926277 Coronary Heart Disease

8/8/2019 926277 Coronary Heart Disease

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Coronary HeartCoronary Heart

DiseaseDisease

M Chadi Alraies M.D.M Chadi Alraies M.D.



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The main reason to invest in prevention is The main reason to invest in prevention isto promote health and extend life, improveto promote health and extend life, improvefunctioning and prevent suffering.functioning and prevent suffering.

"The Role of Prevention in Health Reform", Russell,"The Role of Prevention in Health Reform", Russell,Louise B., Ph.D., The New England Journal of Medicine,Louise B., Ph.D., The New England Journal of Medicine, July 29, 1993;329 (5):352 July 29, 1993;329 (5):352--354.354.



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General considerationsGeneral considerations

number one killer in thenumber one killer in theUnited States andUnited States and

worldwide. worldwide.

Every minute,Every minute, anan American dies of American dies of coronary heart disease.coronary heart disease.

Coronary heart diseaseCoronary heart diseaseafflicts overafflicts over 1313 millionmillion Americans. Americans.



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The estimated cost for cardiovascular disease in The estimated cost for cardiovascular disease in

1994 by the American Heart Association is1994 by the American Heart Association is 128 128

billion dollarsbillion dollars..



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An 82 An 82--yearyear--old woman presents for her annual examination. Sheold woman presents for her annual examination. Shehas hypertension and is on chronic has hypertension and is on chronic --blocker therapy. She deniesblocker therapy. She deniesall cardiac symptoms. She takes a daily 1all cardiac symptoms. She takes a daily 1--mile walk, and hermile walk, and her

exercise tolerance has not changed during the past year.exercise tolerance has not changed during the past year. Physical examination shows a blood pressure of 138/86 mm Hg,Physical examination shows a blood pressure of 138/86 mm Hg,

a regular pulse of 80/min, and a respiratory rate of 16/min. Hera regular pulse of 80/min, and a respiratory rate of 16/min. Herjugular venous pressure is 10 cm H2O, her carotid upstrokes arejugular venous pressure is 10 cm H2O, her carotid upstrokes arenormal, and her lungs are clear. Cardiac examination reveals anormal, and her lungs are clear. Cardiac examination reveals a

normal S1, a single S2, and a grade 3/6 early systolic murmur atnormal S1, a single S2, and a grade 3/6 early systolic murmur atthe upper left sternal border that radiates to her carotids.the upper left sternal border that radiates to her carotids. Abdominal examination is benign, and there is 1+ peripheral Abdominal examination is benign, and there is 1+ peripheraledema. Laboratory data are remarkable for a total cholesterol of edema. Laboratory data are remarkable for a total cholesterol of 210 mg/dL (5.43 mmol/L), with an LDL cholesterol of 110210 mg/dL (5.43 mmol/L), with an LDL cholesterol of 110mg/dL (2.84 mmol/L).mg/dL (2.84 mmol/L).

Her echocardiogram from 2 years ago showed moderate calcificHer echocardiogram from 2 years ago showed moderate calcificaortic stenosis, with a maximum aortic velocity of 3.6 m/saortic stenosis, with a maximum aortic velocity of 3.6 m/s(normal, <1.5 m/s) a mean gradient of 30 mm Hg (normal, <5(normal, <1.5 m/s) a mean gradient of 30 mm Hg (normal, <5mm Hg) and a valve area of 1.2 cm2 (normal, >2 cm2) withmm Hg) and a valve area of 1.2 cm2 (normal, >2 cm2) withnormal left ventricular systolic function. Echocardiography now normal left ventricular systolic function. Echocardiography now shows a maximum aortic jet velocity of 4.2 m/s, mean gradientshows a maximum aortic jet velocity of 4.2 m/s, mean gradientof 44 mm Hg, and a valve area of 1.0 cm2.of 44 mm Hg, and a valve area of 1.0 cm2.



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W hich is the most appropriate next step? W hich is the most appropriate next step?

A Reassurance A Reassurance

B Begin a cardiac rehabilitation programB Begin a cardiac rehabilitation program C Begin hydrochlorothiazideC Begin hydrochlorothiazide

D Start statin therapy D Start statin therapy

E Refer for aortic valve replacementE Refer for aortic valve replacement



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R isk factorsR isk factors

Abnormal lipids Abnormal lipids

Smoking Smoking

HypertensionHypertension

Diabetes mellitusDiabetes mellitus

Abdominal obesity Abdominal obesity

Psychosocial factorsPsychosocial factors

Consumption of too few fruitsConsumption of too few fruits

and vegetables.and vegetables.

