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The A B C s 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.

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the a b c s of cad prevention

The ABCsof CAD Prevention

Gina Ryan, PharmD, BCPS, CDE

Clinical Associate Professor

Mercer University College of Pharmacy and Health Sciences

program disclosures
Program Disclosures
  • Gina Ryan has received a CE grant Ortho McNeil.
case a
Case A

Your favorite cousin, Selena, is a 42-year 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 pre-hypertension 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.

slide4
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

slide5

C

insulin resistance,

elevated blood pressure, abdominal obesity

and dyslipidemia

Metabolic syndrome is comprised of

which of the following disorders

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
metabolic syndrome a b c s
Metabolic Syndrome - ABCs

ABCs

A – Antiplatelets & A1c - blood glucose

B - Blood pressure

C - Cholesterol

antiplatelets
Antiplatelets
  • Aspirin
  • Clopidogrel
  • Prasugrel
antiplatelets1
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

antiplatelets2
Antiplatelets
    • Primary Prevention
    • BP<150/90
  • Men
    • 45-79 yo with >10% risk*
  • Women
    • 55-79 yowith >10% risk
  • Dose – 81 mg

*usually 3

Chest 2008;133(6) supplement 71S-109S

slide11
A- A1c

glycosylated hemoglobin – for diabetes

reports glucose average over 6-8 weeks

normal 3-6%

goal in diabetes <6.5-7%

A1c

Nathan et al Diabetes Care2006;29:1963-1972.

b blood pressure
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
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

Statins are first line

Circulation. 2002;106:3143-3421

Grundy et al Circulation. 2004;110(2):227-239

what can selena do
What can Selena do?
  • Weight loss
    • How much?
      • 5-10%
      • 11-20%
      • 21-30%
      • >30%
what can selena do1
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 can selena do2
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
DIRECTDietary Intervention Randomized Control Trial
  • RCT, 2 yrs N=322
  • All groups consumed same amt of calories

Shai et al NEJM; 359:229-241

what can selena do3
What can Selena do?

Exercise

How much and how often?

_____ minutes per day ____ days per week at least.

  • 15 ; 2
  • 30; 5
  • 45; 6
  • 60; 6
  • What intensity?
minimum amount of exercise for weight loss
Minimum amount of exercise for weight loss

B

30 minutes per day

5 days per week

weight loss surgery
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
Preventing DiabetesMetformin
  • 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
Preventing DiabetesRosiglitazone

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
Preventing DiabetesACE 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

a 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

preventing cvd
PreventingCVD
  • 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/calculator.asp

Hirsh et al. Chest 2008; 133:71S-105S.

weight loss drugs
Weight Loss Drugs

*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
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
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 b1
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”

slide32
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

slide33

A lipoprotein is

A

lipid soluble sphere that carries cholesterol and triglycerides through the body

slide34
High density lipoprotein cholesterol (HDL-C) carries mostly ___________ from the ______ to the _______.

a. cholesterol; periphery; liver

b. cholesterol; liver; periphery

c. triglycerides; periphery; liver

d. triglycerides; liver; periphery

slide35
A

HDL-C carries mostly

cholesterol from the

periphery to the liver.

reverse cholesterol transport

slide36
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

slide37
B

Low density lipoprotein

cholesterol (LDL-C) carries mostly cholesterolfrom the

liver to the periphery.

slide38
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

slide39
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 a b c s
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.

case c
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.

a1c and cvd clinical trials
A1c and CVDClinical 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 a b c s
What would you like to do for RT’s ABCs?

Please work in a group and develop your MTM plan.

rt s info
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 a b c s
Reviewing RT’s ABCs

http://hp2010.nhlbihin.net/atpiii/calculator.asp

summary
Summary
  • Controlling blood pressure and cholesterol
  • Aspirin therapy
  • Blood glucose control is important in preventing microvascular complications
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