SECONDARY PREVENTION OF CORONARY ARTERY DISEASE

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1 SECONDARY PREVENTION OF CORONARY ARTERY DISEASE DR. BENJAMIN STOCKINS UNIVERSIDAD DE LA FRONTERA TEMUCO CHILE RIO DE JANEIRO, 2012

2 EPIDEMIOLOGY OF CORONARY ARTERY DISEASE Prevalence in the world: 100 million people First cause of death in the world Increasing in low income countries Hypertension, high cholesterol, tobacco contribute to ¾ of cases 50% of patients don t receive effective medication CHILE: 27% of total mortality TEMUCO: 26.1% of total mortality

3 AMI: Hospital mortality Pre U. Cor. U. Cor. Reperfusión International studies

5 ATHEROSCLEROSIS BEGINS EARLY IN LIFE Atherosclerosis in young adults: The Korean war experience Enos JAMA 1953

6 MYOCARDIAL INFARCTION Trombosis Coronaria Arritmia y pérdida muscular Muerte Súbita Isquemia Miocardica Angina Hibernación Remodelamiento CC Dilatación Ventricular Ateroesclerosis HVI IC Factores de Riesgo (Lipidos, PA,DM) Resistencia a Insulina Plaquetas, Fibrinógeno, etc IC Terminal Dzau V. Braunwald E. Am Heart J. 121(4 Part 1): 1244, 1991

7 William Kannel William Castelli Daniel Levy

8 Tipo: JPG

9 TOBACCO - Directly atherogenic - Increases carboxihemoglobin, fibrinogen y thromboxan - Increases platelet aggregation -Smokers have double risk of AMI -Stoping reduces risk in 1/3 -It is easy to start again -Varenicicline (23% smoking cessation)

10 OR (99% CI) INTERHEART: Tobacco and AMI Never Cont Cases OR

11 ELEVATED BLOOD PRESSURE - RISK FACTOR FOR: -CHD -Heart failure -Peripheral vascular disease -Renal failure -Stroke

12 CHOLESTEROL: Log linear relation between LDL-C and coronary risk Epidemiology Coronary risk (Log-Linear) 100 LDL-C (mg/dl)? Clinical studies Up to which level?

13 JACC 43: , 2004

14 DIABETES MELLITUS Mortality and Morbidity 80% die due to CV causes Death happens 10 years before controls 2-4 times more risk of AMI and Stroke Similar prognosis to non DM patients with a previous CV event

15 DIABETES MELLITUS Mortality and Morbidity A good metabolic control prevents microvacular complications Less clear with OPTIMAL care in relation to macrovascular complications Epidemiological and clinical studies indicate a benefit of glucose control

16 Hazard ratio DIABETES: Fatal and Non-Fatal Myocardial Infarction 5 p< % decrease per 1% decrement in HbA1c Updated mean HbA 1c UKPDS 35. BMJ 2000; 321:

17 OVERWEIGHT AND OBESITY Fat is associated with an increase secretion of free fatty acids, hyperinsulinemia, insulin resistance, hypertension and dyslipidemia * Overweight BMI Kg/m2 * Obesity BMI > 30 Kg/m2

18 OBESITY CAD is more associated with abdominal obesity (> 102 cm in men and 88 cm in women) (chilean data: > 87 cm in men and 83 cm in women)

19 Risk factor INTERHEART Association with Risk Factors % Cont % Cases PAR 1 (99% CI) PAR 2 (99% CI) ApoB/ApoA-1(5 v1) (49.6, 58.6) 49.2 (43.8, 54) Curr smoking (33.9,39.0) 35.7,(32.5,39.1) Diabetes (11.2, 13.5) 9.9 (8.5, 11.5) Hypertension (21.7, 25.1) 17.9 (15.7, 20.4) Abd Obesity (3 v 1) (30.2, 37.4) 20.1 (15.3, 26) Psychosocial (22.6, 35.8) 32.5 (25, 40.8) Veg & fruits daily (10.0, 16.6) 13.7 (9.9, 18.6) Exercise (20.1, 31.8) 12.2 (5.5, 25.1) Alcohol (9.3, 20.2) 6.7 (2.0, 20.2) Combined (88.1, 92.4) Yusuf S,.Lanas F. Lancet 2004;364:

