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“Effective Strategies to Educate Patients in Coronary Artery Disease Risk Reduction”

“Effective Strategies to Educate Patients in Coronary Artery Disease Risk Reduction”. John G. McGinnity M.S., P.A.-C. Associate Professor Wayne State University Detroit, Michigan jmcginnity@wayne.edu.

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“Effective Strategies to Educate Patients in Coronary Artery Disease Risk Reduction”

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  1. “Effective Strategies to Educate Patients in Coronary Artery Disease Risk Reduction” John G. McGinnity M.S., P.A.-C. Associate Professor Wayne State University Detroit, Michigan jmcginnity@wayne.edu Disclosure information: Honorarium from AstraZeneca, Novartis, BMS-SA, Speaker Bureau: Pfizer

  2. Trends in Cardiovascular Risk Factors in the U.S. Population Aged 20-74 NHES: 1960-62, NHANES:1971-75 to 1999-2000 JAMA 2005. 293: 1868-74. AHA 2006 Heart and Stroke update

  3. 0 Cardiovascular Disease Mortality Trends for Males and Females United States: 1979-2003* CDC/NCHS. AHA 2006 Heart and Stroke update * Preliminary

  4. Leading Causes of Death for All Males and Females: United States, 2003* Total CVD (preliminary) Cancer Accidents Chronic Lower Respiratory Diseases Diabetes Mellitus Alzheimer’s Disease 484 500 427 400 287 300 268 Deaths (thousands) 200 100 68 60 66 45 39 35 0 Males Females CDC/NCHS.AHA 2006 Heart and Stroke update * Preliminary

  5. Rates of AMI Mortality During Hospitalization, by Age P <0.001 Vaccarino V, et al. N Engl J Med. 1999

  6. Foam Fatty Intermediate Atheroma Fibrous Complicated cells streak lesion plaque lesion/rupture From first decade From third decade From fourth decade Growth mainly by lipid accumulation Smooth muscle, collagen Thrombosis, hematoma Atherosclerosis Timeline Adapted from: Pepine CJ. Am J Cardiol. 1998;82:21H-24H.

  7. 100 100 14% 80 80 18% 60 60 MI Patients (%) 68% 40 40 20 20 0 0 Ambrose1988 Little1988 Nobuyoshi1991 Giroud1992 All 4Studies <50% 50%–70% >70% The Majority of MIs Are Caused by Lesions With <50% Stenosis Coronary Stenosis Severity Prior to Myocardial Infarction (MI) Falk et al. Circulation. 1995;92:657-671.

  8. 62% (4893/7892) Men 69% (2744/3977) Women Most Coronary Events Occur in Persons With No Recorded History of MI % of Patients Hospitalized for MI Who Had No History of MI The Majority of Patients Hospitalized for MI Had No Prior History of MI Rosamond et al. N Engl J Med. 1998;339:861-867.

  9. Percentage of Population With 2 Risk Factors 30% <22% 22.0% to 24.9% NA 25.0% to 29.9% Percent Change, 1991-1999 Percentage of the US Population With ≥2 Risk Factors Risk Factors = High BP, High Cholesterol, Diabetes, Obesity, Smoking 1991 1999 2003 Risk Factors=High BP, High Cholesterol, Diabetes†, Obesity, Smoking *Risk factors are self reported. †Diabetes is CHD risk equivalent. Greenlund et al. Arch Intern Med 2004;164:181-188. CDC MMWR Morb Motal Wkly Rep. 2005;54:113-117.

  10. Concurrent Hypertension, Dyslipidemia, and Smoking Increase CVD Risk 9 Dyslipidemia 4 Hypertension 3 16 6 4.5 Smoking 1.6 Poulter N. Am J Hypertens. 1999;12:92S-95S.

  11. Risk of CHD in Mild Hypertension by Intensity of Associated Risk Factors 40 42 36 30 21 10-Year Probability of Event (%) 24 18 14 10 12 6 4 6 0 Risk Factors SBP 150-160 mm Hg + + + + + + TC 240-262 mg/dL − + + + + + HDL-C 33-35 mg/dL − − + + + + Diabetes − − − + + + Cigarette smoking − − − − + + ECG-LVH − − − − − + Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S.

  12. Calculating the Risk JAMA 2001; 285(19):2486-97

  13. Emerging Risk Factors:CRP and Recurrent MI, CHD Death Ridker PM et al. N Engl J Med. 2005;352:20-28. Nissen et al. N Engl J Med. 2005;352:29-38.

  14. Trends in Mean Total Blood Cholesterol Among Adolescents Ages 12-17 by Race, Sex, and Survey NHES: 1966-70; NHANES: 1971-74 and 1988-94 0 CDC/NCHS. Prev Med 1998;27:879-90.

