the abcs of cad prevention gina ryan, pharmd, bcps, cde clinical associate professor mercer...

The The AABBCCssof CAD Preventionof CAD Prevention

The The AABBCCssof CAD Preventionof CAD Prevention

Gina Ryan, PharmD, BCPS, CDEGina Ryan, PharmD, BCPS, CDEClinical Associate ProfessorClinical Associate ProfessorMercer University College of Mercer University College of

Pharmacy and Health SciencesPharmacy and Health Sciences

Program Disclosures

• Gina Ryan has received a CE grant Ortho McNeil.

Case AYour 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 pressureb. elevated blood pressure and Type 1 diabetesc. insulin resistance, elevated blood pressure, abdominal obesity, and dyslipidemiad. hypoglycemia and dyslipidemia

Metabolic syndrome is comprised of which of the following disorders

CC

insulin insulin resistance, resistance,

elevated blood elevated blood pressure, pressure, abdominal abdominal

obesityobesity

and and dyslipidemiadyslipidemia

Metabolic SyndromeRisk 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 - ABCs

ABCsA – Antiplatelets & A1c - blood glucose

B - Blood pressureC - Cholesterol

Antiplatelets• Aspirin• Clopidogrel• Prasugrel

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

AntiplateletsPrimary Prevention• BP<150/90

• Men– 45-79 yo with >10% risk*

• Women– 55-79 yo with >10% risk– Dose – 81 mg

Chest 2008;133(6) supplement 71S-109S

*usually 3

A1c

A- A1c glycosylated hemoglobin – for diabetesreports glucose average over 6-8 weeksnormal 3-6%goal in diabetes <6.5-7%

Nathan et al Diabetes Care 2006;29:1963-1972.

B - Blood Pressure

JAMA 2003; 289: 2560-2572

JNC VII optimal <120/80pre-hypertension 120-140/80-90Stage 1 140/90-159/99Stage 2 >160/100

First-line Treatment beta blockers, HCTZ, ACE inhibitors

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/dlCAD <70 mg/dl

Circulation. 2002;106:3143-3421Grundy et al Circulation. 2004;110(2):227-239

Statins

are first

line

What can Selena do?• Weight loss

– How much?a. 5-10% b. 11-20%c. 21-30%d. >30%

AA5-10% 5-10%

How much weight loss?

What can Selena do?Weight loss – How fast?

What is the maximum rate of safe weight loss?a. 1-2 lbs per monthb. 1-2 lbs per weekc. 5 lbs per weekd. 30 lbs by Labor Day

What is the maximum rate of safe weight loss?

BB1-2 1-2

lbs/weeklbs/week

What can Selena do?Weight Loss – How to?

Choose the correct option. In order to loose weight Selena needs toa. Reduce her carbohydrate intake, but she can eat as much fat as she wantsb. Reduce her fat intake, but she can eat as much carbhydrates as she wantsc. Reduce her calories so that she burns more energy than she consumes

d. Mediterranean Diet – high veggies and poultry & fish

DIRECTDietary Intervention Randomized Control

Trial

• RCT, 2 yrs N=322• All groups consumed same amt of calories

Kg LDL adherence

Low fat &Restricted cal

-2.9 -0.05 90%

Mediterranean& restricted cal

-4.4 -5.6 85%

Low CHO-4.7 -3 78%

Shai et al NEJM; 359:229-241

What can Selena do?Exercise

How much and how often?_____ minutes per day ____ days per week at

least.a. 15 ; 2b. 30; 5c. 45; 6d. 60; 6

– What intensity?

Minimum amount of exercise for weight loss

BB

30 30 minutes per minutes per day day

55 days per days per weekweek

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 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 DiabetesRosiglitazone

DREAM TrialRCT, N=5,269, IFG + IGT, 3 yrsprimary endpoint – death or diabetes

rosiglitazone & life style recommendations reduced risk by 60%

vs placebo & life style recommendations

DREAM Lancet 2006; 368:1096

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

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

Agent $/30 day$ for 1 lb weight loss

Phentermine 54 10

Sibutramine 110 141

Exenatide* 230 535

Orlistat 27 34

*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?