Too much alcohol Too much alcohol

Lack of regular physical activity.Lack of regular physical activity.



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What is the number one What is the number one preventable cause of preventable cause of

cardiovascular diseasecardiovascular disease worldwide? worldwide?

SMOKING!SMOKING!



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1 1 year after quitting, the year after quitting, the

risk of coronary heartrisk of coronary heart

disease decreases bydisease decreases by 5050%%



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Framingham scoreFramingham score



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W omen Men



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Define the metabolicDefine the metabolic

syndrome?syndrome?



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The metabolic syndrome The metabolic syndrome

Three or more of the following: Three or more of the following:

Abdominal obesity Abdominal obesity

Triglycerides

Triglycerides 150150 mg/dLmg/dL

HDL cholesterol <HDL cholesterol < 4040 mg/dL for men and <mg/dL for men and < 5050mg/dL for womenmg/dL for women

Fasting glucoseFasting glucose 110110 mg/dLmg/dL

Hypertension.Hypertension.



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A A 7272--yearyear--old woman is seen for a routine office evaluation toold woman is seen for a routine office evaluation toestablish care. Past medical history includes only hypertension,establish care. Past medical history includes only hypertension,

hyperlipidemia, and a familial history of coronary artery disease.hyperlipidemia, and a familial history of coronary artery disease.She does not smoke. She is active and walks daily and deniesShe does not smoke. She is active and walks daily and deniesangina, dyspnea, fatigue, and edema.angina, dyspnea, fatigue, and edema.

Physical examination reveals a blood pressure of Physical examination reveals a blood pressure of 128128//7070 mmmmHg. There are no carotid bruits. There is a normal SHg. There are no carotid bruits. There is a normal S11 and aand a

physiologically split Sphysiologically split S22. There is a grade. There is a grade 22//66 midsystolic murmurmidsystolic murmurthat does not radiate and is best heard at thethat does not radiate and is best heard at the 22nd right intercostalnd right intercostalspace. The rest of the physical examination is unrevealing.space. The rest of the physical examination is unrevealing.

W hich of the following diagnostic tests is most appropriate at W hich of the following diagnostic tests is most appropriate atthis time?this time?

A No further testing at this time A No further testing at this time B Transthoracic echocardiography B Transthoracic echocardiography

C ElectronC Electron--beam C T beam C T

D Treadmill stress echocardiogramD Treadmill stress echocardiogram

EE 2424--hour ambulatory electrocardiographic monitoring hour ambulatory electrocardiographic monitoring



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PathophysiologyPathophysiology



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Lipid metabolism in relation toLipid metabolism in relation to

formation of atherosclerotic lesionsformation of atherosclerotic lesions



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Formation of a fatty streak in an arteryFormation of a fatty streak in an artery



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Formation of atheromaFormation of atheroma



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Plaque rupturePlaque rupture

Many atherosclerotic plaques remain stable orMany atherosclerotic plaques remain stable or

progress only gradually.progress only gradually.

Rupture, often related to the inflammatory Rupture, often related to the inflammatory process.process.

The rupture causes« The rupture causes«

Turbulent flow Turbulent flow

Extrusion of lipids and fatty gruelExtrusion of lipids and fatty gruel

Exposure of tissue factorExposure of tissue factor



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All result in a cascade of events culminating in All result in a cascade of events culminating inintravascular thrombosis.intravascular thrombosis.

The outcome of these events is« The outcome of these events is«

Complete vessel occlusion.Complete vessel occlusion. Partial vessel occlusion (causing the symptoms of unstablePartial vessel occlusion (causing the symptoms of unstable

angina or myocardial infarction)angina or myocardial infarction)

Restabilization often with more severe stenosis.Restabilization often with more severe stenosis.

Transient occlusion and/or embolization of platelet and

Transient occlusion and/or embolization of platelet andthrombin debris, which may result in elevation in serumthrombin debris, which may result in elevation in serum

troponin, predispose to clinical events and portend atroponin, predispose to clinical events and portend a worse prognosis. worse prognosis.



