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8/7/2019 A1 Wright Treating CV Risk Factors
1/17
12/15/201
Partners in Healthcare Education, LLC
Treating Cardiovascular Risk
Factors in Medically Complex
Patients
1
Wendy L. Wright, MS, RN, ARNP, FNP, FAANP
Owner Wright & Associates Family Healthcare
Partner Partners in Healthcare Education
Disclosures
Grants: Novartis, DaiichiGrants: Novartis, Daiichi--SankyoSankyo
Speaker Bureau: OrthoSpeaker Bureau: Ortho--McNeil, Abbott,McNeil, Abbott,Novartis, GSK,Novartis, GSK, SanofiSanofi--Pasteur, DSI, Takeda,Pasteur, DSI, Takeda,
Wright, 20102
Upon completion of this lecture, the participantwill be able to:
Discuss the epidemiological impact of CAD in 2011
List the maor risk factors im actin a ressive
Objectives
3
CAD
Identify treatment options for the medicallycomplex patient at risk of cardiovascular disease
The Problem:
Cardiovascular Disease is Deadly!
4www.Hypertensiononline.org
500,000
600,000
700,000
800,000
900,000
Deaths
Alzheimer
CLRD
Cancer
CVD and Other Causes of Death
CVD and other major causes of death: both sexes.(United States: 2006). Source: NCHS and NHLBI.
0
100,000
200,000
300,000
400,000
All Ages
8/7/2019 A1 Wright Treating CV Risk Factors
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12/15/201
Partners in Healthcare Education, LLC
Bob47-year-old Caucasian Sales Executive
Presents for a physical examination
No complaints at present and feels well PMH
7
-
Obesity since young adulthood
Bipolar disorder
Smoker
Family HistoryFather died age 62 - MI
Bob Social History
Tobacco use: 1- 2 pack daily; 25 years
Alcohol: 1 2 beers nightly Exercise: none Married, 2 children in high school
8
a es execu ve w o rave s o meaway from home)
MedicationsMultivitamin 1 po dailyASA 81 mg 1 po daily Lithium 300 mg 1 pill two times daily
BobPhysical Examination
Height: 5 8
Weight: 287 lbs
BMI: 43.9
9
Waist circumference: 46
BP: 138/90 (2 readings)
Pulse: 86 bpm and regular
EKG: Left axis deviation
No conduction abnormalities or ischemic changes
BobLaboratory Parameters
FBS: 106 mg/dL (60 99)
BUN: 16 mg/dL (9 21)
Creatinine: 1.0 mg/dL (0.8- 1.4)
10
.
HDL: 34 mg/dL (> 40)
Triglycerides: 156 mg/dL (
8/7/2019 A1 Wright Treating CV Risk Factors
3/17
12/15/201
Partners in Healthcare Education, LLC
Interrelation Between Atherosclerosisand Insulin Resistance
Hypertension
Obesity
Hyperinsulinemia
13
Diabetes
Hypertriglyceridemia
Small, dense LDL
Low HDL
Hypercoagulability
InsulinInsulinResistanceResistance
InsulinInsulinResistanceResistance
AtherosclerosisAtherosclerosisAtherosclerosisAtherosclerosis
Slide source: Lipidsonline.org
Insulin Resistance Primarily, the plasma glucose level regulates
the physiologic control of insulin secretion
When an individual develops insulin resistance,the normal amount of insulin is not able to
14
To compensate, insulin secretion is increaseduntil the plasma glucose levels return to normal
Eventually, the pancreas may NOT be able tocompensate
Clinicia ns Manual on Insulin Resistance. H E Lebovitz Science Press 2002 London,UKhttp://care.diabetesjournals.org/cgi/content/full/27/2/602
Causes of Insulin Resistance
Adiposity and Physical Conditioning
25% each.50% of IR patients
15
Genetic Factors..50% of IR Patients
First World Congress on Insulin Resistant Syndrome; 2003, Nov20-23, Los Angeles, California, USAhttp://care.diabetesjournals.org/cgi/content/full/27/2/602
Insulin Resistance
47 million people in the USA have
the insulin resistance syndrome.
16
Flegal, KM., Carroll MD., et al. Prevalence and Trends in Obesity AmongUS Adults, 1999-2000. JAMA. 2002; 288:1723-1727.Mokdad, AH, Ford ES. Et al. Prevalence of obesity, diabetes and obesity related
health risk factors 2001. JAMA. 2003; 289:76-79.
