An Evidence-Based Approach for Preventing Heart Disease

1. An Evidence-Based Approach for Preventing Heart Disease Brian V. Reamy, M.D., Col, USAF, MC Professor & Chair – Dept. of Family Medicine Uniformed Services University

2. Understand advances in how to assess a patient’s risk for cardiovascular disease Plan a treatment strategy to reduce risk Understand recent advances in prevention Objectives

3. Introduction 2,447,910 deaths in U.S. in 2005 861,826 deaths from Cardiovascular disease 1 of every 2.8 deaths in U.S. is from CV disease AHA Heart disease & Stroke Statistics – 2008 Update. Circulation 117:e25-e146.

4. Traditional risk factors can predict who will have CV events in 90% of all cases. HTN, Smoking, FHx, Hyperlipidemia Introduction – Prevention of CVD

5. Background: best summary of the origins & progression of atherosclerosis: McGill et al. Preventing Heart Disease in the 21st Century: Implications of the pathobiologic determinants of atherosclerosis in youth (PDAY) study. Circulation 2008:117:1216-1227. Convergence of data from several trials over the past 4 decades has shown that ASCVD starts as early as age 2 years and progresses at a predictable rate based on your individual risk factors. Prevention - Introduction

6. Models show that optimizing risk factors in adolescents and maintaining optimum risk status thru age 50 years could prevent 90% of ASCVD. Prevention - Introduction

7. Primary Prevention: treatment of patients with lifestyle changes or medications before they have manifest cardiovascular disease. CVD Prevention

8. Secondary Prevention: treatment of patients with lifestyle changes or medications after they have developed clinical CVD. CVD Prevention

9. Older age & male gender Smoking Elevated BP Dyslipidemia Fhx of CVD in father < 55 or mother <65 yrs. Diabetes BMI > 25 OR increased waist circumference Activity level (sedentary>>>vigorous activity) Hs-CRP level and other novel serum biomarkers…. Risk Factors

10. Patient’s who have manifest CVD are high risk Calculation of risk for all others uses risk calculators These calculators include a variety of CV risks Framingham: limitation is the lack of additive risk for age > 80 yrs or Family history http://hp2010.nhlbihin.net/atpiii/calculator.asp Reynolds Risk Score: limitations:it is used only for patients > age 45 and requires an hs-CRP level http://www.reynoldsriskscore.org/ New calculators likely coming with ATP IV Risk Calculation

11. Risk Rarely miscalculate risk for patients at VERY-HIGH or LOW risk. Miscalculation of risk is an issue for those at intermediate risk. The hope is that enhanced incorporation of genetic risk (Fhx) & novel serum biomarkers can help to properly classify these intermediate risk patients as needing or not needing intervention.

12. Current best sources: Primary Prevention: AHA Guidelines for Primary Prevention of Cardiovascular disease and stroke. Circulation 2002;106:388-391 Secondary Prevention: AHA/ACC Guidelines for Secondary Preventin for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation; 2006:113:2363-2372. Evidence Based Guidelines

13. Both 1° & 2°Prevention in women: AHA Guidelines for cardiovascular disease prevention in Women Circulation; 2007;115:1481-1501 Explicit levels of evidence noted in recent guidelines following the Level I,II,III and A,B,C methodology. Evidence-Based Guidelines

14. 1) BP 2) Lipids 3) Diet ETOH? Supplements? 4) Smoking 5) Activity 6) Weight 7) Aspirin use Develop a 7 point Prevention RX for ASCVD with each Patient

15. Evidence-Based Guidelines: BPDiet, weight reduction, salt reduction, increase fruits & veggies, exercise, moderate etoh, medications

16. Evidence-Based Guidelines:LipidsStart w/TLC then follow with meds in 3 – 6 mths if not at goal LDL level. Then address HDL and TG level

17. Increase fruits and veggies Limit ETOH to <2 drinks/day men; < 1/day in women Reduce saturated fat & trans-fats Women: oily fish 2 days per week Choose whole grain high fiber foods. Evidence-Based Guidelines: Dietary Intake

18. Walker & Reamy: Diets for Cardiovascular disease prevention. Am Fam Phy April 1, 2009 “The Mediterranean diet confers morbidity and mortality benefits in patients with known cardiovascular disease” Level A Basic components: Locally grown & minimally processed foods Plant based foods(legumes, nuts, cereals, fruits, veg) Fish & poultry w/ infrequent red meat intake Up to 4 whole eggs per week & moderate dairy intake Olive oil as principal source of fat Moderate amount of red wine with meals Eat from a colorful plate Desserts primarily of fresh fruits Evidence-Based Dietary Guidelines

19. Ask at every visit Advise to quit every visit Assess readiness Assist in developing a plan to quit Arrange the quit plan Avoid exposure to environmental smoke at work and home Evidence Based Guidelines: Smoking – 6 “A’s”

20. 30 minutes of moderate intensity physical activity on most and preferably all days of the week. Moderate intensity = brisk walk or 40-60% MHR Evidence-Based Guidelines: physical activity

21. Maintain BMI 18.5 to 24.9kg/m2 Maintain waist circumference < 40” men < 35” women (measured at iliac crest horizontally) Evidence based guidelines: Weight

22. Evidence-Based Guidelines: Aspirindoses of 75-162 mg/day are as effective as higher doses

23. Omega-3 fatty acids (850-1000mg EPA & DHA) per day as a supplement in women with CHD (Level IIB) Screen women with CHD for depression (IIB) AVOID Hormone replacement therapy and SERM’s for 1° or 2°prevention of CVD (IIIA) Avoid antioxidant vitamin supplements (E,C, beta-carotene) & folic acid for primary or secondary prevention of CVD (IIIA) Evidence based guidelines: unique issues for women

24. 1) BP 2) Lipids 3) Diet ETOH? Supplements? 4) Smoking 5) Activity 6) Weight 7) Aspirin use Develop a 7 point Prevention RX for ASCVD with each Patient

25. Cases or questions?