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Screening and DiagnosisScreening and Diagnosis

StressStress

TestTest

CoronaryCoronary

AngiographyAngiography

ElectroElectro--

cardiogramcardiogram



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A A 2222--yearyear--old women who isold women who is 1616 weeks pregnant is evaluated for weeks pregnant is evaluated foraa 22--hour history of severe anterior chest pain radiating to herhour history of severe anterior chest pain radiating to hermid back. She is a tall, thin woman with a pectus abnormality of mid back. She is a tall, thin woman with a pectus abnormality of

her chest and long, thin fingers. Her blood pressure isher chest and long, thin fingers. Her blood pressure is 140140//8080mm Hg, her pulse ismm Hg, her pulse is 9494/min and regular, and her respiratory rate/min and regular, and her respiratory rateisis 2424/min. Her chest wall is diffusely mildly tender to palpation./min. Her chest wall is diffusely mildly tender to palpation.Her lungs are clear to auscultation. Cardiac auscultation shows aHer lungs are clear to auscultation. Cardiac auscultation shows anormal Snormal S11, a physiologically split S, a physiologically split S22, and a grade, and a grade 22//66 diastolicdiastolic

decrescendo murmur at the left sternal border. There is nodecrescendo murmur at the left sternal border. There is noperipheral edema. Her electrocardiogram shows only nonspecificperipheral edema. Her electrocardiogram shows only nonspecificS TS T-- T changes. Oxygen saturation by pulse oximetry on room air T changes. Oxygen saturation by pulse oximetry on room airisis 9999%. Her D%. Her D--dimer level is mildly elevated.dimer level is mildly elevated.

W hich is the most likely cause of her chest pain? W hich is the most likely cause of her chest pain? A Pulmonary embolus A Pulmonary embolus

B Acute myocardial infarctionB Acute myocardial infarction

C Aortic dissectionC Aortic dissection

D CostochondritisD Costochondritis

E PericarditisE Pericarditis



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Primary & SecondaryPrimary & Secondary

Prevention of CoronaryPrevention of Coronary

Heart DiseaseHeart Disease



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A H A/A CC Secondary A H A/A CC SecondaryPrevention for PatientsPrevention for Patients

With Coronary and Other With Coronary and Other Vascular Disease Vascular Disease

20062006 UpdateUpdate



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Coronary and Other VascularCoronary and Other Vascular

DiseaseDisease

Established coronary disease.Established coronary disease.

Atherosclerotic vascular disease: Atherosclerotic vascular disease:

PeripheralPeripheral arterialarterial disease,disease, Atherosclerotic aortic disease, and Atherosclerotic aortic disease, and

Carotid artery disease.Carotid artery disease.



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SMOKINGSMOKING

Goal: Complete cessation. No exposure toGoal: Complete cessation. No exposure toenvironmental tobacco smoke.environmental tobacco smoke.

Ask about tobacco use status at every visit. Ask about tobacco use status at every visit.

Advise every tobacco user to quit. Advise every tobacco user to quit. Assess the tobacco user·s willingness to quit. Assess the tobacco user·s willingness to quit. Assist by counseling and developing a plan for quitting. Assist by counseling and developing a plan for quitting. Arrange follow Arrange follow--up, referral to special programs, orup, referral to special programs, or

pharmacotherapy (including nicotine replacement andpharmacotherapy (including nicotine replacement andbupropion).bupropion).

Urge avoidance of exposure to environmental tobaccoUrge avoidance of exposure to environmental tobaccosmoke at work and home.smoke at work and home.



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A A 5555--yearyear--old man is evaluated for cough, scant clearold man is evaluated for cough, scant clear--toto--yellow yellow sputum, and malaise of sputum, and malaise of 33 days' duration. He has not had fever,days' duration. He has not had fever,chills, wheezing, or pleuritic chest pain, or recent contact withchills, wheezing, or pleuritic chest pain, or recent contact with

anyone who has been ill. He has aanyone who has been ill. He has a 4040--pack pack--year smoking history year smoking history and has had similar symptoms three times in the pastand has had similar symptoms three times in the past 66 months,months,feeling well in the intervals between episodes.feeling well in the intervals between episodes.

On physical examination, temperature isOn physical examination, temperature is 3737..22 °°C ( C (9999..00 °°F), andF), andpulse rate, respiration rate, and blood pressure are normal. Thepulse rate, respiration rate, and blood pressure are normal. The

cardiopulmonary examination is normal, including clear lungs oncardiopulmonary examination is normal, including clear lungs onauscultation with no signs of consolidation.auscultation with no signs of consolidation.

W hich of the following is the most appropriate initial smoking W hich of the following is the most appropriate initial smoking--cessation management step during this visit?cessation management step during this visit?

