Treatment of Cardiovascular Risk Factors Kevin M Hayes D.O. F.A.C.C. First Coast Heart and Vascular Center
Disclosures: None
Objectives What do risk factors tell us What to check and when Does treatment help To statin or not to statin Future directions
Pathophysiology
Scope of the Problem 30 Prevalence of U.S. Heart Disease 25 24.6 Patients (Millions) 20 15 10 5 12.4 0 1970 1980 1990 2000 2010 2020 2030 2040 2050 Year Foot DK et al. JACC 2000;35:1067-81
Major risk factors Hypertension (high blood pressure) Tobacco use Raised blood glucose (diabetes) Physical inactivity Unhealthy diet Cholesterol/lipids Overweight and obesity
Cardiovascular disease (CVD) deaths vs cancer deaths by age United States: 2008). Writing Group Members et al. Circulation. 2012;125:e2- e220
Estimated average 10-year cardiovascular disease risk in adults 50 to 54 years of age according to levels of various risk factors (Framingham Heart Study). Writing Group Members et al. Circulation. 2012;125:e2- e220.
Estimated 10-year stroke risk in adults 55 years of age according to levels of various risk factors (Framingham Heart Study). Writing Group Members et al. Circulation. 2012;125:e2- e220
Causes of Mortality in Patients With Diabetes
Major Risk Factors That Can t Be Modified Age Gender Heredity, including Ethnicity
Risk Calculator Age 40-79 Age Gender HDL DM Smoking Family history Race TC BP and BP Rx Smoking
2013 ACC / AHA Guideline If, after quantitative risk assessment, a riskbased treatment decision is uncertain, assessment of 1 or more of the following family history, hs-crp, CAC score, or ABI may be considered to inform treatment decision making.
Recommendations 2007 American College of Cardiology Foundation (ACCF) and the American heart Association (AHA) found that: CAC screening should not be used in asymptomatic low or high 10-year CHD risk patients according to Framingham criteria. CAC screening is useful for intermediate 10-year CHD risk (10-20%) according to Framingham criteria. If the CAC core is elevated (>400), no further testing is indicated at this time. A low CAC (<100) effectively excludes obstructive CAD in outpatients with atypical chest pain and ER patients with chest pain; however, stress testing is preferred since it gives a clue of exercise capacity. There is no current evidence that treatment decisions based on CAC scores leads to outcome improvement.
2013 ACC AHA Expert Opinion Thresholds for use of Optional Screening Tests When Risk-Based Decisions Regarding Initiation of Pharmacological Therapy are Uncertain Following Quantitative Risk Assessment Measure Support Revising Risk Assessment Upward Do Not Support Revising Risk Assessment Family history of premature CVD Male <55 years of age Female <65 years of age hs-crp 2 mg/l CAC score 300 Agatston units or 75th percentile for age, sex, and ethnicity* ABI <0.9
Calculator www.cvriskcalculator.com
ASA RBCs Endothelial cells ADP Collagen Thrombin Epinephrine Tx A 2 Serotonin Ca ++ AA release COX PGG 2 -PGH 2 Tx Syn Tx A 2 ASA Tx A 2
There have been 9 primary prevention trials evaluating the role of aspirin in CVD. Not a single trial has been positive so far. When the data are pooled together in a meta-analysis, there is a small, but statistically significant, benefit which is counterbalanced by an equally small but statistically significant risk of bleeding. On balance, the totality of evidence does not yield a favorable benefit-risk ratio for aspirin in primary prevention
The U.S. Preventive Services Task Force (USPSTF) recommends that men with no history of heart disease or stroke aged 45-79 years use aspirin to prevent myocardial infarctions and that women with no history of heart disease or stroke aged 55-79 use aspirin to prevent stroke when the benefit of aspirin use outweighs the potential harm of gastrointestinal hemorrhage or other serious bleeding.
What to do? Statin or no statin
Ridker et al, Circulation 2003;108:2292-2297. JUPITER Trial Design JUPITER Multi-National Randomized Double Blind Placebo Controlled Trial of Rosuvastatin in the Prevention of Cardiovascular Events Among Individuals With Low LDL and Elevated hscrp No Prior CVD or DM Men >50, Women >60 LDL <130 mg/dl hscrp >2 mg/l 4-week run-in Rosuvastatin 20 mg (N=8901) Placebo (N=8901) MI Stroke Unstable Angina CVD Death CABG/PTCA
JUPITER Primary Trial Endpoint : MI, Stroke, UA/Revascularization, CV Death Ridker et al NEJM 2008 Cumulative Incidence 0.00 0.02 0.04 0.06 0.08 HR 0.56, 95% CI 0.46-0.69 P < 0.00001 0 1 2 3 4 Placebo 251 / 8901-44 % Rosuvastatin 142 / 8901 Number at Risk Rosuvastatin Placebo Follow-up (years) 8,901 8,631 8,412 6,540 3,893 1,958 1,353 983 544 157 8,901 8,621 8,353 6,508 3,872 1,963 1,333 955 534 174
Statins - Most benefit Four Statin Benefit Groups: Individuals with clinical ASCVD (acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin ) without New York Heart Association (NYHA) class II-IV heart failure or receiving hemodialysis. Individuals with primary elevations of low-density lipoprotein cholesterol (LDL-C) 190 mg/dl. Individuals 40-75 years of age with diabetes, and LDL-C 70-189 mg/dl without clinical ASCVD. Individuals without clinical ASCVD or diabetes, who are 40-75 years of age with LDL-C 70-189 mg/dl, and have an estimated 10-year ASCVD risk of 7.5% or higher.
Primary prevention ---- Class 1 1. The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL C 70 to 189 mg/dl without clinical ASCVD* to guide initiation of statin therapy for the primary prevention of ASCVD.(Level of Evidence: B)" "2. Adults 40 to 75 years of age with LDL C 70 to 189 mg/dl, without clinical ASCVD or diabetes and an estimated 10-year ASCV risk 7.5% should be treated with moderate- to high-intensity statin therapy.(level of Evidence: A)"
Primary prevention --- Class IIa 1. It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL C 70 to 189 mg/dl, without clinical ASCVD* or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%.(Level of Evidence: B)" "2. Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL C 70 to 189 mg/dl without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment.(level of Evidence: C)"
Non drug Tx Stopping smoking ( Chantix, Patch, Gum) Exercise Weight loss STAMPEED data gastric surgery
Exercise Recommendations to improve lipids with physical activity were also provided. This included regular aerobic physical activity, 3-4 sessions a week, lasting on average 40 minutes per session, and involving moderate- to vigorous-intensity physical activity. This level of physical activity can reduce both LDL-C and non-high-density lipoprotein cholesterol.
Advise adults with a BMI 40 or BMI 35 with obesityrelated comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. A (Strong)
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