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Cardiac Risk Management
Aka: Cardiac Risk Management, CAD Risk Management, Cardiovascular Risk Reduction, Coronary Risk Management, Coronary Heart Disease Prevention, Prevention of Coronary Events, Anticoagulation in Coronary Artery Disease Prevention
- See Also
- Stable Coronary Artery Disease
- Cardiac Risk Factor
- Post Myocardial Infarction Medications
- Framingham Score
- Resources
- ASCVD Risk Estimator (may overestimate risk)
- http://static.heart.org/riskcalc/app/index.html#!/baseline-risk
- Prevention: Approach
- Mnemonic: Remember your ABCDEFs
- Antiplatelet (e.g. Aspirin) or Anticoagulant
- Blood Pressure control
- Cholesterol management
- Diabetes management
- Exercise (or Cardiac Rehabilitation if indicated)
- Fish oil
- Smoking Cessation
- General
- Four health habits dramatically reduce risk
- Tobacco avoidance
- BMI <25 kg/m2 (but even <30 kg/m2 reduces risk)
- Eating 5 or more fruits and vegetables daily
- Aerobic Exercise >150 minutes per week
- Benefits
- Following all 4 habits reduces cardiovascular events by 40%
- Overall survival is extended 14 years in those following all 4 habits
- Even adopting 1 new health habit significantly reduces mortality
- References
- Akesson (2007) Arch Intern Med 167: 2122-27 [PubMed]
- King (2007) Am J Med 120:598-603 [PubMed]
- Management: Risk factor modification
- Heart Healthy Diet
- See DASH Diet
- See Mediterranean Diet (Heart Healthy Diet)
- See Low Fat Diet
- Weight loss (in Overweight patients)
- See Obesity Management
- Hypertension Management
- Blood Pressure control (Ideally less than 130/80)
- Tobacco Cessation
- Regardless of age, Tobacco Cessation reduces risk
- Hermanson (1988) N Engl J Med 319:1365-9 [PubMed]
- Overall mortality reduced as much as 36% in CHD
- Risk reduction more than medications (e.g. ASA)
- Critchley (2003) JAMA 290:86-97 [PubMed]
- Lower Cholesterol
- Diet or pharmacologic treatment
- See Statin use below
- Non-Statins have provided minimal to no significant benefit in Cardiovascular Risk Reduction
- Specific LDL and HDL targets have been replaced with high-intensity Statin if 10 year CV risk >20%
- Historic lipid targets
- LDL Cholesterol <100 mg/dl (very high risk patients should aim for <70 mg/dl)
- Each 40 mg/dl drop in LDL lowers cardiovascular risk by 20% over one year regardless of age
- HDL Cholesterol >40 mg/dl (50 mg/dl for women)
- Triglycerides <150 mg/dl
- Exercise
- See Exercise Prescription
- Aerobic Exercise
- Moderate intensity aerobic Exercise >150 min/week (ideally >300) OR
- Examples: Body pump, swim, bike, garden, walk>3 mph
- Vigorous intensity aerobic Exercise >75 min/week (ideally >150)
- Examples: Bike >10 mph, jog, hike uphill with pack
- Muscle Strengthening
- Exercise all major Muscle groups at least twice weekly
- References
- Anderson (2016) Cochrane Database Syst Rev (1): CD001800 [PubMed]
- Wannamethee (2000) Circulation 102:1358-63 [PubMed]
- Diabetes Mellitus Management
- Keep the Hemoglobin A1C less than 7% in Type I Diabetes and <8% in Type II Diabetes
- Fish Oil Supplementation
- See omega 3 Fatty Acid supplementation
- Fish oil (DHA and EPA) 1000 mg/day
- Reduces risk of death due to cardiovascular events
- Treat comorbid Major Depression
- See Depression Management in Cardiovascular Disease
- Increased risk of Coronary Artery Disease
- Risk of MI related death increased 3.5 fold
- Influenza Vaccine
- Lowers cardiovascular event risk by 50%
- Gurfinkle (2002) Circulation 105: 2143-7 [PubMed]
- Management: Disproved strategies
- Anti-Oxidant regimen
- Negates Statin and Niacin HDL-2 beneficial effects
- No proven efficacy
- Anti-Oxidants
- Vitamin E 400 iu/day
- Increases cardiovascular risk, risk of Congestive Heart Failure and Hemorrhagic Stroke
- Not effective in coronary disease prevention
- Skekelle (2004) J Gen Intern Med 19:380-9 [PubMed]