-Prevalence in men 24%; women 23.8%
Age 60 - 69 years oldPrevalence in men 43.5%; women 42%
Metabolic Syndrome Consensus Definition
Central Obesity > 40 inches male / >35 inches female Raised triglycerides
> 150 mg/dL (or treatment of triglycerides)
Reduced HDL cholesterol
130 mm Hg systolic or > 85 mm Hg diastolic or treatment
toward this goal
Raised fasting plasma glucose level FBS> 99 mg/dL or treatment toward this goal
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults. National Cholesterol Education Program, National Heart, Lung,and Blood Institute, National Institutes of Health. NIH Publication No 01-3670. May 2001
Regardless of NameMetabolic Syndrome is:
Method to identify those at risk for
Early
Aggressive
18
Patients with Metabolic Syndrome have a 3 Xgreater chance of developing CAD and dyingfrom it
Diabetes Care. 2001; 24:683-689.JAMA. 2002; 288:2709-2716.
8/7/2019 A1 Wright Treating CV Risk Factors
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Coronary Artery Disease
19
s ac or:
Obesity
BobPhysical Examination
Height: 5 8
Weight: 287 lbs BMI: 43.6
20
Waist circumference: 46 BP: 138/90 (2 readings)
Pulse: 86 bpm and regular
EKG:
Left axis deviation
No conduction abnormalities or ischemic changes
Definition of Obesity
Obesity is a chronic disease of
multiple etiologies characterized by
21
e presence o excess a pose ssue
Atkinson RL, Hubbard VS. Report on the NIH Workshop on PharmacologicTreatment of Obesity. American Journal of Clinical Nutrition, Vol 60,153-156, Copyright 1994 by The American Society for Clinical Nutrition, Inc
Practical Diagnosis
Waist Circumference
Obtained by taking a measurement between theiliac crest and the bottom of the rib cage aftermild exhalation
22
Waist circumference of > 102 cm (> 40 inches) inmen or 88 cm ( > 35 inches) in women is aimportant component of the metabolic syndromediagnosis
The Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Disease Risk*BMI Classification (Waist Circumference)
(kg/m2) Men < 40 in >40 in
Women < 35 in >35 in
Determine Obesity Classand Disease Risk
Determine Obesity Classand Disease Risk
-
23
* for type 2 diabetes mellitus, hypertension, and CVD
NHLBI Practical Guide. Oct 2000 Table 2, pg 10
. - .
30.0-34.9 Obesity I High Very High
35.0-39.9 Obesity II Very High Very High
> 40 Obesity III Extremely High Extremely High
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)
Source: CDC Behavioral Risk Factor Surveillance System.
24
No Data
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Obesity Trends* Among U.S. AdultsBRFSS, 2009
(*BMI 30, or ~ 30 lbs. overweight for 5 4 person)
Source: CDC Behavioral Risk Factor Surveillance System.
No Data
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Guide for SelectingTreatment
Guide for SelectingTreatment
BODY MASS INDEX (BMI)25-26.9 27-29.9 30-34.9 35-39.9 >40
DIET, PHYSICAL ACTIVITY * *
31
PHARMACOTHERAPY *
SURGERY *
* With ComorbiditiesAlways use as an adjunct to diet and physical activity
NHLBI Practical Guide. Oct 2000 Table 3, pg25
Drugs Approved by FDAfor Treating Obesity
NameApproval
Year UseMechanism of
ActionDEA
Schedule
Dosage/Monthly
Cost
Orlistat Lon - 120 mg
32
enca term pase n or one ~ $120
Phentermine(Adipex,lonamin)
1973 Short-termNorepinephrine
reuptake inhibitor IV15-37.5
mg/d
~ $40
FDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placeboFDA approves drugs that have greater than 5% weight loss above placebo
2020
4040
6060 MenMen WomenWomen
ngein
ngein
orsum(
%)
orsum(
%)
Change in Weight and CHD Risk FactorChange in Weight and CHD Risk FactorClustering: Framingham Offspring StudyClustering: Framingham Offspring Study
Risk factors: Low HDL-C High cholesterol High systolic BP High TG High glucose
33
LossLoss
2.25 kg2.25 kg
GainGain
2.25 kg2.25 kg
00
--2020
--4040
--6060
ChCh
riskfact
riskfact
LossLoss
2.25 kg2.25 kgGainGain
2.25 kg2.25 kg
Weight Change Over 16Weight Change Over 16--Year Follow UpYear Follow Up
Adapted from: Wilson PW, et al.Adapted from: Wilson PW, et al. Arch Intern Med.Arch Intern Med. 1999;159:11041999;159:1104 --11091109
Thoughts to Ponder
Lithium..
