The
ABCs
of CAD Prevention
Gina Ryan, PharmD, BCPS, CDE
Clinical Associate Professor
Mercer University College of Pharmacy
and Health Sciences
Program Disclosures
• Gina Ryan has received a CE grant
Ortho McNeil.
Case A
Your favorite cousin, Selena, is a 42year old female. She is overweight
(BMI 37kg/m2) and does not like to
exercise because it messes up her hair.
Her doctor told her she had prehypertension and pre-diabetes. Your
grandmother had diabetes and died
from heart failure. Your aunt, her
mother, died of an MI at 45. Selena
comes to you to ask you to recommend
something for weight loss. She doesn’t
want to die young.
Metabolic syndrome is comprised of
which of the following disorders
a. insulin resistance and elevated blood
pressure
b. elevated blood pressure and Type 1
diabetes
c. insulin resistance, elevated blood
pressure, abdominal obesity, and
dyslipidemia
d. hypoglycemia and dyslipidemia
Metabolic syndrome is comprised of
which of the following disorders
C
insulin resistance,
elevated blood
pressure,
abdominal obesity
and dyslipidemia
Metabolic Syndrome
Risk Factor
Defining Level
abdominal obesity
men
women
waist circumference
>40 in
>35 in
triglycerides
>150 mg/dl
HDL cholesterol
men
women
<40 mg/dl
<50 mg/dl
blood pressure
>130/85
fasting glucose
>100
Metabolic Syndrome ABCs
ABCs
A – Antiplatelets & A1c - blood glucose
B - Blood pressure
C - Cholesterol
Antiplatelets
• Aspirin
• Clopidogrel
• Prasugrel
Antiplatelets
Secondary Prevention
• All patients with history of stroke or
heart attack
• Dose
ACS - ASA 81-325 mg + clopidogrel
PCI - ASA + prasugrel
Chest 2008;133(6) supplement 71S-109S
Antiplatelets
Primary Prevention
• BP<150/90
• Men
– 45-79 yo with >10% risk*
• Women
– 55-79 yo with >10% risk
– Dose – 81 mg
*usually 3
Chest 2008;133(6) supplement 71S-109S
A1c
A- A1c
glycosylated hemoglobin – for
diabetes
reports glucose average over 6-8
weeks
normal 3-6%
goal in diabetes <6.5-7%
Nathan et al Diabetes Care 2006;29:1963-1972.
B - Blood Pressure
JNC VII
optimal <120/80
pre-hypertension 120-140/80-90
Stage 1 140/90-159/99
Stage 2 >160/100
First-line Treatment
beta blockers, HCTZ, ACE inhibitors
JAMA 2003; 289: 2560-2572
C - Cholesterol
• Total Cholesterol <175 mg/dl
• HDL-C >60 mg/dl
• VLDL-C (TG) <150 mg/dl
• LDL-C
0 risk <130 mg/dl
>2 risks <100 mg/dl
CAD <70 mg/dl
Circulation. 2002;106:3143-3421
Grundy et al Circulation. 2004;110(2):227-239
What can Selena do?
•
Weight loss
–
How much?
a. 5-10%
b. 11-20%
c. 21-30%
d. >30%
How much weight loss?
A
5-10%
What can Selena do?
Weight loss – How fast?
What is the maximum rate of safe
weight loss?
a. 1-2 lbs per month
b. 1-2 lbs per week
c. 5 lbs per week
d. 30 lbs by Labor Day
What is the maximum rate
of safe weight loss?
B
1-2 lbs/week
What can Selena do?
Weight Loss – How to?
Choose the correct option. In order to
loose weight Selena needs to
a. Reduce her carbohydrate intake, but
she can eat as much fat as she wants
b. Reduce her fat intake, but she can eat
as much carbhydrates as she wants
c. Reduce her calories so that she burns
more energy than she consumes
d. Mediterranean Diet – high veggies and
poultry & fish
DIRECT
Dietary Intervention Randomized Control Trial
• RCT, 2 yrs N=322
• All groups consumed same amt of calories
Kg
LDL
adherence
Low fat &
Restricted cal
-2.9 -0.05 90%
Mediterranean
& restricted cal
-4.4 -5.6
85%
-4.7 -3
78%
Low CHO
Shai et al NEJM; 359:229-241
What can Selena do?
Exercise
How much and how often?
_____ minutes per day ____ days per
week at least.
a. 15 ; 2
b. 30; 5
c. 45; 6
d. 60; 6
–
What intensity?
Minimum amount of
exercise for weight loss
B
30 minutes per
day
5 days per week
Weight-Loss Surgery
• BMI >35-40 kg/m2
• Laparascopic vs Laparotomy
• Weight loss 40-88% of presurgery wt
• Mortality -0.3%
• Serious complications – 4.1%
• Cost – $17, 000- 26, 000
Curr Probl Surg 2010; 47:79-174
Preventing Diabetes
Metformin
• Diabetes Prevention Program
– RCT, N=3234,
– IGT
– Metformin reduces risk diabetes – by
31%
– Diet/exercise reduces risk by 58%
DPP Lancet NEJM 2002;p 393
Preventing Diabetes
Rosiglitazone
DREAM Trial
RCT, N=5,269, IFG + IGT, 3 yrs
primary endpoint – death or diabetes
rosiglitazone & life style recommendations
reduced risk by 60%
vs
placebo & life style recommendations
DREAM Lancet 2006; 368:1096
Preventing Diabetes
ACE Inhibitors
• Secondary analysis of trials suggest
ACE inhibitors may prevent diabetesa
• DREAM Trial - Prospective Analysisb
– N=5,269, IGT + IFG, 3 yrs
– ramipril didn’t prevent new onset DM
– rampril did increase odds of
normoglycemia
Hansson et al. Lancet 1999;353:611-6; NEJM 2000;342:145-53;
Abuissa HJ Am Coll Cardiol 2005;46:821-6
bNEJM 2006; 355:1551-1562
a
Preventing
CVD
• ASA Indications
– MI – use ASA and clopidogrel
– 10-yr risk of cardiac event >10%
• Use ASA 75-100 mg/day
– http://hp2010.nhlbihin.net/atpiii/calcula
tor.asp
Hirsh et al. Chest 2008; 133:71S-105S.
