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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
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Program Disclosures
• Gina Ryan has received a CE grant Ortho McNeil.
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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.
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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
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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
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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
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Metabolic Syndrome - ABCs
ABCsA – Antiplatelets & A1c - blood glucose
B - Blood pressureC - Cholesterol
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Antiplatelets• Aspirin• Clopidogrel• Prasugrel
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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
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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
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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.
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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
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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
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What can Selena do?• Weight loss
– How much?a. 5-10% b. 11-20%c. 21-30%d. >30%
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AA5-10% 5-10%
How much weight loss?
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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
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What is the maximum rate of safe weight loss?
BB1-2 1-2
lbs/weeklbs/week
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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
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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
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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?
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Minimum amount of exercise for weight loss
BB
30 30 minutes per minutes per day day
55 days per days per weekweek
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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
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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
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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
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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
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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.
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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
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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?
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Case BYour store has contracted
with a 3rd party payor to provide MTM for its insured. You were chosen to oversee this process.
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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”
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What information would you like to have about KL?
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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
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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
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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
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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
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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
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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.
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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
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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.
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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.
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Reviewing KL’s ABCs
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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.
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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
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What additional information
would you like to have about RT?
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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.
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What would you like to do for RT’s
ABCs?
Please work in a group and develop your MTM plan.
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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
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Reviewing RT’s ABCs
http://hp2010.nhlbihin.net/atpiii/calculator.asp
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Summary• Controlling blood pressure and
cholesterol• Aspirin therapy• Blood glucose control is important
in preventing microvascular complications
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Questions