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Beyond Statins: What Therapies Really Work

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Beyond Statins: What Therapies Really Work

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    1. Beyond Statins: What Therapies Really Work? The FDA has approved the PLAC test to predict coronary events for almost 2 years, and in June 2005 the PLAC test became the first, and only, FDA approved test for stroke. It is a better inflammatory marker than others because it is: Specific for vascular inflammation, i.e. not elevated from common infections or arthritis. It is independent of all major CV risk factors, including BMI and the Metabolic Syndrome. It is highly correlated with the presence of rupture prone plaque and appears to be a maker of inflammation, and not simply a marker associated with inflammation.The FDA has approved the PLAC test to predict coronary events for almost 2 years, and in June 2005 the PLAC test became the first, and only, FDA approved test for stroke. It is a better inflammatory marker than others because it is: Specific for vascular inflammation, i.e. not elevated from common infections or arthritis. It is independent of all major CV risk factors, including BMI and the Metabolic Syndrome. It is highly correlated with the presence of rupture prone plaque and appears to be a maker of inflammation, and not simply a marker associated with inflammation.

    2. Rapidly Changing Epidemiology of Acute Myocardial Infarction

    3. Reductions in All Forms of Acute Myocardial Infarction

    4. Use of Preventive Therapies

    5. This analysis sought to determine the lifetime risk of atherosclerotic CVD and the effect that risk factor burden has on lifetime risk1 Study subjects were 3,564 men and 4,362 women, all participants of the Framingham Heart Study, who were free of CVD (myocardial infarction, coronary insufficiency, angina, stroke, claudication) at age 501 There were 1,757 CVD events, and 1,641 died free of CVD during follow-up. A CV event was defined as CV death, MI, coronary insufficiency, angina, atherothrombotic stroke, or claudication1 Results showed that the lifetime risk at age 50 for CVD was 51.7% in men and 39.2% in women1 Lifetime risk for CVD with 2 or more major risk factors caused the risk to go to 68.9% in men and 50.2% in women1 Major risk factors defined as total cholesterol =240 mg/dL, systolic blood pressure =160 mm Hg, diastolic blood pressure =100 mm Hg, smoker, or diabetic Lifetime risk with optimal risk factor control (<5% of subjects) was 5.2% in men and 8.2% in women1 Optimal risk factors are defined as total cholesterol <180 mg/dL, blood pressure <120/<80 mm Hg, nonsmoker, and nondiabetic; nonoptimal risk factors are defined as total cholesterol of 180 to 199 mg/dL, systolic blood pressure of 120 to 139 mm Hg, diastolic blood pressure of 80 to 89 mm Hg, nonsmoker, and nondiabetic According to the authors, given the high lifetime risks and lower survival in those with intermediate or high risk factor burden at 50 years of age, these data may be useful in communicating risks and supporting intensive preventive therapy1This analysis sought to determine the lifetime risk of atherosclerotic CVD and the effect that risk factor burden has on lifetime risk1 Study subjects were 3,564 men and 4,362 women, all participants of the Framingham Heart Study, who were free of CVD (myocardial infarction, coronary insufficiency, angina, stroke, claudication) at age 501 There were 1,757 CVD events, and 1,641 died free of CVD during follow-up. A CV event was defined as CV death, MI, coronary insufficiency, angina, atherothrombotic stroke, or claudication1 Results showed that the lifetime risk at age 50 for CVD was 51.7% in men and 39.2% in women1 Lifetime risk for CVD with 2 or more major risk factors caused the risk to go to 68.9% in men and 50.2% in women1 Major risk factors defined as total cholesterol =240 mg/dL, systolic blood pressure =160 mm Hg, diastolic blood pressure =100 mm Hg, smoker, or diabetic Lifetime risk with optimal risk factor control (<5% of subjects) was 5.2% in men and 8.2% in women1 Optimal risk factors are defined as total cholesterol <180 mg/dL, blood pressure <120/<80 mm Hg, nonsmoker, and nondiabetic; nonoptimal risk factors are defined as total cholesterol of 180 to 199 mg/dL, systolic blood pressure of 120 to 139 mm Hg, diastolic blood pressure of 80 to 89 mm Hg, nonsmoker, and nondiabetic According to the authors, given the high lifetime risks and lower survival in those with intermediate or high risk factor burden at 50 years of age, these data may be useful in communicating risks and supporting intensive preventive therapy1

    6. Optimal CV Risk Reduction Existing risk assessment tools pose multiple challenges to the primary care physician Newer risk factor measures, particularly those relevant to the clotting and fibrolytic systems, can provide additional useful information for clinicians wishing to further assess an individual’s level of risk. Existing risk assessment tools pose multiple challenges to the primary care physician Newer risk factor measures, particularly those relevant to the clotting and fibrolytic systems, can provide additional useful information for clinicians wishing to further assess an individual’s level of risk.

