually assess fasting lipid profile in all patients. Profile should include total cholesterol, high-density lipoprotein, lowdensity lipoprotein, and triglycerides. Add Statin drug therapy according to guide in Appendix B. The addition of non-statins does not reduce cardiovascular risk and should be reserved for patients with tolerability issues. Monitoring: 1. Lipids a. Baseline and at 6 week intervals until goal is achieved. b. Every 6-12 month intervals for ongoing monitoring c. Repeat periodically and whenever lipid therapy is changed/ restarted d. Clinical changes such as development of a new ASCVD risk factor warrant more frequent lipid testing (AACE, Q3.3) 2. Liver function tests: baseline and repeat only if clinically needed 3. Additional testing: 1

2 See Table 13 in 2017 AACE Guidelines for additional screenings specific to non-statin drugs (e.g. periodic coagulation monitoring with use of Omega-3 fatty acids and other drugs affecting coagulation). Creatine kinase if significant myalgias or muscle weakness.develop.individuals receiving statins should be evaluated for new onset diabetes according to diabetes screening guidelines (ACC/AHA, 2013). Statins used in combination with other cholesterol-lowering therapies may require more intensive monitoring (ACA/AHA, 2013, p.40). Consultation with an endocrinologist or lipid specialist may be necessary. 2

3 Atrial Fibrillation 1. Etiology a. Cardiac structural abnormalities: i. Fibrosis ii. Dilatation iii. Ischemia iv. Infiltration v. Hypertrophy b. Atrial electrical abnormalities c. Extra-cardiac factors i. Hypertension ii. Obesity iii. Sleep Apnea iv. Hyperthyroidism v. Alcohol/drugs 2. Treatment a. Anticoagulation, based on CHA2DS2-VASc risk factors b. Left Ventricle Dysfunction i. Beta Blocker ii. Digoxin (not first line therapy) 3. Rhythm Control a. Medications b. Catheter ablation c. Cardioversion d. Surgery 4. Rate Control a. Medications Antiplatelet agents/anti-coagulants Consider the use of aspirin in men age years and in women age years for primary prevention of myocardial infarction and for the primary prevention of strokes when the potential benefit outweighs the potential harm of an increase in gastrointestinal bleeding. For secondary prevention, consider aspirin mg or clopidogrel 75 mg if aspirin contraindicated. 3

4 Beta blockers post MI ACE inhibitors post MI Oral beta-blocker therapy should be initiated within the first 24 hours of myocardial infarction in the absence of contraindications and continued for a minimum of 6 months. Angiotensin converting enzyme (ACE) inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction less than 0.40 and in those with hypertension, diabetes mellitus and chronic kidney disease unless contraindicated. The benefits of long-term therapy with an ACE inhibitor or an angiotensin ll receptor blocker (ARB) have been demonstrated for patients with a specific indication for such therapy, such as heart failure, diabetes, vascular disease, hypertension or chronic kidney disease. Indefinite therapy with ACE inhibitor or ARB after MI in most patients is recommended. In those patients at lower risk, the benefits of long-term therapy should be weighed against the potential burdens. For patients who are intolerant of ACE inhibitors, ARBs are recommended. Combining an ACE inhibitor and an ARB may result in an increase in adverse events. Immunizations Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults 65 years and those with chronic heart disease age 19 and older. Additional doses of this vaccine will be needed depending on the health status and age. In addition, all adults 65 and those with chronic heart disease should receive the pneumococcal conjugate vaccine (PCV13). Variable factors affect the interval and order of the pneumococcal vaccines. Influenza vaccine yearly for all patients who do 4

5 not have a contraindication. Self-Management Education 1. Assess educational needs and provide self-management education. 2. Provide access to an interdisciplinary team 3. Develop individualized educational plans to optimize care and promote wellness that includes: a. Education on medication adherence b. Explanation of medication management and cardiovascular risk reduction strategies in terms the patient can understand c. A comprehensive review of all therapeutic options d. A description of appropriate levels of exercise e. Introduction of self-monitoring skills f. Information on how to recognize worsening cardiovascular symptoms and take appropriate action g. Reassess periodically during assessment contacts. 4. Identify support groups and networks for patient participation Sources: Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd-Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PWF ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of 5