- Vitamin C 500-1000 mg/day
- Beta Carotene 25000 u/day (increases cardiovascular risk)
- B Vitamins offer no benefit in Cardiac Risk
- Vitamin B12 Supplementation 400 mg qd
- Vitamin B6 supplementation 10 mg qd
- (2006) N Engl J Med 354:1567-77 [PubMed]
- Estrogen Replacement (Hormone Replacement Therapy)
- Stop HRT in those at risk for coronary disease
- No longer thought to be protective against CAD
- Data based on NIH Women's Health Initiative
- References
- (2002) JAMA 288:321-333 [PubMed]
- Waters (2002) 288:2432-40 [PubMed]
- Medications: Platelet activation inhibitors
- See Antiplatelet Therapy for Vascular Disease
- Aspirin
- Indication for primary prevention (no known Coronary Artery Disease)
- As of 2018, Aspirin has fallen out of favor for primary prevention
- May still be beneficial in Diabetes Mellitus patients for primary prevention
- Appears to have less benefit for primary prevention in non-diabetic risk factors
- Continue for secondary prevention in patients with vascular disease
- Also with risk of serious GI Bleeding
- (2018) Presc Lett 25(11): 61
- Prior Indications: Framingham 10 year risk 10% or higher in age 50 to 69
- Benefits are less strong in age 60-69
- Dosing
- Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
- Aspirin 81 mg is sufficient for most patients
- Berger (2008) Am J Med 121(1): 43-9 [PubMed]
- Some postulate that enteric coating makes the 81 mg Aspirin less effective
- Some recommend 162 mg daily if enteric coated Aspirin used
- Aspirin resistance confers 3x cardiovascular risk
- Consider lab screening in high risk patients
- Optical aggregation for Aspirin resistance
- Use Clopidogrel for Aspirin resistant patients
- Reference
- Gum (2003) J Am Coll Cardiol 41:961-5 [PubMed]
- Aspirin with Proton Pump Inhibitor
- Indicated for history of bleeding peptic ulcer
- Less bleeding risk than Clopidogrel
- Chan (2005) N Engl J Med 352:238-44 [PubMed]
- Aspirin use without vascular disease
- Overall NNT 254 on Aspirin for 7 years to prevent one cardiovascular event
- At the expense of 1 major bleeding episode in same group
- Berger (2011) Am Heart J 162(1): 115-24 [PubMed]
- Women without vascular disease
- Reduces stroke risk but not Myocardial Infarction risk
- Associated with higher risk of GI Bleeding
- Not recommended for women at low vascular risk
- Ridker (2005) N Engl J Med 352:1293-304 [PubMed]
- Prior Gastrointestinal Bleeding
- Avoid Aspirin (and other antiplatelet agents) for primary prevention after prior GI Bleed
- Limit Aspirin after GI Bleed to secondary prevention (known cardiovascular disease)
- Platelet ADP Receptor Antagonist (e.g. Clopidogrel, Ticagrelor, Prasugrel)
- See Platelet ADP Receptor Antagonist
- Marginally more effective than Aspirin in preventing CV events
- (1996) Lancet 348(9038): 1329-39 [PubMed]
- Aside from post-coronary stenting, avoid combining with Aspirin in stable cardiovascular disease
- Dual Antiplatelet Therapy is more effective CV prevention, but raises the major bleeding risk
- Bittl (2016) Circulation 134(10): e156-78 +PMID:27026019 [PubMed]
- Indicated in known vascular disease if Aspirin contraindicated
- References
- Cannon (2002) Am J Cardiol 90:160-2 [PubMed]
- Medications: Antihypertensives
- Goal Blood Pressure
- CAD, CRF, DM: <130/80
- Other patients: <140/90 (consider as goal for most patients after JNC 8)
- Keep diastolic Blood Pressure >60 mmHg to maintain perfusion (especially in Diabetes Mellitus, age >60 years)
- First-line antihypertensives in CAD Prevention
- Beta-Blockers
- Metoprolol Succinate titrate up to 200 mg orally daily
- Continue for at least 3 years after MI, indefinately for CHF, Angina
- ACE Inhibitors (or Angiotensin Receptor Blockers)
- Anticipate a small increase in Serum Creatinine on starting ACE Inhibitors (or ARBs)
- Stop or decrease ACE Inhibitor dose if Serum Creatinine rises >30% over baseline
