Cardiac Risk Management

1. See Also
   1. Cardiac Risk Factor
   2. Post Myocardial Infarction Medications
   3. Framingham Score
2. Resources
   1. Risk Assessment Tool (Available for PDAs)
      1. http://www.nhlbi.gov/guidelines/cholesterol
      2. Uses Framingham data to direct CAD Risk Management
   2. Risk reduction measures in Patient Education handouts
      1. http://www.heartdecision.org
3. Prevention: Approach
   1. Mnemonic: Remember your ABCDEFs
      1. Antiplatelet (e.g. Aspirin) or Anticoagulant
      2. Blood Pressure control
      3. Cholesterol management
      4. Diabetes management
      5. Exercise (or Cardiac Rehabilitation if indicated)
      6. Fish oil
      7. Smoking Cessation
   2. General
      1. Four health habits dramatically reduce risk
         1. Tobacco avoidance
         2. BMI <25 kg/m2 (but even <30 kg/m2 reduces risk)
         3. Eating 5 or more fruits and vegetables daily
         4. Aerobic Exercise >150 minutes per week
      2. Benefits
         1. Following all 4 habits reduces cardiovascular events by 40%
         2. Overall survival is extended 14 years in those following all 4 habits
         3. Even adopting 1 new health habit significantly reduces mortality
      3. References
         1. Akesson (2007) Arch Intern Med 167: 2122-27
         2. King (2007) Am J Med 120:598-603
4. Management: Risk factor modification
   1. See Mediterranean Diet (Heart Healthy Diet)
   2. Weight loss
   3. Blood Pressure control (Goal less than 130/80)
   4. Tobacco Cessation
      1. Regardless of age, Tobacco Cessation reduces risk
         1. Hermanson (1988) N Engl J Med 319:1365-9
      2. Overall mortality reduced as much as 36% in CHD
         1. Risk reduction more than medications (e.g. ASA)
         2. Critchley (2003) JAMA 290:86-97
   5. Lower Cholesterol
      1. Diet or pharmacologic treatment
      2. LDL Cholesterol <100 mg/dl (very high risk patients should aim for <70 mg/dl)
         1. Each 40 mg/dl drop in LDL Cholesterol lowers cardiovascular risk by 20% over one year regardless of age
      3. HDL Cholesterol >40 mg/dl (50 mg/dl for women)
      4. Triglycerides <150 mg/dl
      5. See Statin use below
   6. Aerobic Exercise (30-45 minutes, 3-6 times per week)
      1. Low level Exercise (walking, gardening) is effective
      2. Wannamethee (2000) Circulation 102:1358-63
   7. Aggressively treat Diabetes Mellitus
      1. Keep the Hemoglobin A1C less than 7% (guidelines since ACCORD study suggest Type II Diabetes goal <8%)
   8. Fish Oil Supplementation (omega 3 Fatty Acid supplementation)
      1. Fish oil (DHA and EPA) 1000 mg/day
      2. Reduces risk of death due to cardiovascular events
   9. Treat comorbid Major Depression
      1. See Depression Management in Cardiovascular Disease
      2. Increased risk of Coronary Artery Disease
      3. Risk of MI related death increased 3.5 fold
   10. Influenza Vaccine
       1. Lowers cardiovascular event risk by 50%
       2. Gurfinkle (2002) Circulation 105: 2143-7
5. Management: Disproved strategies
   1. Anti-oxidant regimen
      1. Negates Statin and Niacin HDL-2 beneficial effects
      2. No proven efficacy
      3. Anti-oxidants
         1. Vitamin E 400 iu/day
            1. Increases cardiovascular risk, risk of Congestive Heart Failure and Hemorrhagic Stroke
            2. Not effective in coronary disease prevention
            3. Skekelle (2004) J Gen Intern Med 19:380-9
         2. Vitamin C 500-1000 mg/day
         3. Beta Carotene 25000 u/day (increases cardiovascular risk)
         4. B Vitamins offer no benefit in Cardiac Risk
            1. Vitamin B12 Supplementation 400 mg qd
            2. Vitamin B6 supplementation 10 mg qd
            3. (2006) N Engl J Med 354:1567-77
   2. Estrogen Replacement (Hormone Replacement Therapy)
      1. Stop HRT in those at risk for coronary disease
      2. No longer thought to be protective against CAD
      3. Data based on NIH Women's Health Initiative
      4. References
         1. (2002) JAMA 288:321-333
         2. Waters (2002) 288:2432-40
6. Medications: Platelet activation inhibitors
   1. Aspirin
      1. Indication
         1. Framingham 10 year risk 10% or higher
      2. Dosing
         1. CAD risk: non-enteric coated 81 mg or enteric coated 162 mg orally daily
         2. CAD Disease: 162-325 mg orally daily
      3. Aspirin resistance confers 3x cardiovascular risk