    7. TNT Study: Impact of Glucometabolic Characteristics on Risk of Major Cardiovascular Events Among All Patients The factors associated with residual risk are the criteria commonly used to make a diagnosis of metabolic syndrome. According to the Treating to New Targets study, patients who have low levels of high-density lipoprotein, a fasting glucose >100 mg/dL, obesity, hypertriglyceridemia, and hypertension are placed at risk despite the lowering of low-density lipoprotein with high-dose atorvastatin. These 5 factors could then represent additional targets for intervention with the hope that some of the residual risk could be reduced. At present, attention has been directed to the possibility that an intervention that lowers fasting glucose could remove some of this residual risk. Reference: Deedwania P, Barter P, Carmena R, et al, for the Treating to New Targets Investigators. Reduction of low-density lipoprotein cholesterol in patients with coronary heart disease and metabolic syndrome: analysis of the Treating to New Targets study. Lancet. 2006;368:919-928.TNT Study: Impact of Glucometabolic Characteristics on Risk of Major Cardiovascular Events Among All Patients The factors associated with residual risk are the criteria commonly used to make a diagnosis of metabolic syndrome. According to the Treating to New Targets study, patients who have low levels of high-density lipoprotein, a fasting glucose >100 mg/dL, obesity, hypertriglyceridemia, and hypertension are placed at risk despite the lowering of low-density lipoprotein with high-dose atorvastatin. These 5 factors could then represent additional targets for intervention with the hope that some of the residual risk could be reduced. At present, attention has been directed to the possibility that an intervention that lowers fasting glucose could remove some of this residual risk. Reference: Deedwania P, Barter P, Carmena R, et al, for the Treating to New Targets Investigators. Reduction of low-density lipoprotein cholesterol in patients with coronary heart disease and metabolic syndrome: analysis of the Treating to New Targets study. Lancet. 2006;368:919-928.

    8. Intensity of Medical Therapy and Outcomes Patients were categorized blindly according to prospective, predefined criteria as "poor" treatment without diet or lipid drugs, or smoking; "moderate" treatment on American Heart Association diet and lipid-lowering drugs, or on strict low-fat diet (<10% of calories) without lipid drugs; and "maximal" treatment with diet <10% of calories as fat, regular exercise, and lipid active drugs dosed to target goals of low-density lipoproteins <2.3 mmol/L (90 mg/dl), high-density lipoproteins > 1.2 mmol/L (45 mg/dL), and triglycerides < 1.1 mmol/L (100 mg/dL). Over 5 years, coronary events occurred in 6.6%, 20.3%, and 30.6% of patients on maximal, moderate, and poor treatment, respectively (P=0.001). Patients were categorized blindly according to prospective, predefined criteria as "poor" treatment without diet or lipid drugs, or smoking; "moderate" treatment on American Heart Association diet and lipid-lowering drugs, or on strict low-fat diet (<10% of calories) without lipid drugs; and "maximal" treatment with diet <10% of calories as fat, regular exercise, and lipid active drugs dosed to target goals of low-density lipoproteins <2.3 mmol/L (90 mg/dl), high-density lipoproteins > 1.2 mmol/L (45 mg/dL), and triglycerides < 1.1 mmol/L (100 mg/dL). Over 5 years, coronary events occurred in 6.6%, 20.3%, and 30.6% of patients on maximal, moderate, and poor treatment, respectively (P=0.001).

    9. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    10. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    13. How to Achieve these New Targets Multi-drug treatment for Atherosclerosis High dose statin Bile acid sequestrants Ezetimibe Niacin Fenofibrate Omega-3 Fatty Acids Wait for new drugs Niacin/laropiprant Anacetrapib Darapladib/Varespladib Mipomersen Others

    14. Non-HDL Reduction and CHD Risk

    15. Nicotinic Acid: 2010 Meta-Analysis Seven trials, 5137 patients met inclusion criteria Compared to placebo group, niacin therapy significantly reduced Coronary artery revascularization (RR [relative risk]: 0.307 with 95% CI: 0.150-0.628; P = .001), Nonfatal myocardial infarction ([MI]; RR: 0.719; 95% CI: 0.603-0.856; P = .000), Stroke, and TIA ([transient ischemic attack] RR: 0.759; 95%CI: 0.613-0.940; P = .012), Cardiac mortality (RR: 0.883: 95% CI: 0.773-1.008; p= 0.066).

