Cardiovascular Medicine Book

Coronary Artery Disease

Hyperlipidemia

Hypertension

http://www.fpnotebook.com/

Cardiac Risk ManagementAka: CAD Risk Management, Cardiovascular Risk Reduction, Coronary Risk Management, Coronary Heart Disease Prevention, Prevention of Coronary Events, Anticoagulation in Coronary Artery Disease Prevention

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  1. See Also
    1. Cardiac Risk Factor
    2. Post Myocardial Infarction Medications
  2. Resources
    1. Risk Assessment Tool (Available for PDAs)
      1. http://www.nhlbi.gov/guidelines/cholesterol
      2. Uses Framingham data to direct CAD Risk Management
    2. Risk reduction measures in Patient Education handouts
      1. http://www.heartdecision.org
  3. Prevention: Approach
    1. Mnemonic: Remember your ABCDEFs
      1. Antiplatelet (e.g. Aspirin) or anticoagulant
      2. Blood Pressure control
      3. Cholesterol management
      4. Diabetes management
      5. Exercise (or Cardiac Rehabilitation if indicated)
      6. Fish oil
      7. Smoking Cessation
    2. General
      1. Four health habits dramatically reduce risk
        1. Tobacco avoidance
        2. BMI <25 kg/m2 (but even <30 kg/m2 reduces risk)
        3. Eating 5 or more fruits and vegetables daily
        4. Aerobic Exercise >150 minutes per week
      2. Benefits
        1. Following all 4 habits reduces cardiovascular events by 40%
        2. Overall survival is extended 14 years in those following all 4 habits
        3. Even adopting 1 new health habit significantly reduces mortality
      3. References
        1. Akesson (2007) Arch Intern Med 167:2122
        2. King (2007) Am J Med 120:598
  4. Management: Risk factor modification
    1. See Mediterranean Diet (Heart Healthy Diet)
    2. Weight loss
    3. Blood Pressure control (Goal under 125/75)
    4. Tobacco Cessation
      1. Regardless of age, Tobacco Cessation reduces risk
        1. Hermanson (1988) N Engl J Med 319:1365
      2. Overall mortality reduced as much as 36% in CHD
        1. Risk reduction more than medications (e.g. ASA)
        2. Critchley (2003) JAMA 290:86
    5. Lower Cholesterol
      1. Diet or pharmacologic treatment
      2. LDL Cholesterol <100 mg/dl
      3. HDL Cholesterol >40 mg/dl (50 mg/dl for women)
      4. Triglycerides <150 mg/dl
      5. See Statin use below
    6. Aerobic Exercise (30-45 minutes, 3-6 times per week)
      1. Low level Exercise (walking, gardening) is effective
      2. Wannamethee (2000) Circulation 102:1358
    7. Aggressively treat Diabetes Mellitus
      1. Keep the Hemoglobin A1C less than 7%
    8. Treat comorbid Major Depression
      1. See Depression Management in Cardiovascular Disease
      2. Increased risk of Coronary Artery Disease
      3. Risk of MI related death increased 3.5 fold
    9. Influenza Vaccine
      1. Lowers cardiovascular event risk by 50%
      2. Gurfinkle (2002) Circulation 105:2143
  5. Management: Disproved strategies
    1. Anti-oxidant regimen
      1. Negates Statin and Niacin HDL-2 beneficial effects
      2. No proven efficacy
      3. Anti-oxidants
        1. Vitamin E 400 iu/day
          1. Not effective in coronary disease prevention
          2. Skekelle (2004) J Gen Intern Med 19:380
        2. Vitamin C 500-1000 mg/day
        3. Beta Carotene 25000 u/day
        4. B Vitamins offer no benefit in Cardiac Risk
          1. Vitamin B12 Supplementation 400 mg qd
          2. Vitamin B6 supplementation 10 mg qd
          3. (2006) N Engl J Med 354:1567
    2. Estrogen Replacement (Hormone Replacement Therapy)
      1. Stop HRT in those at risk for coronary disease
      2. No longer thought to be protective against CAD
      3. Data based on NIH Women's Health Initiative
      4. References
        1. (2002) JAMA 288:321
        2. Waters (2002) 288:2432
  6. Medications: Platelet activation inhibitors
    1. Aspirin
      1. Indication
        1. Framingham 10 year risk 10% or higher
      2. Dosing (use non-enteric coated if possible for best absorption)
        1. CAD risk: 80-160 mg orally daily
        2. CAD Disease: 160-325 mg orally daily