20 WHAT CAN WE DO? 1. LIFESTYLE 2. DRUGS

21 EXERCISE Proposed benefits: -Improves endotelial function -Less progression of coronary lesions -Reduction in Thrombogenesis -Increase of coronary colaterals -Rehabilitation programs can reduce death after AMI in 25%

22 PHYSICAL ACTIVIY * 30 minutes of moderate vigorous exercise reduces risk of CAD * Lower levels of exercise are also useful * Cardiac rehabilitation programs

23 DIET: Efficacy of NCEP II diet on C-LDL Mean reduction of TC and LDLC is 10% Great variability between individuals: - 20% respond as good as with drugs - 25% have no response - 55% response close to the mean (10%) This variability justifies to insist with diet in all individuals

24 EFFICACY OF DIET IN PATIENTS IN SECONDARY PREVENTION LDL CHOLESTEROL LEVELS AFTER ONE YEAR % OF PATIENTS < Nutrición ó + 8 < Control ó + Martínez S, Stockins B, UFRO 2004

25 CORONARY ARTERY DISEASE SECONDARY PREVENTION Statins ACEI/ARA II Aspirin Beta Blockers * Clopidogrel DRUG THERAPY

26 STATINS Reduce TC and LDLC Reduce major coronary events Reduce CV mortality Reduce coronary procedures Reduce stroke Reduce total mortality

27 Patients with CHD event (%) CORONARY EVENTS IN STATIN STUDIES CARE - S 4S - S LIPID - S HPS - S ASCO ASCOT - S * T - P * HPS - P AFCAPS - S CARE - P WOSCOPS - S LIPID - P 4S - P AFCAPS - P WOSCOPS - P LDL-C (mg/dl) Secondary Prevention Primary Prevention Simvastatin Pravastatin Lovastatin Atorvastatin S=statin treated P=placebo treated *Extrapolated to 5 years Modified from Kastelein JJP. Atherosclerosis. 1999;143(Suppl 1): S17-S21.

28 PROVE IT

JUPITER STUDY ROSUVASTATIN / PLACEBO IN PATIENTS WITH RAISED CRP (> 2 mg/l) * 18.

29 JUPITER STUDY ROSUVASTATIN / PLACEBO IN PATIENTS WITH RAISED CRP (> 2 mg/l) * pacientes con PCR >2 mg/l y CLDL < 130 mg/dl * CLD 50% y PCR en 37% * Suspendido precozmente a 1.9 años Ridtker PM et al N Eng J Med 2008; 359:

30 ACE INHIBITORS (ARB) MAIN ACTIONS 1. Patients with Heart Failure and left ventricular dysfunction: - Reduce risk of death - Reduce recurrrent AMI - Reduce progression of HF 2. Patients after AMI: - Reduce risk of death 3. Patients with several risk factors (primary prevention) - Reduce risk of death - Reduce risk of AMI

31 Patients reaching composite endpoint [MI, stroke, CV death] (%) ACE INHIBITORS (RAMIPRIL) HOPE primary events (I) p < Placebo 17.8% 10 Ramipril 14% Follow-up (days) HOPE Study Investigators New Engl J Med 2000;342:

32 BETA BLOCKERS Benefits in patients after AMI: - Reduction in all cause mortality - Reduction in reinfarction - Reduction in CV death - Improvement of heart failure - Relieve symptoms - Treatment of hypertension

ANTIPLATELET AGENTS SECONDARY PREVENTION Aspirin 75-325 mg: - 25% reduction of a new AMI - Reduction in all