    16. Fibrates: 2010 Meta-analysis Randomized controlled trials to evaluate the role of fibrates in the prevention of cardiovascular events in patients with type 2 diabetes mellitus. A total of 11,590 patients from 6 published randomized placebo-controlled trials The use of fibrates did not significantly affect the risk of all-cause mortality or cardiac mortality, and also did not affect the risk of stroke, unstable angina, or invasive coronary revascularization. However, the relative risk of non-fatal myocardial infarction was significantly reduced by about 21% (pooled relative risk 0.79, p=0.006) with the use of fibrates.

    17. Fibrates in Hypertriglyceridemic Subgroups

    18. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    20. NHANES III: Poor SBP Control Underlies Inadequate BP Control Overall Slide ID: 7792 A significantly lower percentage of patients reach systolic BP goals (34.3%) than reach diastolic BP goals (73%). Further analysis of data from the National Health and Nutrition Examination Survey III (NHANES III) (1988-1994) showed that in patients with hypertension (systolic BP ?140 mm Hg or diastolic BP ?90 mm Hg or taking antihypertensive medication), average diastolic BP is 82 mm Hg and average systolic BP is 145 mm Hg.1 With a target BP of < 140/< 90 mm Hg, 73% of patients with hypertension are at or below their diastolic BP goal, but only 34.3% are at or below their systolic BP goal.1-3 A greater emphasis on lowering systolic BP is needed to improve BP control in the US population. References 1. Burt VL et al. Hypertension. 1995;26:60-69. 2. Whyte JL et al. J Clin Hypertens (Greenwich). 2001;3:211-216. 3. LaPuerta P. Am J Hypertens. 1999;12:92A Slide ID: 7792 A significantly lower percentage of patients reach systolic BP goals (34.3%) than reach diastolic BP goals (73%). Further analysis of data from the National Health and Nutrition Examination Survey III (NHANES III) (1988-1994) showed that in patients with hypertension (systolic BP ?140 mm Hg or diastolic BP ?90 mm Hg or taking antihypertensive medication), average diastolic BP is 82 mm Hg and average systolic BP is 145 mm Hg.1 With a target BP of < 140/< 90 mm Hg, 73% of patients with hypertension are at or below their diastolic BP goal, but only 34.3% are at or below their systolic BP goal.1-3 A greater emphasis on lowering systolic BP is needed to improve BP control in the US population. References 1. Burt VL et al. Hypertension. 1995;26:60-69. 2. Whyte JL et al. J Clin Hypertens (Greenwich). 2001;3:211-216. 3. LaPuerta P. Am J Hypertens. 1999;12:92A

    21. Published Guidelines Have Set Clear Treatment Goals Recent guidelines1,2,3,4 have been consistent in advocating aggressive therapy to lower levels of blood pressure in patients with hypertension and cardiovascular risk factors. Current JNC 7 guidelines as well as those of the American Diabetes Association (ADA), National Kidney Foundation (NKF), and International Society on Hypertension in Blacks (ISHIB) all urge clinicians to bring patients, particularly those at increased risk due to special clinical situations, to the new lower goals by aggressive titration of agents and use of combination therapy when appropriate. Aggressive therapy and aggressive follow-up will improve the poor cardiovascular outcomes now seen in this high-risk population. 1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560–2572. 2. Arauz-Pacheco C, Parrott MA, Raskin P; American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26(suppl):S80–S82. 3. Douglas JG, Bakris GL, Epstein M, et al. Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med. 2003;163:525–541. 4. Bakris GL, Williams M, Dworkin L, et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000;36:646–661. Recent guidelines1,2,3,4 have been consistent in advocating aggressive therapy to lower levels of blood pressure in patients with hypertension and cardiovascular risk factors. Current JNC 7 guidelines as well as those of the American Diabetes Association (ADA), National Kidney Foundation (NKF), and International Society on Hypertension in Blacks (ISHIB) all urge clinicians to bring patients, particularly those at increased risk due to special clinical situations, to the new lower goals by aggressive titration of agents and use of combination therapy when appropriate. Aggressive therapy and aggressive follow-up will improve the poor cardiovascular outcomes now seen in this high-risk population. 1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560–2572. 2. Arauz-Pacheco C, Parrott MA, Raskin P; American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26(suppl):S80–S82. 3. Douglas JG, Bakris GL, Epstein M, et al. Management of high blood pressure in African Americans: consensus statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med. 2003;163:525–541. 4. Bakris GL, Williams M, Dworkin L, et al. Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000;36:646–661.