- Thiazide Diuretics
- Chlorthalidone or Indapamide is preferred over Hydrochlorothiazide
- Other agents: Calcium Channel Blockers
- May be higher mortality in general CAD
- Especially avoid short acting agents (e.g. Nifedipine)
- Less effective CAD prevention than other agents
- Black (2003) JAMA 289:2073-82 [PubMed]
- Indications
- Black patients (CCBs are more effective than ACE/ARB agents)
- Rest and Variant Angina
- Silent ischemia
- Microvascular Angina (syndrome X)
- Use in combination with nitrates
- Preparations
- Dihydropyridine Calcium Channel Blocker
- Consider for Hypertension, Angina (may be added to Beta Blocker)
- Amlodipine
- Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil)
- Avoid unless Beta Blocker not tolerated
- Medications: AntiHyperlipidemic therapy with Statin
- Effective in preventing future cardiovascular events
- Benefit even in patients over age 80 years
- Goal LDL Cholesterol (historic targets replaced with low-intensity and high-intensity protocols)
- Most patients: 100 mg/dl
- High risk patients: <70 mg/dl (Intensive lipid lowering)
- NNT 20-40 to prevent one Myocardial Infarction or death
- LaRosa (2005) N Engl J Med 352:1425-35 [PubMed]
- Josan (2008) CMAJ 178(5): 576-84 [PubMed]
- Pedersen (2005) JAMA 294:2437-45 [PubMed]
- Statins independently lower CAD risk with Plaque stabilization and are first-line tools in preventive cardiology
- Collins (2004) Lancet 363:757-67 [PubMed]
- Maycock (2002) J Am Coll Cardiol 40:1777-85 [PubMed]
- Statins in high cardiovascular disease risk (10 year risk >20%)
- Number Needed to Treat (NNT) 25 on Statin for 10 years to prevent one significant cardiovascular event
- Baigent (2005) Lancet 366(9493): 1267-78 [PubMed]
- Statins in low to moderate cardiovascular disease risk (10 year risk with Framingham Score of 6%)
- Number Needed to Treat (NNT) 80 on Statin for 10 years to prevent one significant cardiovascular event
- Tonelli (2011) CMAJ 183(16): E1189-1202 [PubMed]
- Medications: Reduce Homocysteine (e.g. Folic Acid)
- Supplementation only benefits venous events, but does not affect arterial cardiovascular risk
- Folic Acid supplementation 1000 mg daily
- Not beneficial post-stenting
- Lange (2004) N Engl J Med 350:2673-81 [PubMed]
- References
- Schnyder (2002) JAMA 288:973-9 [PubMed]
- Rimm (1998) JAMA 279:359-64 [PubMed]
- Medications: Other
- See Post Myocardial Infarction Medications
- See Angina
- Supplements that show initial benefit
- Coenzyme Q10 60 mg PO bid (more helpful in reduction in Statin-Induced Myalgias)
- Singh (2003) Mol Cell Biochem 246:75-82 [PubMed]
- Implantable Cardioverter Defibrillators
- Used post-MI for high risk of ventricular Arrhythmia
- Did not reduce mortality (n=674) over >30 months
- Hohnloser (2004) N Engl J Med 351:2481-8 [PubMed]
- Medications: Avoid NSAIDs (other than Aspirin)
- NSAIDs are associated with increased risk of cardiovascular events
- Even short-term NSAID use 5 years after coronary event increases CAD event risk
- Associated with 19 more events in 1000 patients with CAD
- Antman (2007) Circulation 115(12):1634-42 [PubMed]
- Moore (2007) BMC Musculoskelet Disord 8:73 [PubMed]
- Schjerning Olsen (2011) Circulation 123(20):2226-35 [PubMed]
- Wehrmacker (2006) Compr Ther 32(4):236-9 [PubMed]
- Step-wise approach to Analgesics (in order of least to most cardiovascular risk)
- Acetaminophen (lowest cardiovascular risk)
- Aspirin (cardioprotective)
- Tramadol (but has other risks)
- Opioid Analgesics (e.g. Vicodin)
- Salsalate
- Naproxen (Naprosyn)
- Cox-2 selective NSAIDs such as Celecoxib or Diclofenac (most cardiovascular risk)
- References
- Prescriber's Letter (2008) 15(2): 8
- References
- Ferketich (2000) Arch Intern Med 160:1261-8 [PubMed]
- Frasure-Smith (1993) JAMA 270:1819-25 [PubMed]
- (2001) Lancet 357:89-95 [PubMed]
- Pflieger (2011) Am Fam Physician 83(7): 819-26 [PubMed]