33 ANTIPLATELET AGENTS SECONDARY PREVENTION Aspirin mg: - 25% reduction of a new AMI - Reduction in all cause of mortality - Reduction of stroke - Addition of Clopidogrel in ACS and after PCI (not in stable disease)

34 Stop smoking Blood pressure < 140/90 mm Hg) Diabetics BP < 130/80 mm Hg) Normal BMI (18,5 24,9 kg/m 2 ) Abdominal perimeter < 102 cm in men < 88 cm in women 150 minutos/week of physical activity Use of effective drugs Lipid profile TC <200 mg/dl TG < 150 mg/dl LDLC < 100 mg/dl Desirable LDLC <70 mg/dl HDLC >40 mg/dl HbA < 7%

35 Prevalence of modifiable risk factors in LA Smoking 22-45% Obesity 18-27% Hypertension 9-29% Hypercholesterolemia 6-20% Diabetes mellitus 2 4-9%

36 RAP de Infarto del Miocardio en Chile (Population attributable risk) % No F & V Estrés =88% Sedentarismo Obesidad Hipertensión ApoB/A1 Tabaco Lanas F Rev Med Chil. 2008;136:555

37 NATIONAL HEALTH SURVEY 2010 (AGE: OVER 17) Prevalence (%) ENS 2003 ENS Actual smoker Overweight Obesity Diabetes mellitus Sedentarism Hypertension * Symptoms of depression during the last year

38 WHO: PREVENTIVE STATEGY 1. PREVENTION IN THE WHOLE POPULATION 2. PREVENTION IN INDIVIDUALS ON HIGH RISK 3. SECONDARY PREVENTION - SHOULD BE COMPLEMENTARY - MOST INTERVENTIONS ARE IN INDIVIDUALS ON GROUPS 2 AND 3 - MOST CASES COME FROM GROUP 1 (MUCH MORE NUMEROUS)

39 AUGE (GES) PLAN SECONDARY PREVENTION OBJETIVES TO GUARANTY PROPER TREATMENT TO PEOPLE WITH PREVALENT DISEASES WHICH HAVE AN EFFECTIVE TREATMENT MYOCARDIAL INFARCTION TO PROVIDE AT LEAST THROMBOLYSIS AT ANY HOSPITAL OF THE COUNTRY DURING THE ACUTE EPISODE TO PROVIDE EFFECTIVE DRUGS FOR SECONDARY PREVENTION AT ANY PRIMARY, SECONDARY OR TERTIARY CARE FACILITY

40 PRIMARY CARE FACILITIES IN CHILE RESOURCES: General or family doctor Nurse (s), nutritionist EKG, basic lab Effective drugs ** Controls at tertiary centres are difficult and people remain most of the time under treatment at these centers

SURVEY IN TEMUCO, CHILE 2011-245 PATIENTS -PREVIOUS ACS, MEDICAL OR

41 SURVEY IN TEMUCO, CHILE PATIENTS -PREVIOUS ACS, MEDICAL OR SURGICAL REVASCULARIZATION -UNDER CONTROL AT PCC IN TEMUCO -ONE YEAR AFTER THE EVENT

42 Frecuencia logro meta (%) Evaluación clínica al momento de control Promedio grupo (n=202) 84,4% 50,7% 44,4% 18,8% 62,6% 15,0%

43 Evaluación al momento del control

44 EUROASPIRE I, II and III Netherlands Finland Slovenia Germany France Czech Republic Italy Hungary Euro Heart Survey - ESC congress, Vienna, September 2007

45 100% 80% Prevalence of smoking, obesity* and central obesity** *Body mass index = 30 kg/m 2 **Waist circumference = 88 cm for women and = 102 cm for men 50% 30% 0% Smoking Obesity Central obesi ty Survey % 25.0% 42.2% Survey % 32.6% 53.0% Survey % 38.0% 54.9% Euro Heart Survey - ESC congress, Vienna, September 2007

Prevalence of raised blood pressure*, elevated TC** and LDL-C***, and self-reported diabetes mellitus *SBP/DBP = 140/90 mmhg for non-diabetics or = 130/80 mmhg diabetics ** TC =4.