    22. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    25. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    26. Unadjusted Mortality According to Glucose Metabolism: Data from AusDiab In The Australian Diabetes, Obesity, and Lifestyle (AusDiab) Study, the status of glucose intolerance was related to both all-cause mortality and cardiovascular disease (CVD) mortality over a 6-year follow-up. There were graded increases in both all-cause mortality and CVD mortality across the range from normal glucose tolerance (NGT) to known diabetes mellitus (KDM). Of note is the fact that both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) — two conditions that could be termed “prediabetes” — demonstrated intermediate mortality rates between normal glucose tolerance and diabetes mellitus. This would indicate that conditions associated with a high risk for future diabetes could be considered targets for intervention in order to reduce mortality. The exact factors that govern risk within prediabetes are under evaluation and are still being debated. These factors could include “traditional factors,” such as dyslipidemia, hypertension, dysglycemia, and the proinflammatory and prothrombotic factors associated with insulin resistance. Reference: Barr EL, Zimmet PZ, Welborn TA, et al. Risk of cardiovascular and all-cause mortality in individuals with diabetes mellitus, impaired fasting glucose, and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). Circulation. 2007;116:151-157.Unadjusted Mortality According to Glucose Metabolism: Data from AusDiab In The Australian Diabetes, Obesity, and Lifestyle (AusDiab) Study, the status of glucose intolerance was related to both all-cause mortality and cardiovascular disease (CVD) mortality over a 6-year follow-up. There were graded increases in both all-cause mortality and CVD mortality across the range from normal glucose tolerance (NGT) to known diabetes mellitus (KDM). Of note is the fact that both impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) — two conditions that could be termed “prediabetes” — demonstrated intermediate mortality rates between normal glucose tolerance and diabetes mellitus. This would indicate that conditions associated with a high risk for future diabetes could be considered targets for intervention in order to reduce mortality. The exact factors that govern risk within prediabetes are under evaluation and are still being debated. These factors could include “traditional factors,” such as dyslipidemia, hypertension, dysglycemia, and the proinflammatory and prothrombotic factors associated with insulin resistance. Reference: Barr EL, Zimmet PZ, Welborn TA, et al. Risk of cardiovascular and all-cause mortality in individuals with diabetes mellitus, impaired fasting glucose, and impaired glucose tolerance: the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab). Circulation. 2007;116:151-157.

    27. Intensive Office Glycemic Control: 2009 Meta-analysis

    28. Risk of Severe Hypoglycemia with Intensive DM Management

    31. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    32. When gauging the health benefits from smoking cessation one is encouraged to assess both the short-term and long-term improvements. In the short term: Cosmetic benefits from smoking cessation such as improved oral hygiene and skin tone may start to occur within a matter of days or weeks. Within 3 months, lung function may begin to improve and there may be a decrease in coughing, sinus congestion, fatigue and shortness of breath. Around the year mark, coronary heart disease, the leading cause of death in the United States, improves with smoking cessation to a point where excess risk is reduced by 50% and continues to decline thereafter. Within the 5-15 year mark, The risk of stroke for smoking cessators returns to the level of a person who has never smoked. Other potential long-term benefits include: the risk of lung cancer, the most common cause of cancer death in the United States, declines steadily after smoking cessation; and by 10 years after cessation, the risk of lung cancer is 30-50% that of continuing smokers. And beyond this, Smoking cessation is also known to reduce the risk of cancers of the larynx, oral cavity, esophagus, pancreas, urinary bladder and of developing ulcers of the stomach or duodenum. Other long-term benefits include the rate of decline in lung function among former smokers returns to that of never smokers, reducing the risk of COPD. And, the risk of coronary heart disease, after 15 years of abstinence, becomes similar to that of a person who have never smoked. Clearly, a patient has health benefits to gain if they successfully cessate.When gauging the health benefits from smoking cessation one is encouraged to assess both the short-term and long-term improvements. In the short term: Cosmetic benefits from smoking cessation such as improved oral hygiene and skin tone may start to occur within a matter of days or weeks. Within 3 months, lung function may begin to improve and there may be a decrease in coughing, sinus congestion, fatigue and shortness of breath. Around the year mark, coronary heart disease, the leading cause of death in the United States, improves with smoking cessation to a point where excess risk is reduced by 50% and continues to decline thereafter. Within the 5-15 year mark, The risk of stroke for smoking cessators returns to the level of a person who has never smoked. Other potential long-term benefits include: the risk of lung cancer, the most common cause of cancer death in the United States, declines steadily after smoking cessation; and by 10 years after cessation, the risk of lung cancer is 30-50% that of continuing smokers. And beyond this, Smoking cessation is also known to reduce the risk of cancers of the larynx, oral cavity, esophagus, pancreas, urinary bladder and of developing ulcers of the stomach or duodenum. Other long-term benefits include the rate of decline in lung function among former smokers returns to that of never smokers, reducing the risk of COPD. And, the risk of coronary heart disease, after 15 years of abstinence, becomes similar to that of a person who have never smoked. Clearly, a patient has health benefits to gain if they successfully cessate.