  15. Therapeutic Goals for LDL-C at Various Risk Levels: NCEP ATP III and NCEP 2004 Grundy SM et al. Circulation. 2004;110:227-239; NCEP ATP III. 2002. NIH Publication No. 02-5215. Available at:http://www.nhlbi.nih.gov/guidelines/cholesterol/.

  16. ATP III Changes HDL Classification • Low HDL-C now a risk factor & treatment target • Modest increases in HDL-C = CHD risk reduction • Low HDL-C strongly associated with CHD • High HDL-C reduces risk 1% decreasein LDL-C reduces CHD risk by 1% 1%increasein HDL-C reduces CHD risk by 3% NCEP ATP III. Circulation. 2002;106:3145-3421. Gray et al. Ann Intern Med. 1994;121:252-258.

  17. CHD Reduction in Secondary Prevention Trials Pedersen et al. Circulation. 1998;97:1453-1460. LIPID Study Group. N Engl J Med. 1998;339:1349-1357. Sacks et al. Circulation. 1998;97:1446-1452. HPS Collaborative Group. Lancet. 2002;360:7-22. Waters et al. Am J Cardiol. 2004;93:154-158.

  18. Statin-Associated Rhabdomyolysis: Adverse Event Reports* 120 † 100 Cerivastatin Fluvastatin Atorvastatin Lovastatin Pravastatin Simvastatin Ezetimibe Rosuvastatin‡ * U.S. data (FDA Adverse Events Reporting System) shown for all statins. † Cerivastatin withdrawn from U.S. market August 2001. ‡ U.S. plus other global data (on file at Astra Zeneca) shown for rosuvastatin only. Data points correspond to reports received 4/03 – 9/03, 10/03 – 3/04, 4/04 – 9/04, and 10/04 – 3/05. Adapted from “AstraZeneca rosuvastatin Clinical Information” web site, Figure 3. Available at http://www.rosuvastatininformation.com/gUserFiles/adverse_event19julv2.pdf. Accessed August 5, 2005. 80 60 Reported cases per 1 million prescriptions 40 20 0 3/99 – 8/99 9/99 – 2/00 3/00 – 8/00 9/00 – 2/01 3/01 – 8/01 9/01 – 2/02 3/02 – 8/02 9/02 – 2/03 3/03 – 8/03 8/03 – 2/04 3/04 – 8/04 10/04 – 3/05

  19. Statin-Associated Rhabdomyolysis: Fatal Event Reports* Cerivastatin Fluvastatin Atorvastatin Lovastatin Pravastatin Simvastatin Ezetimibe Rosuvastatin‡ * U.S. data (FDA Adverse Events Reporting System) shown for all statins. † Cerivastatin withdrawn from U.S. market August 2001. ‡ U.S. plus other global data (on file at Astra Zeneca) shown for rosuvastatin only. Data points correspond to reports received 4/03 – 9/03, 10/03 – 3/04, 4/04 – 9/04, and 10/04 – 3/05. Adapted from “AstraZeneca rosuvastatin Clinical Information” web site, Figure 4. Available at http://www.rosuvastatininformation.com/gUserFiles/adverse_event19julv2.pdf. Accessed August 5, 2005. 25 † 20 Reported cases per 1 million prescriptions 15 10 5 0 3/99 – 8/99 9/99 – 2/00 3/00 – 8/00 9/00 – 2/01 3/01 – 8/01 9/01 – 2/02 3/02 – 8/02 9/02 – 2/03 3/03 – 8/03 8/03 – 2/04 3/04 – 8/04 10/04 – 3/05

  20. No Diabetes Diabetes Age-Adjusted Prevalence of Heart Disease and Stroke Among Adults Aged 35 Years With and Without Diabetes: US, 1999-2001 40 35 30 25 Prevalence (%) 20 15 10 5 0 Coronary Heart Stroke Other Heart Disease Conditions MMWR. 2003;52(44):1055-1068.

  21. Hypertension Affects Approximately 65 Million Americans: 28% of Adults 50 40% Males 38% 40 Females 29% 28% 27% 27% 30 Population WithHypertension (%) 20 10 0 Non-Hispanic White Non-Hispanic Black Mexican American Fields LE et al. Hypertension. 2004;44:398-404.

  22. Men Women 150 150 SBP SBP African-American 130 130 White 110 110 Mexican-American mm Hg mm Hg 80 80 DBP DBP 70 70 0 0 18-29 30-39 40-49 50-59 60-69 70-79 80 18-29 30-39 40-49 50-59 60-69 70-79 80 Age (years) Systolic Blood Pressure Increases With Age NHANES III Burt et al. Hypertension. 1995;25:305-313.