6 Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63: Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240 e327. James, P.A., Oparil, S., Carter, B.L., Cushman, W.C, Dennison-Himmelfarb, C., Handler, J., Ortiz, E. (2014). Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311, 5, Atrial fibrillation: The management of atrial fibrillation. (2014, June). National Clinical Guideline Centre. National Institute for Health and Care Excellence (NICE), CG180. Retrieved from January, C.T., Wann, S., Alpert, J.S., Calkins, H., Cigarroa, J.E., Cleveland, J.C., Yancy, C.W. (2014, December). AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation. Journal of the American College of Cardiology, 64, 21. Amsterdam, E. A.,Wenger, N.K., Brindis, R.G., Casey D.E., Ganiats, T.G., Holmes, D.R.,, Zieman, S.J. (2014). AHA/ACC Guideline for the management of patients with non-st elevation acute coronary syndromes: A report of the ACC/AHA task force on practice guidelines Circulation, 130, Retrieved from Centers for Disease Control and Prevention. (2017). Immunization schedules. Retrieved from JNC 8 guidelines for the management of hypertension in adults. (2014, October 1). American Family Physician, 90(7), Guidelines reviewed/updated: Revision date 8/2004, 9/2005, 1/2007, 3/2009, 10/2010, 7/26/11, 8/1/2013, 8/6/2015 Guideline reviewed/approved: 11/2/ Medical Policy Committee 6

7 Clinical Review & Education Special Communication 2014 Guideline for Management of High Blood Pressure Figure Hypertension Guideline Management Algorithm Adult aged 18 years with hypertension Implement lifestyle interventions (continue throughout management). Set blood pressure goal and initiate blood pressure lowering-medication based on age, diabetes, and chronic kidney disease (CKD). General population (no diabetes or CKD) Diabetes or CKD present Age 60 years Age <60 years All ages Diabetes present No CKD All ages CKD present with or without diabetes Blood pressure goal SBP <150 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Blood pressure goal SBP <140 mm Hg DBP <90 mm Hg Nonblack Black All races Initiate thiazide-type diuretic or ACEI or ARB or CCB, alone or in combination. a Initiate thiazide-type diuretic or CCB, alone or in combination. Initiate ACEI or ARB, alone or in combination with other drug class. a Select a drug treatment titration strategy A. Maximize first medication before adding second or B. Add second medication before reaching maximum dose of first medication or C. Start with 2 medication classes separately or as fixed-dose combination. At goal blood pressure? No Yes Reinforce medication and lifestyle adherence. For strategies A and B, add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). For strategy C, titrate doses of initial medications to maximum. At goal blood pressure? Yes Reinforce medication and lifestyle adherence. Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class not previously selected and avoid combined use of ACEI and ARB). No At goal blood pressure? No Yes Reinforce medication and lifestyle adherence. Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to physician with expertise in hypertension management. No At goal blood pressure? Yes Continue current treatment and monitoring. b SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker. a ACEIs and ARBs should not be used in combination. b If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic plan. 516 JAMA February 5, 2014 Volume 311, Number 5 jama.com Copyright 2014 American Medical Association. All rights reserved. Downloaded From: on 06/19/2017

8 Appendix B Statin Benefit Groups Statin Therapy Intensity Statin Dosing Age with clinical atherosclerotic cardiovascular disease (ASCVD) High(Moderate if not candidate for high-intensity) Atorvastatin mg Rosuvastatin mg Age 21 with LDL 190mg/dl Age with diabetes and LDL mg/dl Age without diabetes or ASCVD and estimated 10 year risk of 7.5% High (Moderate if not candidate for high-intensity. Use maximum tolerated statin intensity) Moderate Moderate to high Atorvastatin mg Rosuvastatin mg Atorvastatin mg Fluvastatin XL 80 mg Fluvastatin 40 mg BID Lovastatin 40 mg Pitavastatin 2-4 mg Pravastatin mg Rosuvastatin 5-10 mg Simvastatin mg Simvastatin mg