    34. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    35. Optimal Dietary Habits Reduce Mortality in Prevention Studies Prospective cohort studies show significant improvements in CV mortality with Mediterranean-style diets The Cardiovascular Health Study followed 5201 subjects =65 years of age for 7 years. The Physician’s Health Study followed 20,551 men for 17 years. Both studies found an inverse association between blood levels of n-3 fatty acids and risk of death. The Nurses’ Health Study followed 84,688 women for 16 years. High consumption of fish (5/wk) was associated with 45% risk reduction in CHD death (RR 0.55, 95% CI 0.33–0.90). The Healthy Aging: A Longitudinal Study in Europe followed 2339 men and women, 70 years to 90 years of age, from 11 European countries. Adherence to a Mediterranean-style diet was associated with a 23% risk reduction in 10-year all-cause mortality (HR 0.77, 95% CI 0.68–0.88). Two reports from the European Prospective Investigation into Cancer and Nutrition quantified adherence to a Mediterranean-style diet on a scale of 0 to 9, with a higher number indicating greater adherence. Both demonstrated that greater adherence was associated with lower mortality.Prospective cohort studies show significant improvements in CV mortality with Mediterranean-style diets The Cardiovascular Health Study followed 5201 subjects =65 years of age for 7 years. The Physician’s Health Study followed 20,551 men for 17 years. Both studies found an inverse association between blood levels of n-3 fatty acids and risk of death. The Nurses’ Health Study followed 84,688 women for 16 years. High consumption of fish (5/wk) was associated with 45% risk reduction in CHD death (RR 0.55, 95% CI 0.33–0.90). The Healthy Aging: A Longitudinal Study in Europe followed 2339 men and women, 70 years to 90 years of age, from 11 European countries. Adherence to a Mediterranean-style diet was associated with a 23% risk reduction in 10-year all-cause mortality (HR 0.77, 95% CI 0.68–0.88). Two reports from the European Prospective Investigation into Cancer and Nutrition quantified adherence to a Mediterranean-style diet on a scale of 0 to 9, with a higher number indicating greater adherence. Both demonstrated that greater adherence was associated with lower mortality.

    36. Optimal Diet for CVD Prevention and Treatment

    38. Weight Loss and Risk Factors

    39. Optimal Medical Therapy for Atherosclerosis Reduction in LDL-C Reduction in non-HDL-C Blood pressure control without hypotension RAS blockers Others Reduction in platelet aggregation ASA Thienopyridine Glycemic control without hypoglycemia Smoking cessation/avoidance of side-stream smoke Weight reduction/maintenance at optimal Healthy choices Portion control Dietary supplements Aerobic and strength fitness

    40. Exercise reduces CV and all-cause mortality

    42. Frequency (%) of Elective, Urgent, and Emergent PCI in the United States

    43. Chronic Stable CAD: PCI vs Conservative Medical Management Katritis et al conducted a meta-analysis of 11 randomized trials that compared PCI with conservative medical management in patients with chronic stable CAD. While PCI effectively relieves angina, it does not offer any long-term advantage over medical management in terms of death, MI, or need for additional revascularization.Katritis et al conducted a meta-analysis of 11 randomized trials that compared PCI with conservative medical management in patients with chronic stable CAD. While PCI effectively relieves angina, it does not offer any long-term advantage over medical management in terms of death, MI, or need for additional revascularization.

    44. Survival Free of Death from Any Cause and Myocardial Infarction

    45. BARI-2D Trial

    46. BARI 2D: All-cause death for medical therapy vs type of revascularization

    47. BARI 2D: Death, MI, stroke for medical therapy vs type of revascularization

    49. Conclusions Multiple therapies beyond statins reduce “hard” CVD endpoints Non-HDL is a viable treatment target Optimal medical therapy manages “residual risk” Simultaneous multiple risk factor reduction Involves behavior change and drugs in every case Avoids adverse events (hypoglycemia, hypotension) When applied with modest achievement of goals Makes elective PCI and revascularization truly “optional” Reduces but does not completely avoid future ACS

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