What do you need to consider?
Thyroid
Kidne function
Worsening insulin resistance?
Must avoid certain medications:
NSAIDs
HCTZ
34
Lithium
Lithium is cleared completely through therenal system
Drugs and conditions that influence renal
serum lithium concentrations
Such drugs include: thiazide diuretics,NSAIDs, ACE inhibitors, Calcium channelblockers (diltiazem and verapamil), Caffeine
35
Thiazides and Lithium
In fact, concomitant use of diuretics has longbeen associated with the development oflithium toxicity
Thiazide diuretics are thought to be theworst because they act distally on the renaltubule (same location as lithium is cleared)causing an increase in the re-absorption oflithium
36
8/7/2019 A1 Wright Treating CV Risk Factors
7/17
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Partners in Healthcare Education, LLC
Think of All theAntihypertensives
Most antihypertensives nowhave HCTZ in them
occur
37
Other Drugs Can Lower LithiumLevels
Osmotic diuretics enhance lithiumexcretion and are often used forlithium toxicit
Caffeine and theophylline alsodecrease lithium levels andtherefore need to be monitored ifused concomitantly
38
Coronary Artery Disease
39
Risk Factor:
Diabetes
BobLaboratory Parameters
FBS: 106 mg/dL (60 99) BUN: 16 mg/dL (9- 21)
Creatinine: 1.0 mg/dL (0.8-1.1)
40
T. Cholesterol: 220 mg/dL (< 200)
HDL: 34 mg/dL (> 40)
Triglycerides: 156 mg/dL (
8/7/2019 A1 Wright Treating CV Risk Factors
8/17
12/15/201
Partners in Healthcare Education, LLC
Screening for Diabetes
According to the ADA, screening shouldbegin on all individuals 45 years of age andolder1
Repeated q 3 years if normal
If at risk, can begin screening at an earlier
43
age i.e. obese, sedentary lifestyle
**American College of Endocrinology1: Begin screening at age 25 years, in at risk
individuals
www.diabetes.org accessed on 2-2-2008
www.aace.com accessed on 2-2-2008
A1C
Recommendations:
A1C may be used for screening >6.5% - consistent with diabetes
. - .
Last 6 weeks of blood sugars is driving factorin the A1C
www.diabetes.org
44
What Is Good Control? A1C
AACE: < 6.5%
ADA: < 7.0% ***
45
AACE: < 110 mg/dL
ADA: 70 130 mg/dL
2 hour postprandial: AACE:
8/7/2019 A1 Wright Treating CV Risk Factors
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Intensive
glycemic control
Intensive
management of
comorbid
AACE: Managing Diabetes
Lifestyle
intervention
American Association of Clinical Endocrinologists
49
conditions*
A1C 6.5% Glucose (mg/dL)
Preprandial110 Postprandial 140
Lipid modifying BP lowering ASA for prevention of
vascular events
Optimal nutrition Physical activity Smoking cessation Weight control
AACE. Endocr Pract. 2002;8(suppl 1):40-65.*Dyslipidemia, hypertension, early renal disease
BetaBeta--cellcell
dysfunctiondysfunction
Major Targeted Sites of Oral Drug Classes
Pancreas
Muscleand fatLiver
Sulfonylureas
Meglitinides
DPP-4 inhibitors
Incretin Memetics
50
GlucoseGlucose
absorptionabsorption
Hepatic glucoseHepatic glucose
overproductionoverproductionInsulinInsulin
resistanceresistance
DPP-4=dipeptidyl peptidase-4; TZDs=thiazolidinediones.DeFronzo RA. Ann Intern Med. 1999;131:281303.Buse JB et al. In: Williams Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders; 2003:14271483.
Glucose level
Biguanides
TZDs Biguanides
TZDs
Alpha-
glucosidaseinhibitors
Gut
DPP-4 inhibitors
Biguanides
Bile AcidSequestrants
Incretin Memetics
Treatment of Patient Based on AIC
A1C is less than 7.3% A1C is 7.3% - 9.2%
51
Monnier L, Lapinski, H, Colette C. Contributions of fasting and postprandial plasma glucose increments to
the overall diurnal hyperglycemia of type 2 diabetic patients: Variations with increasing levels of HbA(1c).Diabetes Care. 2003;26:881-885.
B -blockadeBlood ressure control
A AspirinACE inhibitionA1C control
Managing diabetes as a CHD risk equivalent:ABCs of coronary prevention
52Adapted from Cohen JD. Lancet. 2001;357:972-3.
