american college of cardiology, puerto rico chapter guidelines applied to practice (gap)

American College of American College of Cardiology, Puerto Rico Cardiology, Puerto Rico

ChapterChapter

Guidelines Applied to Practice (GAP)

February 6, 2006February 6, 2006

Eduardo J. Viruet M.D., F.A.C.C.Eduardo J. Viruet M.D., F.A.C.C.

American College of Cardiology Puerto Rico American College of Cardiology Puerto Rico ChapterChapter

Guías de Cardiología Aplicadas a la PrácticaGuías de Cardiología Aplicadas a la PrácticaCasos ClínicosCasos Clínicos

Guías de Cardiología Aplicadas a Guías de Cardiología Aplicadas a la Prácticala Práctica

Casos ClínicosCasos Clínicos

• 68-year-old man with history of 68-year-old man with history of dyslipidemia, arterial hypertension and dyslipidemia, arterial hypertension and Diabetes Mellitus II Diabetes Mellitus II

• Chest discomfort associated to strenuous Chest discomfort associated to strenuous physical activityphysical activity

• LDL levels = 170 mg/dlLDL levels = 170 mg/dl

What is the adequate initial therapy? What is the adequate initial therapy? What preventive measures should be taken ?What preventive measures should be taken ?

Pharmacotherapy for ChronicPharmacotherapy for ChronicStable Angina PectorisStable Angina Pectoris

•Pharmacotherapy to Prevent MI and Death

•Pharmacotherapy to Reduce Ischemia and Relieve Symptoms


Therapy to Prevent MI and Death

•AspirinAspirin

•Beta BlockersBeta Blockers

•StatinsStatins

•ACE inhibitorsACE inhibitors


Therapy to Reduce Ischemia and Relieve Symptoms

•Nitrates

•Beta BlockersBeta Blockers

•Calcium channel BlockersCalcium channel Blockers


ABCDEABCDE Formula Formula– AASA and antianginalSA and antianginal– BBeta-blockers and blood eta-blockers and blood

pressurepressure– CCholesterol and cigarettesholesterol and cigarettes– DDiet and diabetes mellitusiet and diabetes mellitus– EEducation and exerciseducation and exercise

Goal: Complete Cessation and No Exposure to Environmental Tobacco Smoke

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Cigarette Smoking RecommendationsCigarette Smoking Recommendations

•Ask about tobacco use status at every visit.

•Advise every tobacco user to quit.

•Assess the tobacco user’s willingness to quit.

•Assist by counseling and developing a plan for quitting.

•Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion.

•Urge avoidance of exposure to environmental tobacco smoke at work and home.

Goal: <140/90 mm Hg or <130/80 if diabetes or chronic kidney disease


Blood Pressure Control RecommendationsBlood Pressure Control Recommendations

Blood pressure 120/80 mm Hg or greater:

Initiate or maintain lifestyle modification: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits vegetables and low fat dairy products

Blood pressure 140/90 mm Hg or greater (or 130/80 or greater for chronic kidney disease or diabetes)

As tolerated, add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors with addition of other drugs such as thiazides as needed to achieve goal blood pressure


Physical Activity RecommendationsPhysical Activity Recommendations

Assess risk with a physical activity history and/or an exercise test, to guide prescription

Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities

Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF)


Goal: 30 minutes 7 days/week, minimum 5 days/week



Lipid Management GoalLipid Management Goal

LDL-C should be less than 100 mg/dL

Further reduction to LDL-C to < 70 mg/dL is reasonable


*Non-HDL-C = total cholesterol minus HDL-C


If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*

Risk Category LDL-C and non-HDL-C Goal

Initiate TLCConsider

Drug Therapy

High risk: CHD or CHD risk equivalents (10-year risk >20%)and

<100 mg/dL if TG > 200 mg/dL,

non-HDL-C should be < 130 mg/dL

100 mg/dL >100 mg/dL (<100 mg/dL: consider drug

options)

Very high risk:ACS or established CHDplus: multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors

<70 mg/dL, non-HDL-C < 100

mg/dL

All patients >100 mg/dL (<100 mg/dL: consider drug

options)

Grundy, S. et al. Circulation 2004;110:227-39.

Lipid Management Goals: NCEPLipid Management Goals: NCEP

ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol, TLC=Therapeutic lifestyle changes

Lipid Management RecommendationsLipid Management Recommendations

If baseline LDL-C > 100 mg/dL, initiate LDL-lowering drug therapy

If on-treatment LDL-C > 100 mg/dL, intensify LDL-lowering drug therapy (may require LDL lowering drug combination)

If baseline is LDL-C 70 to 100 mg/dL, it is reasonable to treat to LDL < 70 mg/dL

Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event. For patients hospitalized, initiate lipid-lowering medication as recommended below prior to discharge according to the following schedule:



When LDL lowering medications are used, obtain at least a 30-40% reduction in LDL-C levels.


Lipid Management RecommendationsLipid Management Recommendations

If TG are 200-499 mg/dL, non-HDL-C should be < 130 mg/dL

Further reduction of non-HDL to < 100 mg/dL is reasonable

Therapeutic options to reduce non-HDL-C: More intense LDL-C lowering therapy I (B) orNiacin (after LDL-C lowering therapy) IIa (B) orFibrate (after LDL-C lowering therapy) IIa (B)

If TG are > 500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy. Achieve non-HDL-C < 130 mg/dL, if possible




Weight Management RecommendationsWeight Management Recommendations


Goal: BMI 18.5 to 24.9 kg/m2Waist Circumference: Men: < 40 inches Women: < 35 inches


Assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated.