46 Prevalence of raised blood pressure*, elevated TC** and LDL-C***, and self-reported diabetes mellitus *SBP/DBP = 140/90 mmhg for non-diabetics or = 130/80 mmhg diabetics ** TC =4.5 mmol/l; *** LDL-C =2.5 mmol/l 100% 80% 50% 30% 0% Raised BP Elevated TC Elevated LDL-C Diabetes Survey Survey Survey Euro Heart Survey - ESC congress, Vienna, September 2007 Euro Heart Survey - ESC congress, Vienna, September 2007

Cardiovascular Protective Drug Therapies 100% 80% 50% 30% 0% Antiplatelets Beta-blockers ACE/ARB's Statins Survey 1 80.8 56.

47 Cardiovascular Protective Drug Therapies 100% 80% 50% 30% 0% Antiplatelets Beta-blockers ACE/ARB's Statins Survey Survey Survey Euro Heart Survey - ESC congress, Vienna, September 2007

48 Drugs in secondary prevention (PURE study) Yusuf S... Lanas F Lancet 28 Ago 2011

49 The EUROACTION Intervention: A nurse coordinated multidisciplinary family based preventive cardiology Programme In hospitals for coronary patients and their families In general practice for individuals at high risk of developing cardiovascular disease and their partners

50 The EUROACTION preventive cardiology program - RESULTS continued - Percentage of participants achieving the primary endpoints at 1 year Coronary patients High-risk patients Int (n=1061) UC (n=306) Int (n=1118) UC (n=252) Not smoking 58% 47% 73% 72% Saturated fat (<10% of total energy) 55% 40% Oily fish ( 3 times per week) 17% 8% 11% 6% Fish ( 20 g per day) 79% 67% 83% 66% Fruit and vegetables ( 400 g per day) 72% 35% 78% 39% Physical activity ( 30 min, 4 times per week) 54% 20% 50% 22% Body mass index (<25 kg/m 2 ) 27% 21% 23% 22% Ideal waist circumference (men <94 cm; women <80 cm) 31% 21% 23% 15% Blood pressure (<140/90 mm Hg or <130/85 mm Hg in individuals with diabetes) 65% 55% 58% 41% Total cholesterol (<5 mmol/l) 77% 71% 36% 31% LDL-cholesterol (<3 mmol/l) 81% 74% 45% 35% HbA1c (<7% in individuals with diabetes) 56% 53% 80% 65% Antiplatelet drugs 93% 92% 13% 10% β blockers 76% 80% 17% 16% Angiotensin-converting enzyme inhibitors 52% 56% 29% 20% Statins 86% 80% Data in red indicate a statistically significant difference between the intervention and treatment groups (p<0.05) 38% 23%

51 CORONARY ARTERY DISEASE SECONDARY PREVENTION OBJETIVES PROLONGUE LIFE EXPECTANCY REDUCE MORBIDITY IMPROVE QUALITY OF LIFE STRATEGY TEAM WORK BETWEEN PRIMARY, SECONDARY AND TERTIARY CARE CENTERS START PREVENTION BEFORE DISCHARGE NURSES ARE KEY ACTORS FOR SUCCESS

52 CONCLUSIONS 1. IT IS DIFFICULT TO CONTROL RISK FACTORS EVEN IN POPULATION HIGHLY SENSIBILIZED AND AT HIGHER RISK 2. USE OF MEDICACATION IS OFTEN PRIVILIGED OVER CHANGES OF LIFESTYLE 3. OUR FUTURE IS PROBABLY THE USE OF INTELLIGENT INTERVENTIONS AT A YOUNGER AGE OF LIFE

53 Tipo: JPG

Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION

Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION Dr Kornelia Kotseva National Heart & Lung Insitute Imperial College London, UK on behalf of all investigators participating