A Recommend nicotine gum A Recommend nicotine gum B Provide a clear, personalized message to the patientB Provide a clear, personalized message to the patient

C Refer the patient to a behavioralC Refer the patient to a behavioral--modification programmodification program

D Prescribe bupropionD Prescribe bupropion



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BLOOD PRESSURE CON TROLBLOOD PRESSURE CON TROL

Goal:Goal: For patients withFor patients with blood pressureblood pressure140140//9090 mm Hg (ormm Hg (or 130130//8080 mm Hg formm Hg forindividuals with chronic kidney disease orindividuals with chronic kidney disease or

diabetes.diabetes. Initiate or maintain lifestyle modificationInitiate or maintain lifestyle modification³ ³

weight control; increased physical activity; weight control; increased physical activity;alcohol moderation; sodium reduction; andalcohol moderation; sodium reduction; andemphasis on increased consumption of freshemphasis on increased consumption of freshfruits, vegetables, and low fruits, vegetables, and low--fat dairy products.fat dairy products.



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BLOOD PRESSURE CON TROLBLOOD PRESSURE CON TROL

Add blood pressure medication, Add blood pressure medication,

Treating initially with ß Treating initially with ß--blockers and/or ACEblockers and/or ACE

inhibitors.inhibitors. Addition of other drugs such as thiazides as Addition of other drugs such as thiazides as

needed to achieve goal blood pressureneeded to achieve goal blood pressure..

Use JNCUse JNC 77



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A 55 A 55--yearyear--old man is evaluated for epigastric discomfort that hasold man is evaluated for epigastric discomfort that hasbeen increasing in frequency despite the use of antacids. Thebeen increasing in frequency despite the use of antacids. Thediscomfort occurs with exercise, but at times he is able todiscomfort occurs with exercise, but at times he is able toexercise without provocation of his symptoms. He has no otherexercise without provocation of his symptoms. He has no other

medical conditions and takes only an 81medical conditions and takes only an 81--mg aspirin daily andmg aspirin daily andoccasional chondroitin sulfate for joint aches.occasional chondroitin sulfate for joint aches.

Physical examination, including vital signs and cardiacPhysical examination, including vital signs and cardiacexamination, is normal. Electrocardiogram shows normal sinusexamination, is normal. Electrocardiogram shows normal sinusrhythm with normal waveforms. Lipid tests show totalrhythm with normal waveforms. Lipid tests show total

cholesterol of 199 mg/dL (5.15 mmol/L), LDL cholesterol of cholesterol of 199 mg/dL (5.15 mmol/L), LDL cholesterol of 131 mg/dL (3.39 mmol/L), and HDL cholesterol of 35 mg/dL131 mg/dL (3.39 mmol/L), and HDL cholesterol of 35 mg/dL(0.91 mmol/L).(0.91 mmol/L).

W hat is the most appropriate next step in the evaluation of this W hat is the most appropriate next step in the evaluation of thispatient?patient? A Measurement of C A Measurement of C--reactive proteinreactive protein

B Measurement of coronary calcium by electronB Measurement of coronary calcium by electron--beam C T beam C T

C Measurement of serum homocysteineC Measurement of serum homocysteine

D Exercise electrocardiographic stress testD Exercise electrocardiographic stress test

E Exercise echocardiogramE Exercise echocardiogram



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LIPIDLIPID

MANAGEMEN TMANAGEMEN T



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LDLLDL

´The lower the betterµ´The lower the betterµ



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HDLHDL

´The higher the betterµ´The higher the betterµ



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LIPID MANAGEMEN TLIPID MANAGEMEN T

1.1. Start dietary therapy.Start dietary therapy.2.2. Reduce intake of saturated fats (to <Reduce intake of saturated fats (to <77% of total% of total

calories),calories),3.3.

Cholesterol (to <Cholesterol (to <200200 mg/d).mg/d).4.4. LDLLDL--C <C <100100 mg/dLmg/dL5.5. nonnon--HDLHDL--C should be <C should be <130130 mg/dLmg/dL6.6. Adding plant stanol/sterols ( Adding plant stanol/sterols (22 g/d) and viscous fiberg/d) and viscous fiber

(>(>1010 g/d) will further lower LDLg/d) will further lower LDL--C.C.7.7. Encourage increased consumption of omegaEncourage increased consumption of omega--33 fatty fatty

acids in the form of fish or in capsule form ( acids in the form of fish or in capsule form (11 g/d)g/d)for risk reduction.for risk reduction.



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Assess fasting lipid profile in all patients, and Assess fasting lipid profile in all patients, and

within within 2424 hours of hospitalization for those withhours of hospitalization for those withan acute cardiovascular or coronary eventan acute cardiovascular or coronary event..



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For hospitalized patients, initiate lipidFor hospitalized patients, initiate lipid--lowering medication aslowering medication asrecommended below before discharge according to the following recommended below before discharge according to the following schedule:schedule: LDLLDL--C should be <C should be <100100 mg/dL and«mg/dL and«

Further reduction of LDLFurther reduction of LDL--C to <C to <7070 mg/dL is reasonable.mg/dL is reasonable. If baseline LDLIf baseline LDL--C isC is 100100 mg/dL, initiate LDLmg/dL, initiate LDL--lowering drug therapy.lowering drug therapy.

