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Aggressive Therapy of Hypercholesterolemia in Acute Coronary Syndromes

Aggressive Therapy of Hypercholesterolemia in Acute Coronary Syndromes. Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center, Los Angeles, CA California Chairman, AHA "Get with the Guidelines". Who are we talking about?.

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Aggressive Therapy of Hypercholesterolemia in Acute Coronary Syndromes

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  1. Aggressive Therapy of Hypercholesterolemia inAcute Coronary Syndromes Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center, Los Angeles, CA California Chairman, AHA "Get with the Guidelines"

  2. Who are we talking about? • Known vascular disease CAD Carotid PVD Aortic Aneurysm • Vascular equivalents DM • High risk 10 year risk > 20% NCEP III -- JAMA 2000;285:2486

  3. Risk Category LDL Goal(mg/dL) LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) LDL Level at Which to ConsiderDrug Therapy (mg/dL) CHD or CHD Risk Equivalents(10-year risk >20%) <100 100 130 (100–129: drug optional) 2+ Risk Factors (10-year risk 20%) <130 130 10-year risk 10–20%: 130 10-year risk <10%: 160 0–1 Risk Factor <160 160 190 (160–189: LDL-lowering drug optional) LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories

  4. Methods for Modifying Cholesterol Levels 1 - Diet 2 - Exercise 3 - Drugs 4 - Partial ileal bypass 5 - Portacaval shunting 6 - Apheresis adsorption column (LDL apheresis) plasma exchange double membrane dextran sulfate precipitation immunoabsorption 7 - Liver transplantation

  5. Atherosclerosis

  6. Egg McMuffin Calories 290 Calories from fat 110 Total fat 12 g Saturated fat 4.5 g Cholesterol 235 mg Sodium 790 mg Carbohydrates 27g Protein 17g http://www.mcdonalds.com/countries/usa/

  7. Lifestyle Heart Trial Ornish D, et al. Lancet 1990;336:129

  8. Lifestyle Heart Trial Ornish D, et al. Lancet 1990;336:129

  9. Lifestyle Heart Trial Intervention group LDL after 1 year Mean = 93 mg/dl + 43 mg/dl NCEP Goal 55.3% 44.7% Ornish D, et al. Lancet 1990;336:129

  10. Mediterranian Diet J. THOMSON "Chart of the Mediterranean Sea" Edin.18I7

  11. Lyon Heart Trial • <35% energy as fat • <10% energy saturated fat • <4% energy as linoleic acid • >0.6% of energy as alpha-linolenic (18:3 or n-3) • Eat more bread • Eat more fish, less meat • Eat more vegetables • Must have fruit every day • All butter and margarine replaced with olive oil and canola oil • First MI • Randomized • Mediterranian vs Prudent • 5 year trial stopped early De Lorgeril et al Circulation 1999;99:779

  12. Lyon Heart Trial Survival with: No MI Survival with: No MI Angina CHF CVA PE Periph embol Stable angina PTCA, CABG Restenosis Survival with: No MI Angina CHF CVA PE Periph embol De Lorgeril et al Circulation 1999;99:779

  13. Lyon Heart Trial Differences in LDL-C De Lorgeril et al Circulation 1999;99:779

  14. Goals of Diet(s) • Disease-specific Renal Diabetes • Weight loss Thousands • Lipid management Hundreds • Survival Mediterranian Fish

  15. Exercise

  16. Exercise • 6,213 men • ETT for clinical reasons • 2,534 normal • 3,679 with CAD • Mean f/u 6.2 years • Age 59 + 11 • Peak capacity stronger predictor than cigs, HTN, DM, Chol Myers, NEJM 2002;346:793

  17. Effect of Exercise on Lipids • 2906 men • age 30-64 years • exercise treadmill test to exhaustion • classified into 6 groups based on average miles run per week Kokkinos Arch Int Med 1995:155:415

  18. Effect of Exercise on Lipids Kokkinos Arch Int Med 1995:155:415

  19. Cholesterol-Lowering Drugs

  20. Cholesterol Modifying Agents

  21. 4S

  22. Summary of Key End-points Simvastatin vs. placebo Total mortality p=0.0003 CAD mortality p<0.00001 Major coronary events p<0.00001 PTCA/CABG p<0.00001 Event-free survival p<0.00001 0.2 0.4 0.6 0.8 1.0 1.2 Relative risk (95% CI) Reduced Increased

  23. Effects of Statin on Total Mortality (4S)Diabetics (n= 201) vs Non-Diabetics (n=4242) 43% risk reduction 28% risk reduction Presented at the ACC Meeting March 19-22, 1995

  24. When should weSTARTtherapy?

  25. P=0.048 MIRACL Schwartz JAMA 2001;285:1711

  26. CHAMP Fonarow, AJC 2001;87:819

  27. CHAMP Fonarow, AJC 2001;87:819

  28. When should weSTARTtherapy? AS SOON AS POSSIBLE!!!!

  29. Use diet and exercise on all patients, wait 3-6 months for statin therapy: 4% will have LDL < 100 mg/dL • Start statin in the hospital, recommend diet and exercise: 96% get needed therapy 4% "overtreated" Why start drugs in the Hospital?

  30. How do you improve your rate of therapy?

  31. Improving Process of Care • Finding a "Champion" • Develop a team • Baseline measurement • Use the team to develop new processes pocket reminders standard orders computer reminders • Follow-up measurement

  32. Clinician Checklist

  33. Patient Checklist

  34. Get With the Guidelines!

  35. The Guidelines

  36. How often do we provide these therapies?

  37. State Standings Ranked by CV indicators, mammog, immune, etc Jencks et al. JAMA 2000;284:1670

  38. What is the GWTG Plan? • Hospitals • Medical Groups Kaiser Tenet CHCW • Large payors • Government • Educational programs • Tools • Carrots • Sticks Everything still in development

  39. Management of MedRx • On transfer out of the ICU ABC2D aspirin beta blocker cholesterol agent converting enzyme inhibitor (ACE) diabetes • On the ward hypertension therapy smoking cessation BMI recommendations exercise recommendations

  40. CSMC Cardiothoracic Surgery All CABG-only, 10/1/2001 to 12/31/2001 compare to 1999 data

  41. Effects of Various Cardiac Therapies

  42. Effects of Various Cardiac Therapies

  43. Effects of Various Cardiac Therapies

  44. Why should you do this? • JCAHO • Oryx • HEDIS • Marketing • I swear by Apollo the physician, by Aesculapius, Hygeia, and Panacea, and take to witness all the gods, all the goddesses to keep according to my ability and my judgement the following oath: ...

  45. End

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