      3. Aspirin resistance confers 3x cardiovascular risk
        1. Consider lab screening in high risk patients
          1. Optical aggregation for Aspirin resistance
        2. Use Clopidogrel for Aspirin resistant patients
        3. Reference
          1. Gum (2003) J Am Coll Cardiol 41:961
      4. Aspirin with Proton Pump Inhibitor
        1. Indicated for history of bleeding peptic ulcer
        2. Less bleeding risk than Clopidogrel
        3. Chan (2005) N Engl J Med 352:238
      5. Aspirin use in women without vascular disease
        1. Reduces stroke risk but not MI risk
        2. Associated with higher risk of GI Bleeding
        3. Not recommended for women at low vascular risk
        4. Ridker (2005) N Engl J Med 352:1293
    2. Clopidogrel (Plavix)
      1. More effective than Aspirin in preventing CV events
      2. Avoid combining with Aspirin (avoid the combination in all but highest risk)
      3. Indicated in known vascular disease
      4. Cannon (2002) Am J Cardiol 90:160
  7. Medications: Antihypertensives
    1. Goal Blood Pressure
      1. CAD, CRF, DM: <130/80
      2. Other patients: <140/90
    2. Agents
      1. Beta-Blockers
      2. ACE Inhibitors
      3. Thiazide Diuretics
      4. Calcium Channel Blockers
        1. May be higher mortality in general CAD
        2. Less effective CAD prevention than other agents
          1. Black (2003) JAMA 289:2073
        3. Indications
          1. Rest and variant Angina
          2. Silent ischemia
          3. Microvascular Angina (Syndrome X)
            1. Use in combination with nitrates
  8. Medications: AntiHyperlipidemic therapy with Statin
    1. Effective in preventing future cardiovascular events
    2. Benefit even in patients over age 80 years
    3. Goal LDL Cholesterol: 100 mg/dl
      1. Variable evidence for benefit <70 mg/dl
      2. Intensive lipid lowering may have substantial benefit
        1. LaRosa (2005) N Engl J Med 352:1425
      3. No benefit in study of intensive lowering post-MI
        1. Pedersen (2005) JAMA 294:2437
    4. References
      1. Collins (2004) Lancet 363:757
      2. Maycock (2002) J Am Coll Cardiol 40:1777
  9. Medications: Reduce Homocysteine (e.g. Folic Acid)
    1. Folic Acid supplementation 1000 mg qd
      1. Not beneficial post-stenting
        1. Lange (2004) N Engl J Med 350:2673
    2. References
      1. Schnyder (2002) JAMA 288:973
      2. Rimm (1998) JAMA 279:359
  10. Medications: Other
    1. See Post Myocardial Infarction Medications
    2. Supplements that show initial benefit
      1. Coenzyme Q10 60 mg PO bid
        1. Singh (2003) Mol Cell Biochem 246:75
    3. Implantable Cardioverter Defibrillators
      1. Used post-MI for high risk of ventricular arrhythmia
      2. Did not reduce mortality (n=674) over >30 months
      3. Hohnloser (2004) N Engl J Med 351:2481
  11. Medications: Avoid NSAIDs (other than Aspirin)
    1. NSAIDs are associated with increased risk of cardiovascular events
      1. Antman (2007) Circulation 115(12):1634
      2. Moore (2007) BMC Musculoskelet Disord 8:73
      3. Wehrmacker (2006) Compr Ther 32(4):236
    2. Step-wise approach to Analgesics (in order of least to most cardiovascular risk)
      1. Acetaminophen (lowest cardiovascular risk)
      2. Aspirin (cardioprotective)
      3. Tramadol (Analgesics)
      4. Opioid Analgesics (e.g. Vicodin)
      5. Salsalate
      6. Naproxen (Naprosyn)
      7. Cox-2 selective NSAIDs such as Celecoxib (most cardiovascular risk)
    3. References
      1. Prescriber's Letter (2008) 15(2): 8
  12. References
    1. Ferketich (2000) Arch Intern Med 160:1261
    2. Frasure-Smith (1993) JAMA 270:1819
    3. (2001) Lancet 357:89

Coronary heart disease risk clinical management plan (C1445948)

ConceptsIntellectual Product (T170)
EnglishCoronary heart disease risk clinical management plan
Spanishplan de manejo clínico de riesgo de enfermedad coronaria, plan de manejo clinico de riesgo de enfermedad coronaria
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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