If onIf on--treatment LDLtreatment LDL--C isC is 100100 mg/dL, intensify LDLmg/dL, intensify LDL--lowering drug lowering drug therapy (may require LDLtherapy (may require LDL--lowering drug combination.lowering drug combination.

If baseline LDLIf baseline LDL--C isC is 7070 toto 100100 mg/dL, it is reasonable to treat to LDLmg/dL, it is reasonable to treat to LDL--CC

<<7070 mg/dL.mg/dL. If triglycerides areIf triglycerides are 200200 toto 499499 mg/dL, nonmg/dL, non--HDLHDL--C should be <C should be <130130

mg/dL. And«mg/dL. And«

Further reduction of nonFurther reduction of non--HDLHDL--C to <C to <100100 mg/dL is reasonable.mg/dL is reasonable.



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Therapeutic options to Therapeutic options to reduce nonreduce non--HDL:HDL:

More intense LDLMore intense LDL--CC² ²lowering therapy lowering therapy

Niacin orNiacin or

Fibrate therapy Fibrate therapy

If triglycerides areIf triglycerides are 500500 mg/dL, therapeuticmg/dL, therapeutic

options to prevent pancreatitis are fibrate oroptions to prevent pancreatitis are fibrate or

niacin before LDLniacin before LDL--lowering therapy.lowering therapy.



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(HMG(HMG--Co A) reductase inhibitors (statins)Co A) reductase inhibitors (statins)

Aggressive LDL lowering is associated with Aggressive LDL lowering is associated withgreater benefits.greater benefits. The Heart Protection Study (HPS), simvastatin The Heart Protection Study (HPS), simvastatin 4040

mg a day reduces vascular events by more thanmg a day reduces vascular events by more than 2020%.%. The PROVE The PROVE--I T trial showed that vascular eventsI T trial showed that vascular events

were reduced with more aggressive lipid lowering were reduced with more aggressive lipid lowering (atorvastatin(atorvastatin 8080 mg/d compared to pravastatinmg/d compared to pravastatin 4040

mg/d following an acute coronary syndrome),mg/d following an acute coronary syndrome),providing more evidence of "lower is better" providing more evidence of "lower is better"

The TN T ( Treating to New Targets) The TN T ( Treating to New Targets)



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(HMG(HMG--Co A) reductase inhibitors (statins)Co A) reductase inhibitors (statins)

Although true regression of plaque is Although true regression of plaque is

uncommon even with intensive lipid therapy (asuncommon even with intensive lipid therapy (asin the REVERSAL and AS TEROID trials),in the REVERSAL and AS TEROID trials),

progression can be prevented at least in theprogression can be prevented at least in theshort run in many patients.short run in many patients.



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HDLHDL Has been shown to be Cardioprotective in theHas been shown to be Cardioprotective in the

Framingham Heart Study, and in retrospectiveFramingham Heart Study, and in retrospectiveanalyses of intervention trials such as the Coronary analyses of intervention trials such as the Coronary Primary Prevention Trial and the Multiple Risk Primary Prevention Trial and the Multiple Risk

Factor Intervention T

rialFactor Intervention T

rial55--77

The data were consistent with a The data were consistent with a 22%% toto 33%%decrease in CHD risk for each decrease in CHD risk for each 1 1 mg/dL mg/dL increase in HDLincrease in HDL,, after adjustment to control forafter adjustment to control forother risk factors.other risk factors.



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Treatment of low HDL Treatment of low HDL

Niacin in high dosages ( Niacin in high dosages (22² ²33 g/d or more)g/d or more)

Gemfibrozil ( Gemfibrozil (600600 mg twice daily)mg twice daily)

A 32A 32 yearyear old woman is brought to the hospital with chest pain at rest after aold woman is brought to the hospital with chest pain at rest after a