If waist circumference (measured at the iliac crest) >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.

The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. With success, further weight loss can be attempted if indicated.

*BMI is calculated as the weight in kilograms divided by the body surface area in meters2. Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.


Diabetes Mellitus Recommendations


Goal: Hb A1c < 7%


Lifestyle and pharmacotherapy to achieve near normal HbA1C (<7%).

Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended).

Coordinate diabetic care with patient’s primary care physician or endocrinologist. )

HbA1c = Glycosylated hemoglobin



• 65-year-old woman with history of Diabetes Mellitus 65-year-old woman with history of Diabetes Mellitus II, and arterial hypertension II, and arterial hypertension

• Chest discomfort and fatigue at minimal physical Chest discomfort and fatigue at minimal physical activity on optimal medical therapyactivity on optimal medical therapy

• Patients also complains of leg swelling, 2 pillows Patients also complains of leg swelling, 2 pillows orthopnea, dyspnea on exercise orthopnea, dyspnea on exercise

What will be the adequate diagnostic test?What will be the adequate diagnostic test?

Invasive Testing in Chronic Stable Angina

Recommendations for Coronary Angiography

•Patients with disabling (Canadian Cardiovascular

Society [CCS] classes III and IV) chronic stable angina despite medical therapy

•Patients with high-risk criteria on clinical assessment or noninvasive testing regardless of anginal severity

Invasive Testing in Chronic Stable Angina

Recommendations for Coronary Angiography

•Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia

•Patients with angina and symptoms and signs of congestive heart failure


• 64 years old male with history of arterial 64 years old male with history of arterial hypertension and chronic smokinghypertension and chronic smoking

• Complaining of chest pain with moderate Complaining of chest pain with moderate physical activityphysical activity

• Baseline EKG shows CLBBBBaseline EKG shows CLBBB

What will be the adequate diagnostic test?What will be the adequate diagnostic test?

Cardiac Stress Imaging in Patients With Chronic Stable Angina

•Abnormal rest ECG or are using digoxin

•LBBB or electronically paced ventricular rhythm

•Prior revascularization (either PCI or CABG) pre-excitation

•Wolff-Parkinson-White syndrome or more than 1 mm of rest ST depression

Guías de Cardiología Aplicadas a la Guías de Cardiología Aplicadas a la PrácticaPráctica


• 48 years old male with history of 48 years old male with history of arterial hypertension and arterial hypertension and dyslipidemiadyslipidemia

• Family history of premature CADFamily history of premature CAD

• Complains of neck and left shoulder Complains of neck and left shoulder pain with moderate exercisepain with moderate exercise

Guías de Cardiología Aplicadas a la Guías de Cardiología Aplicadas a la PrácticaPráctica


• EKG with inverted T waves in anterior EKG with inverted T waves in anterior leadsleads

• Exercise stress test with myocardial Exercise stress test with myocardial perfusion showed stress induced perfusion showed stress induced large anterior ischemic defectlarge anterior ischemic defect

What is the next step of therapy?What is the next step of therapy?

High-risk criteria on noninvasive testing

•Severe resting left ventricular dysfunction (LVEF < 35%)

•High-risk treadmill score (score ≤-11)

•Severe exercise left ventricular dysfunction

(exercise LVEF <35%)

High-risk criteria on noninvasive testing

•Stress-induced large perfusion defect

•Stress-induced multiple perfusion defects of moderate size

•Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201)

High-risk criteria on noninvasive testing• Stress-induced moderate perfusion defect

with LV dilation or increased lung uptake (thallium-201)

• Echocardiographic wall motion abnormality (involving greater than two segments) developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)

• Stress echocardiographic evidence of extensive ischemia


• 68 years old female with history of 68 years old female with history of Diabetes Mellitus II and dyslipidemiaDiabetes Mellitus II and dyslipidemia

• History of “heart attack “ in the pastHistory of “heart attack “ in the past

• EKG shows inferior Q wavesEKG shows inferior Q waves

• Asymptomatic at this momentAsymptomatic at this moment

What is the next step of therapy?What is the next step of therapy?

Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

•Aspirin in the absence of contraindication in patients with prior MI

•Beta blockers as initial therapy in the absence of contraindications in patients with prior MI

Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients

•Low-density lipoprotein-lowering therapy in patients with documented CAD and LDL cholesterol greater than 130 mg/dL, with a target LDL of less than 100 mg/dL

•ACE inhibitor in patients with CAD1 who also have diabetes and/or systolic dysfunction

American College of American College of Cardiology, Puerto Rico Cardiology, Puerto Rico

ChapterChapter

Guidelines Applied to Practice (GAP)

San Juan Intercontinental; Febrero 6: Eduardo J. Viruet MDSan Juan Intercontinental; Febrero 6: Eduardo J. Viruet MD

Casa del Médico, Mayaguez; Febrero 7: Francisco Jaume MDCasa del Médico, Mayaguez; Febrero 7: Francisco Jaume MD

Casa del Médico, Ponce; Febrero 8: Nélida GonzálezCasa del Médico, Ponce; Febrero 8: Nélida González MDMD

American College of Cardiology American College of Cardiology Puerto Rico ChapterPuerto Rico Chapter

GAPGAP


american college of cardiology, puerto rico chapter guidelines applied to practice (gap)

Documents

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mgdl ldl levels

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treatment ldlc

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lipid management goal

risk categoryldlc