  23. Extent of Awareness, Treatment and Control of High Blood Pressure by Age NHANES: 1999-2002 Source: MMWR. Vol. 54, No. 1, Jan. 14, 2005.

  24. JNC 7 Classification and Management of BP for Adults BP classification SBP* mmHg DBP* mmHg Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Prehypertension 120–139 or 80–89 No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications.‡ Stage 2 Hypertension >160 or >100 Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

  25. Accurate BP Measurement:Home BP Monitoring www.dableducational.org Hypertension 2005;45:142-161

  26. CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment* 8 7 6 5 CVmortalityrisk 4 3 2 1 0 115 / 75 135 / 85 155 / 95 175 / 105 SBP / DBP (mm Hg) *Individuals aged 40-69 years, starting at BP 115/75 mm Hg. Lewington et al. Lancet. 2002;360:1903-1913.

  27. Hypertension: A Risk Factor for Cardiovascular Disease Kannel WB. JAMA. 1996;275:1571-1576.

  28. 256 256 128 128 64 64 32 32 16 16 8 8 4 4 2 2 1 1 0 0 120 140 160 180 70 80 90 100 110 Blood Pressure: Lower Is Better Ischemic Heart Disease Mortality Age at Risk (Y) Age at Risk (Y) 80-89 80-89 70-79 70-79 60-69 60-69 50-59 50-59 40-49 40-49 Ischemic Heart Disease Mortality Ischemic Heart Disease Mortality Usual Systolic BP (mm Hg) Usual Diastolic BP (mm Hg) Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.

  29. JNC 7: Lifestyle Modifications to Prevent and Manage Hypertension DASH = Dietary Approaches to Stop Hypertension. Chobanian AV et al. JNC 7: Complete Report. 2003. Available at:http://hyper.ahajournals.org/cgi/content/full/42/6/1206.

  30. Multiple Antihypertensive Agents Are Needed to Achieve Target BP No. of antihypertensive agents Trial Target BP (mm Hg) 1 2 3 4 ALLHAT SBP <140/DBP <90 UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 AASK MAP <92 IDNT SBP <135/DBP <85 DBP = diastolic blood pressure; MAP = mean arterial pressure; SBP = systolic blood pressure. Bakris et al. Am J Kidney Dis. 2000;36:646-661. Lewis et al. N Engl J Med. 2001;345:851-860. Cushman et al. J Clin Hypertens. 2002;4:393-404.

  31. JNC 7: Compelling Indications for Antihypertensive Drug Classes Recommended Drugs AldoCompelling Indication Diuretic BB ACEI ARB CCB ANT Heart failure • • • •   • Post MI   • •     • High coronary disease risk • • •   •   Diabetes • • • • •   Chronic kidney disease     • •     Recurrent stroke prevention •   •       Aldo ANT = aldosterone antagonist. Chobanian AV et al. JNC 7: Complete Report. 2003. Available at:http://hyper.ahajournals.org/cgi/content/full/42/6/1206.

  32. Complications of Hypertension:Target Organ Damage Kannel WB. JAMA. 1996;275:1571-1576

  33. Prevalence of Current Smoking for Americans Age 18 and Older by Race/Ethnicity and Sex NHIS:2004 MMWR, Vol. 54, (44); Nov. 11, 2005, CDC/NCHS. NH – non-Hispanic. AHA 2006 Heart and Stroke update

  34. Adherence Action: Smokingwww.smokefree.gov “Connects patients to their States Quitline” Quitlines National Hotline Card

  35. All The Excuses Are Covered! www.smokefree.gov

  36. Smoking Cessation Adherence Resources The Quitlines and Patient Support www.smokefree.gov CDC Tobacco Information and Prevention Source (TIPS) www.cdc.gov/tobacco U.S. National Institutes of Health, National Cancer Institute www.cancer.gov/cancertopics/tobacco American Academy of Family Physicians Tobacco-free education program for kids www.tarwars.org Smoke Less States National Tobacco Policy Initiative www.smokelessstates.org American Legacy Foundation's Great Start 1-866-66-START (A Quitline for pregnant smokers)

  37. Prevalence of Overweight among Students in Grades 9-12 by Sex and Race/Ethnicity YRBS: 2003 BMI 95th percentile or higher. MMWR, Vol. 53,No. SS-2, May 21,2004, CDC/NCHS.AHA 2006 Heart and Stroke update

  38. Age-Adjusted Prevalence of Obesity in Americans Ages 20-74 by Sex and Survey NHES, 1960-62; NHANES, 1971-74, 1976-80, 1988-94 and 1999-2002 Note: Obesity is defined as a BMI of 30.0 or higher. Health, United States, 2004, CDC/NCHS. AHA 2006 Heart and Stroke update

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