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A 32 A 32--yearyear--old woman is brought to the hospital with chest pain at rest after aold woman is brought to the hospital with chest pain at rest after aparty. She has had similar pain previously, primarily in the morning and rarely party. She has had similar pain previously, primarily in the morning and rarely with exertion. The pain usually subsides spontaneously and occasionally is with exertion. The pain usually subsides spontaneously and occasionally isassociated with diaphoresis but rarely dyspnea. She almost lost consciousnessassociated with diaphoresis but rarely dyspnea. She almost lost consciousnessat work during the most recent episode. She smokes a half pack of cigarettes aat work during the most recent episode. She smokes a half pack of cigarettes a

week and has occasionally inhaled cocaine. She is otherwise healthy and takes week and has occasionally inhaled cocaine. She is otherwise healthy and takesno medications. She has no family history of coronary artery disease.no medications. She has no family history of coronary artery disease. Her blood pressure is 128/70 mm Hg and pulse rate is 72/min. There is noHer blood pressure is 128/70 mm Hg and pulse rate is 72/min. There is no

neck vein distention or carotid bruits. The lungs are clear and cardiacneck vein distention or carotid bruits. The lungs are clear and cardiacexamination reveals a normal S1 and S2 and a faint midexamination reveals a normal S1 and S2 and a faint mid--systolic click but nosystolic click but nomurmur. Examination of the abdomen and extremities is normal.murmur. Examination of the abdomen and extremities is normal.Electrocardiogram shows a 1Electrocardiogram shows a 1--mV inferior S TmV inferior S T--segment elevation; a subsequentsegment elevation; a subsequent

electrocardiogram is normal. Serum troponin concentration is 1.5 times theelectrocardiogram is normal. Serum troponin concentration is 1.5 times theupper limit of normal. Therapy with heparin, aspirin, metoprolol, andupper limit of normal. Therapy with heparin, aspirin, metoprolol, andnitroglycerin is begun. The next morning, coronary angiography showsnitroglycerin is begun. The next morning, coronary angiography showsnormal angiographic appearance of the arteries and normal left ventricularnormal angiographic appearance of the arteries and normal left ventricular wall motion. The patient is prescribed a daily aspirin and encouraged to stop wall motion. The patient is prescribed a daily aspirin and encouraged to stopusing cocaine.using cocaine.

W hat additional medical therapy should be prescribed at discharge? W hat additional medical therapy should be prescribed at discharge? A Angiotensin A Angiotensin--converting enzyme inhibitorconverting enzyme inhibitor B B --blockerblocker

C CalciumC Calcium--channel blockerchannel blocker D ClopidogrelD Clopidogrel



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AC TIVI TY AC TIVI TY

EncourageEncourage 3030 toto 6060 minutes of moderateminutes of moderate--

intensity aerobic activity, such as brisk walking intensity aerobic activity, such as brisk walking all days of the week ( all days of the week (55 days is acceptable).days is acceptable).

Supplemented by an increase in daily lifestyleSupplemented by an increase in daily lifestyleactivities (eg, walking breaks at work, gardening,activities (eg, walking breaks at work, gardening,

household work).household work).

Encourage resistance training Encourage resistance training 22 days per week.days per week.



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W EIGH T MANAGEMEN T W EIGH T MANAGEMEN T

Assess body mass index and/or waist Assess body mass index and/or waist

circumference on each visit and consistently.circumference on each visit and consistently.

Encourage weight maintenance/reductionEncourage weight maintenance/reductionthrough an appropriate balance of physicalthrough an appropriate balance of physicalactivity, caloric intake.activity, caloric intake.



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DIABE TES MANAGEMEN TDIABE TES MANAGEMEN T

Goal:Goal: HbAHbA11c <c <77%%



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AN TIPLA TELE T AGEN TS/ AN TIPLA TELE T AGEN TS/ AN TICOAGULAN TS AN TICOAGULAN TS

Start aspirinStart aspirin 7575 toto 162162 mg/d unlessmg/d unless

contraindicated.contraindicated.

For patients undergoing CABG, aspirin shouldFor patients undergoing CABG, aspirin shouldbe started withinbe started within 4848 hours after surgery.hours after surgery.

Doses higher thanDoses higher than 162162 mg/d can be continuedmg/d can be continued

for up tofor up to 11 year.year.



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Start and continue clopidogrelStart and continue clopidogrel 7575 mg/d inmg/d in

combination with aspirin for up tocombination with aspirin for up to 1212 months inmonths inpatients after:patients after:

ACS, PCI with stent placement ACS, PCI with stent placement

Patients who have undergone percutaneousPatients who have undergone percutaneouscoronary intervention with stent placementcoronary intervention with stent placement

should initially receive highershould initially receive higher--dose aspirin atdose aspirin at 325325mg/d formg/d for 11 month for bare metal.month for bare metal.



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Manage warfarin to international normalizedManage warfarin to international normalized

ratio=ratio=22..00 toto 33..00 for paroxysmal or chronic atrialfor paroxysmal or chronic atrialfibrillation or flutterfibrillation or flutter

Use of warfarin in conjunction with aspirinUse of warfarin in conjunction with aspirinand/or clopidogrel is associated with increasedand/or clopidogrel is associated with increased

risk of bleeding and should be monitoredrisk of bleeding and should be monitored

closely.closely.