• 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 BYour store has contracted

with a 3rd party payor to provide MTM for its insured. You were chosen to oversee this process.

Case B48-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?

A lipoprotein isa. a lipid soluble sphere that carries

cholesterol and triglycerides through the body

b. a protein that binds albuminc. an important protein involved in

binding drugsd. eliminated by the kidney

AA lipid soluble lipid soluble

sphere that sphere that carries carries cholesterol and cholesterol and triglycerides triglycerides through the bodythrough the body

A lipoprotein is

High density lipoprotein cholesterol (HDL-C) carries mostly ___________ from the ______ to the _______.

a. cholesterol; periphery; liverb. cholesterol; liver; peripheryc. triglycerides; periphery; liverd. triglycerides; liver; periphery

AA HDL-C carries mostly HDL-C carries mostly

cholesterolcholesterol from the from the

peripheryperiphery to the to the liverliver..

reverse cholesterol transportreverse cholesterol transport

Low density lipoprotein cholesterol (LDL-C) carries mostly ___________ from the ______ to the _______.

a. cholesterol; periphery; liverb. cholesterol; liver; peripheryc. triglycerides; periphery; liverd. triglycerides; liver; periphery

BB Low density lipoprotein Low density lipoprotein cholesterol (LDL-C) cholesterol (LDL-C)

carries mostly carries mostly cholesterolcholesterol from the from the

liverliver to the to the periphery.periphery.

Very-low density lipoprotein cholesterol (VLDL-C) carries mostly ___________ from the ______ to the _______.

a. cholesterol; periphery; liverb. cholesterol; liver; peripheryc. triglycerides; periphery; liverd. triglycerides; liver; periphery

DD Very-low density Very-low density lipoprotein lipoprotein cholesterol (VLDL-cholesterol (VLDL-C) carries mostly C) carries mostly triglycerides triglycerides from from the the liverliver to the to the periphery.periphery.

What would you like to do for KL’s ABCs?

48-year old white maleMeds: atorvastatin 10 mg, irbesartan/HCTZ 300 /12.5 NKA wt 278 Ht 5’8”

A – BG within wnlB – 156/96C – TC – 223, LDL- 148, HDL – 43, TG -160

FM history father died at age 53 of MISocial – drinks and smokes cigars at Saturday night poker games, walks to mailbox and at work.

Reviewing KL’s ABCs

Case CYour 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 profile4/4/10 verapamil SR 240mg po qd #30

4/4/10 HCTZ 12.5 mg qd #30

4/4/10 70/30 human insulin 50 qam and 70 qpm # 40 ml

4/4/10 simvastatin 10 mg po qd #30

2/17/10 HCTZ 12.5 mg qd #30

2/17/10 70/30 human insulin 50 qam and 70 qpm # 40 ml

2/17/10 verapamil SR 240mg po qd #30

2/17/10 HCTZ 12.5 mg qd #30

1/2/10 simvastatin 10 mg po qd #30

1/2/10 70/30 human insulin 50 qam and 70 qpm # 40 ml

1/2/10 verapamil SR 240mg po qd #30

1/2/10 HCTZ 12.5 mg qd #30

1/2/10 70/30 human insulin 50 qam and 70 qpm # 40 ml

What additional information

would you like to have about RT?

A1c and CVDClinical Trials

ACCORD, ADVANCE, VADTLarge RCTs, T2DMCompared 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

ABCs?

Please work in a group and develop your MTM plan.

RT’s Info58 year old female s/p MI , wt 187 Ht 5’6”

A – A1C 7.5% type 2 DMB – 148/82C – 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 qd70/30 human insulin 50 qam and 70 qpm

simvastatin 10 mg po qd

Reviewing RT’s ABCs

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

Summary• Controlling blood pressure and

cholesterol• Aspirin therapy• Blood glucose control is important

in preventing microvascular complications

Questions