Weight Loss Drugs
Agent
Phentermine
$ for 1 lb
$/30 day weight loss
54
10
Sibutramine
110
141
Exenatide*
230
535
Orlistat
27
34
*Off label use
Murno et al BMJ 1968;1:352, Buse Clin Ther 29:139, Jones et al. Int J Obes Relat Met
Disord. 1995;19:41, Sjostrom L et al Lancet 1998;352:167-173. Drug Store.com for
pricing accessed June 12, 2008
What would you tell
Selena?
• Group Caucus
– What questions would you ask Selena
– What do you think Selena should do for
her ABCs?
– Should she be given drugs now?
Case B
Your store has contracted with
a 3rd party payor to provide
MTM for its insured. You
were chosen to oversee this
process.
Case B
48-year old white male, KL, with
history of hypertension and
dyslipidemia. The following meds are
on his prescription profile:
irbesartan/HCTZ 300 /12.5 and
atorvastatin 10 mg po qd. NKA wt
278 Ht 5’8”
What information
would you like to have
about KL?
A lipoprotein is
a. a lipid soluble sphere that carries
cholesterol and triglycerides through
the body
b. a protein that binds albumin
c. an important protein involved in binding
drugs
d. eliminated by the kidney
A lipoprotein is
A
lipid soluble sphere
that carries
cholesterol and
triglycerides
through the body
High density lipoprotein cholesterol
(HDL-C) carries mostly ___________
from the ______ to the _______.
a.
b.
c.
d.
cholesterol; periphery; liver
cholesterol; liver; periphery
triglycerides; periphery; liver
triglycerides; liver; periphery
A
HDL-C carries mostly
cholesterol from the
periphery to the liver.
reverse cholesterol transport
Low density lipoprotein cholesterol
(LDL-C) carries mostly
___________ from the ______ to
the _______.
a. cholesterol; periphery; liver
b. cholesterol; liver; periphery
c. triglycerides; periphery; liver
d. triglycerides; liver; periphery
B
the
Low density lipoprotein
cholesterol (LDL-C)
carries mostly
cholesterol from
liver to the periphery.
Very-low density lipoprotein
cholesterol (VLDL-C) carries
mostly ___________ from the
______ to the _______.
a. cholesterol; periphery; liver
b. cholesterol; liver; periphery
c. triglycerides; periphery; liver
d. triglycerides; liver; periphery
D
Very-low density
lipoprotein cholesterol
(VLDL-C) carries
mostly triglycerides
from the liver to the
periphery.
What would you like
to do for KL’s ABCs?
48-year old white male
Meds: atorvastatin 10 mg,
irbesartan/HCTZ 300 /12.5
NKA wt 278 Ht 5’8”
A – BG within wnl
B – 156/96
C – TC – 223, LDL- 148, HDL – 43, TG -160
FM history father died at age 53 of MI
Social – drinks and smokes cigars at
Saturday night poker games, walks to
mailbox and at work.
Reviewing
KL’s
ABCs
Case C
Your second MTM patient, RT is a 58
year old female with history of type
2 diabetes, hypertension, elevated
cholesterol. Last year she had an
MI. Her blood pressure is 148/82,
her last cholesterol was taken 6
months ago.
RT’s pharmacy profile
4/4/10
verapamil SR 240mg po qd #30
4/4/10
HCTZ 12.5 mg qd #30
4/4/10
70/30 human insulin 50 qam and 70 qpm # 40 ml
4/4/10
simvastatin 10 mg po qd #30
2/17/10
HCTZ 12.5 mg qd #30
2/17/10
70/30 human insulin 50 qam and 70 qpm # 40 ml
2/17/10
verapamil SR 240mg po qd #30
2/17/10
HCTZ 12.5 mg qd #30
1/2/10
simvastatin 10 mg po qd #30
1/2/10
70/30 human insulin 50 qam and 70 qpm # 40 ml
1/2/10
verapamil SR 240mg po qd #30
1/2/10
HCTZ 12.5 mg qd #30
1/2/10
70/30 human insulin 50 qam and 70 qpm # 40 ml
What additional
information
would you like to have
about RT?
A1c and CVD
Clinical Trials
ACCORD, ADVANCE, VADT
Large RCTs, T2DM
Compared A1c <6.5% to A1C 7-7.9%
Results
A1c<6-6.5 did not decrease CVD events
N Engl J Med. 2008;358(24):2545-2559.
N Engl J Med. 2008;358(24):2560-2572.
N Engl J Med. 2009;360(2):129-139.
What would you
like to do for RT’s
ABCs?
Please work in a group and
develop your MTM plan.
RT’s Info
58 year old female s/p MI , wt 187 Ht 5’6”
A – A1C 7.5% type 2 DM
B – 148/82
C – TC – 178, LDL 112, HDL 33, TG 165 (6
months old)
Social – drinks socially, neg smoking
Meds: verapamil SR 240mg po qd
HCTZ 12.5 mg qd
70/30 human insulin 50 qam and 70 qpm
simvastatin 10 mg po qd
Reviewing
RT’s
ABCs
http://hp2010.nhlbihin.net/atpiii/calculator.asp
Summary
• Controlling blood pressure and
cholesterol
• Aspirin therapy
• Blood glucose control is important in
preventing microvascular complications
Questions