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RENINRENIN--ANGIO TENSIN ANGIO TENSIN-- ALDOS TERONE S Y S TEM ALDOS TERONE S Y S TEM

BLOCKERSBLOCKERS



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ACE inhibitors ACE inhibitors

Start and continue indefinitely in all patientsStart and continue indefinitely in all patients

with« with«

LV EFLV EF 4040%.%.

H TN,H TN,

DMDM

Chronic kidney disease.Chronic kidney disease.



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Angiotensin receptor blockers Angiotensin receptor blockers

Intolerance of ACE inhibitorsIntolerance of ACE inhibitors

Heart failureHeart failure

Myocardial infarction with left ventricularMyocardial infarction with left ventricularejection fractionejection fraction 4040%.%.

Consider use in combination with ACEConsider use in combination with ACE

inhibitors in systolicinhibitors in systolic--dysfunction heart failure.dysfunction heart failure.



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A A 5555--yearyear--old man with coronary artery disease is evaluatedold man with coronary artery disease is evaluated 22 weeks after having had a myocardial infarction. On discharge, weeks after having had a myocardial infarction. On discharge,his medications included aspirin, sustainedhis medications included aspirin, sustained--release metoprolol,release metoprolol,

isosorbide mononitrate, lisinopril, and atorvastatin.isosorbide mononitrate, lisinopril, and atorvastatin.Echocardiogram at that time showed inferior and posterior wallEchocardiogram at that time showed inferior and posterior wallakinesis and a left ventricular ejection fraction of akinesis and a left ventricular ejection fraction of 4040%. On%. Onexamination, his heart rate isexamination, his heart rate is 6060/min and his blood pressure is/min and his blood pressure is130130//7070 mm Hg. Jugular venous pressure is normal and themm Hg. Jugular venous pressure is normal and thechest is clear. Cardiac rhythm is regular, with normal Schest is clear. Cardiac rhythm is regular, with normal S11 and Sand S22

and no murmurs or extra heart sounds. Laboratory results fromand no murmurs or extra heart sounds. Laboratory results fromyesterday are potassiumyesterday are potassium 55..77 meq/L ( meq/L (55..77 mmol/L), creatininemmol/L), creatinine 11..00mg/dL ( mg/dL (8888..4242 mol/L), and LDL cholesterolmol/L), and LDL cholesterol 6565 mg/dL ( mg/dL (11..6868mmol/L). Lisinopril therapy is stopped.mmol/L). Lisinopril therapy is stopped.

W ich of the following medications should be started in this W ich of the following medications should be started in thispatient?patient?

1.1. Valsartan Valsartan

2.2. SpironolactoneSpironolactone

3.3. Amlodipine Amlodipine

4.4. EplerenoneEplerenone

5.5. HydralazineHydralazine



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Aldosterone blockade Aldosterone blockade

Use in postUse in post² ²myocardial infarction patients,myocardial infarction patients,

without« without«

Significant renal dysfunction orSignificant renal dysfunction or

HyperkalemiaHyperkalemia

Already receiving therapeutic doses of an ACEI and Already receiving therapeutic doses of an ACEI andBB.BB.

Left ventricular ejection fractionLeft ventricular ejection fraction 4040%% Diabetes or heart failure.Diabetes or heart failure.



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INFLUENZA VACCINA TIONINFLUENZA VACCINA TION

Patients with cardiovascular disease should havePatients with cardiovascular disease should have

an influenza vaccination.an influenza vaccination.



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A ntioxidant A ntioxidant

( (HOPE) trial found that vitamin E may even beHOPE) trial found that vitamin E may even be

harmful by increasing the likelihood of heartharmful by increasing the likelihood of heartfailure and other trials have suggested thatfailure and other trials have suggested that

vitamin E may hinder the effectiveness of statin vitamin E may hinder the effectiveness of statintherapy.therapy.



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Elevated plasma homocysteine levelsElevated plasma homocysteine levels

Associated with an increased risk of vascular Associated with an increased risk of vascular

events.events.

Reduced with dietary supplements of Reduced with dietary supplements of folic acidfolic acid

( (11 mg/d)mg/d) in combination within combination with vitamin B vitamin B66 andand vitamin B vitamin B1212..

RC T showed they are of little or no value inRC T showed they are of little or no value in

preventing vascular events.preventing vascular events.



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Hormone replacement therapy HR THormone replacement therapy HR T

In HERS trial, neither combined estrogenIn HERS trial, neither combined estrogen² ²

progesterone nor estrogen alone therapy isprogesterone nor estrogen alone therapy isprotective (in fact both cause harm).protective (in fact both cause harm).



