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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.


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


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


    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”


    What information would you like to have about kl
    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. cholesterol; periphery; liver

    b. cholesterol; liver; periphery

    c. triglycerides; periphery; liver

    d. triglycerides; liver; periphery


    A ___________ from the ______ to the _______.

    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 ___________ from the ______ to the _______.

    Low density lipoprotein

    cholesterol (LDL-C) carries mostly cholesterolfrom the

    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 mostly ___________ from the ______ to the _______.

    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 mostly ___________ from the ______ to the _______. 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 a b c s
    Reviewing KL’s mostly ___________ from the ______ to the _______. ABCs


    Case c
    Case C mostly ___________ from the ______ to the _______.

    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
    RT’s pharmacy profile mostly ___________ from the ______ to the _______.


    What additional information would you like to have about rt
    What additional information mostly ___________ from the ______ to the _______. would you like to have about RT?


    A1c and cvd clinical trials
    A1c and CVD mostly ___________ from the ______ to the _______. 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 a b c s
    What would you mostly ___________ from the ______ to the _______. like to do for RT’s ABCs?

    Please work in a group and develop your MTM plan.


    Rt s info
    RT’s Info mostly ___________ from the ______ to the _______.

    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 mostly ___________ from the ______ to the _______. RT’s ABCs

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


    Summary
    Summary mostly ___________ from the ______ to the _______.

    • Controlling blood pressure and cholesterol

    • Aspirin therapy

    • Blood glucose control is important in preventing microvascular complications


    Questions mostly ___________ from the ______ to the _______.


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