         1. Consider lab screening in high risk patients
            1. Optical aggregation for Aspirin resistance
         2. Use Clopidogrel for Aspirin resistant patients
         3. Reference
            1. Gum (2003) J Am Coll Cardiol 41:961-5
      4. Aspirin with Proton Pump Inhibitor
         1. Indicated for history of bleeding peptic ulcer
         2. Less bleeding risk than Clopidogrel
         3. Chan (2005) N Engl J Med 352:238-44
      5. Aspirin use in women without vascular disease
         1. Reduces stroke risk but not MI risk
         2. Associated with higher risk of GI Bleeding
         3. Not recommended for women at low vascular risk
         4. Ridker (2005) N Engl J Med 352:1293-304
   2. Clopidogrel (Plavix)
      1. More effective than Aspirin in preventing CV events
      2. Avoid combining with Aspirin (avoid the combination in all but highest risk)
      3. Indicated in known vascular disease
      4. Cannon (2002) Am J Cardiol 90:160-2
7. Medications: Antihypertensives
   1. Goal Blood Pressure
      1. CAD, CRF, DM: <130/80
      2. Other patients: <140/90
   2. First-line antihypertensives in CAD Prevention
      1. Beta-Blockers
      2. ACE Inhibitors
   3. Other antihypertensives for additional Blood Pressure control
      1. Thiazide Diuretics
      2. Calcium Channel Blockers
         1. May be higher mortality in general CAD
            1. Especially avoid short acting agents (e.g. Nifedipine)
         2. Less effective CAD prevention than other agents
            1. Black (2003) JAMA 289:2073-82
         3. Indications
            1. Rest and variant Angina
            2. Silent ischemia
            3. Microvascular Angina (Syndrome X)
               1. Use in combination with nitrates
8. Medications: AntiHyperlipidemic therapy with Statin
   1. Effective in preventing future cardiovascular events
   2. Benefit even in patients over age 80 years
   3. Goal LDL Cholesterol
      1. Most patients: 100 mg/dl
      2. High risk patients: <70 mg/dl (Intensive lipid lowering)
         1. NNT 20-40 to prevent one Myocardial Infarction or death
         2. LaRosa (2005) N Engl J Med 352:1425-35
         3. Josan (2008) CMAJ 178(5): 576-84
         4. Pedersen (2005) JAMA 294:2437-45
   4. Statins independently lower CAD risk with Plaque stabilization and are first-line tools in preventive cardiology
      1. Collins (2004) Lancet 363:757-67
      2. Maycock (2002) J Am Coll Cardiol 40:1777-85
9. Medications: Reduce Homocysteine (e.g. Folic Acid)
   1. Supplementation only benefits venous events, but does not effect arterial cardiovascular risk
   2. Folic Acid supplementation 1000 mg daily
      1. Not beneficial post-stenting
         1. Lange (2004) N Engl J Med 350:2673-81
   3. References
      1. Schnyder (2002) JAMA 288:973-9
      2. Rimm (1998) JAMA 279:359-64
10. Medications: Other
    1. See Post Myocardial Infarction Medications
    2. Supplements that show initial benefit
       1. Coenzyme Q10 60 mg PO bid (more helpful in reduction in Statin-Induced Myalgias)
          1. Singh (2003) Mol Cell Biochem 246:75-82
    3. Implantable Cardioverter Defibrillators
       1. Used post-MI for high risk of ventricular arrhythmia
       2. Did not reduce mortality (n=674) over >30 months
       3. Hohnloser (2004) N Engl J Med 351:2481-8
11. Medications: Avoid NSAIDs (other than Aspirin)
    1. NSAIDs are associated with increased risk of cardiovascular events
       1. Even short-term NSAID use 5 years after coronary event is associated with 19 more events in 1000 patients with CAD
       2. Antman (2007) Circulation 115(12):1634-42
       3. Moore (2007) BMC Musculoskelet Disord 8:73
       4. Schjerning Olsen (2011) Circulation 123(20):2226-35
       5. Wehrmacker (2006) Compr Ther 32(4):236-9
    2. Step-wise approach to Analgesics (in order of least to most cardiovascular risk)
       1. Acetaminophen (lowest cardiovascular risk)
       2. Aspirin (cardioprotective)
       3. Tramadol (Analgesics)
       4. Opioid Analgesics (e.g. Vicodin)
       5. Salsalate
       6. Naproxen (Naprosyn)
       7. Cox-2 selective NSAIDs such as Celecoxib or Diclofenac (most cardiovascular risk)
    3. References
       1. Prescriber's Letter (2008) 15(2): 8
12. References
    1. Ferketich (2000) Arch Intern Med 160:1261-8
    2. Frasure-Smith (1993) JAMA 270:1819-25
    3. (2001) Lancet 357:89-95
    4. Pflieger (2011) Am Fam Physician 83(7): 819-26