C Cholesterol management
Diet
Dont smoke
Decrease diabetes risk
D
Exercise
E
Target Recommendations
A1C
8/7/2019 A1 Wright Treating CV Risk Factors
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55
Risk Factor
Dyslipidemia
BobLaboratory Parameters
FBS: 101 mg/dL (60 99)
BUN: 16 mg/dL (9 21) Creatinine: 1.0 mg/dL (0.8-1.1)
56
.
HDL: 34 mg/dL (> 40)
Triglycerides: 156 mg/dL (
8/7/2019 A1 Wright Treating CV Risk Factors
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Partners in Healthcare Education, LLC
Risk Level Risk Category
LDL-CGoal
(mg/dL)
LDL-C toConsider Drug
Therapy*
(mg/dL)
ModeratelyHigh Risk
2 Risk Factors;10-Year Risk 10%-20%
High Risk CHD or CHD Risk
NCEP Interim Report:LDL-C Goals and Drug Cut Points for High-Risk Patients
8/7/2019 A1 Wright Treating CV Risk Factors
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Partners in Healthcare Education, LLC
ASCOT-Lipid Lowering Arm
LDL starting value133 mg/dL
Aggressive LDL lowering.88 mg/dL
67
Major CV events @ 3 years.. 36%
Major vascular events. 27%
Total coronary events. 29%
Lancet2003; 361:1149-1158 68
The HDL Molecules(s)
Industrial Strength
Vacuum2b
69
Dust Buster
2a
3a
3b
3c
Adapted from Berkley Heart Lab70www.lipidsonline.com
Treatment
71
Alternatives
What Does He Need?
Statin?
Bile Acid Sequestrant?
Niacin? Fibrate?
Omega 3?
Any worries?
Kidney function statins?
72
8/7/2019 A1 Wright Treating CV Risk Factors
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73
Risk Factor:
Hypertension
BobPhysical Examination
Height: 5 8
Weight: 287 lbs
BMI: 43.9
Waist circumference: 46
74
BP: 138/90 (2 readings)
Pulse: 86 bpm and regular
EKG: Left axis deviation
No conduction abnormalities or ischemic changes
BobLaboratory Parameters
FBS: 106 mg/dL (60 99)
BUN: 16 mg/dL (9-21-)
Creatinine: 1.0 mg/dL (0.8-1.1)
75
T. Cholesterol: 220 mg/dL (< 200)
HDL: 34 mg/dL (> 40)
Triglycerides: 156 mg/dL (
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JNC 7: Classification and ManagementJNC 7: Classification and Managementof Blood Pressureof Blood Pressure
No antihypertensive
drug indicated
Thiazide-type diuretics
Drug(s) for compelling
indications
Drug(s) for the
Encourage
Yes
Yes
and
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ARB Trials1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
ValHeFTELITE I
ELITE II
LIFE
CHARM
ON TARGET
HF
CV
85
IDNT
RENAAL
IRMA II
OPTIMAAL
VALIANT
VALUE
MARVAL
MI
Renal/CV
Renal
IPreserve
Newer Trials
Combination therapy
ACE/HCTZ, ARB/HCTZ, ACE/CCB\
Triple therapy
86
Becoming norm
Direct Renin Inhibitors and combinationtherapy
Aliskirin + HCTZ, ACE, ARB, CCB
ARB + CCB
What Does He Need? Think:
LVH
Smoker
Prediabetes
Bipolar Disorder
ACE inhibitor
Beta blocker
CCB
DRI
ARB
Thiazide87
Case StudyCase Study
88
BobPhysical Examination
Height: 5 8
Weight: 287 lbs
BMI: 43.9
89
Waist circumference: 46
BP: 138/90 (2 readings)
Pulse: 86 bpm and regular
EKG: Left axis deviation
No conduction abnormalities or ischemic changes
BobLaboratory Parameters
FBS: 106 mg/dL (60 99)
BUN: 16 mg/dL (9-21)
Creatinine: 1.0 mg/dL (0.8-1.1)
90
.
HDL: 34 mg/dL (> 40)
Triglycerides: 156 mg/dL (
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BobLaboratory Parameters
hs-CRP: 2.7 mg/L (
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Conclusions
Nurse Practitioners and Physician
Assistants are in an excellent position toidentify the individual at risk for CAD
97
Once identified, aggressive treatment formodify obesity, hypertension, dyslipidemiaand diabetes must be employed to reducethe risk of CAD