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A A 3535--yearyear--old man is evaluated during a routine examination. Heold man is evaluated during a routine examination. Hedoes not smoke and has no family history of early coronary does not smoke and has no family history of early coronary artery disease.artery disease.

On examination, BMI isOn examination, BMI is 3535..22, and waist circumference is, and waist circumference is 114114 cmcm( (4545 in). Blood pressure isin). Blood pressure is 142142//8888 mm Hg. The remainder of themm Hg. The remainder of thephysical examination is normal. Laboratory studies indicatephysical examination is normal. Laboratory studies indicateborderline hyperglycemia (fasting plasma glucose,borderline hyperglycemia (fasting plasma glucose, 121121 mg/dLmg/dL[ [66..77 mmol/L]). Serum total cholesterol level ismmol/L]). Serum total cholesterol level is 246246 mg/dL ( mg/dL (66..3636

mmol/L), highmmol/L), high--density lipoprotein level isdensity lipoprotein level is 3131 mg/dL ( mg/dL (00..88mmol/L), and low mmol/L), and low--density lipoprotein level isdensity lipoprotein level is 158158 mg/dL ( mg/dL (44..0505mmol/L).mmol/L).

W hich of the following recommendations is most appropriate W hich of the following recommendations is most appropriatefor this patient?for this patient?

A Electron A Electron--beam C T beam C T B Exercise treadmill testB Exercise treadmill test

C HydrochlorothiazideC Hydrochlorothiazide

D Intensive lifestyle modificationD Intensive lifestyle modification

E Intake of red wineE Intake of red wine



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Pathophysiology of Chronic Ischemia &Pathophysiology of Chronic Ischemia & Acute Coronary Syndromes Acute Coronary Syndromes

Chronic ischemia, including stable angina, isChronic ischemia, including stable angina, isclassically caused by supply and demandclassically caused by supply and demand

mismatch.mismatch.

Precipitants include exercise, eating, coldPrecipitants include exercise, eating, cold

weather, and emotional stress. weather, and emotional stress.



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ACS of ACS of unstable anginaunstable angina andand MI cMI caused by:aused by:

Plaque disruptionPlaque disruption

Platelet and thrombinPlatelet and thrombin--mediated coronary mediated coronary thrombosisthrombosis

Coronary spasmCoronary spasm

Microvascular dysfunction.Microvascular dysfunction.

These episodes occur in the early morning or These episodes occur in the early morning orshortly after arising.shortly after arising.



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Antithrombotic therapy is directed toward Antithrombotic therapy is directed toward

inhibition of platelet activity (aspirin,inhibition of platelet activity (aspirin,

clopidogrel, IIb/IIIa receptor antagonists),clopidogrel, IIb/IIIa receptor antagonists),inhibition of coagulation (unfractionated or low inhibition of coagulation (unfractionated or low--

molecularmolecular--weight heparin), and fibrinolysis for weight heparin), and fibrinolysis forS TS T--segment elevation myocardial infarction.segment elevation myocardial infarction.



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T ypes & Pathoph ysiology of T ypes & Pathoph ysiology of

myocardialmyocardial ischemiaischemia presentation presentation

Symptomatic, causing Symptomatic, causing angina pectoris.angina pectoris.

Completely silent.Completely silent. In patients with diagnosed CAD silent ischemicIn patients with diagnosed CAD silent ischemic

episodes have the same prognostic import asepisodes have the same prognostic import as

symptomatic ones.symptomatic ones.



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Myocardial Hibernation & Stunning Myocardial Hibernation & Stunning

Areas of myocardium that are persistently Areas of myocardium that are persistently underperfused.underperfused.

Still viableStill viable

May develop sustained contractile dysfunction.May develop sustained contractile dysfunction.

May lead to LV failure.May lead to LV failure.

Reversible following coronary revascularization.Reversible following coronary revascularization.

Identified by Identified by Radionuclide testing,Radionuclide testing, (PE T ), MRI,(PE T ), MRI,

Inotropic stimulation with dobutamine.Inotropic stimulation with dobutamine.



Myocardial Hibernation & Stunning Myocardial Hibernation & Stunning

A related phenomenon, termed "myocardial A related phenomenon, termed "myocardial

stunning," is the occurrence of persistentstunning," is the occurrence of persistentcontractile dysfunction following prolonged orcontractile dysfunction following prolonged or

repetitive episodes of myocardial ischemia.repetitive episodes of myocardial ischemia.

926277 Coronary Heart Disease

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Transcript of 926277 Coronary Heart Disease