Cardiovascular Disease Part 2 Jeffrey Zimmet MD, PhD Associate - PDF document

UCSF, Department of Medicine, CME UCSF Internal Medicine Board Certification and Recertification Review Cardiovascular Disease – Part 2 Jeffrey Zimmet MD, PhD Associate Professor of Medicine University of California San Francisco July 2015 Disclosures l None UCSF, Department of Medicine, CME 2 1

UCSF, Department of Medicine, CME 3 From ABIM blueprint for Internal Med Board Exams CASE 1: 45 y.o. male, with no PMH, presents with chest pain x 8 hours UCSF, Department of Medicine, CME 4 2

UCSF, Department of Medicine, CME Case 1: What is the next step? 1) Start aspirin and heparin therapy 2) Start aspirin, low dose heparin and lytic therapy 3) Perform cardiac catheterization 4) Perform echocardiogram 5) Not sure UCSF, Department of Medicine, CME 5 Acute Pericarditis l Characterized by pleuritic, positional chest pain, a rub, possibly a pericardial effusion, EKG with diffuse ST-elevation and PR- depression, and PR-elevation in aVR l Cardiac enzymes can be elevated l Usually responds to oral NSAIDs l Colchicine recommended as adjunctive therapy. l Thrombolytics may result in life-threatening hemorrhagic tamponade UCSF, Department of Medicine, CME 6 3

UCSF, Department of Medicine, CME Question 2: Thrombolytic therapy is strictly contraindicated in all of the following except: 1) Presence of AV-malformations in the brain 2) Any prior history of embolic stroke 3) Recent GI bleed within 1 month 4) Patient with metastatic disease to the brain 5) All of the above UCSF, Department of Medicine, CME 7 Contraindications and Caution with Lytic Therapy • Any prior intracranial hemorrhage Absolute Contraindications • Known structural cerebral vascular lesion (e.g., arteriovenous malformation) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active bleeding (excluding menses) • Significant closed-head trauma or facial trauma within 3 months UCSF, Department of Medicine, CME 8 ACC/AHA Guidelines 2004 4

UCSF, Department of Medicine, CME Relative Contraindications To Lytics • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg) • History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications • Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks) • Recent (< 2 to 4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase/anistreplase: prior exposure (> 5 days ago) or prior allergic reaction to these agents • Pregnancy • Active peptic ulcer ACC/AHA Guidelines 2004 • Current use of anticoagulants: the higher the INR, the higher the risk of bleeding UCSF, Department of Medicine, CME 9 Case 3: 57 year old diabetic with dyslipidemia l A 57-year-old woman with adult-onset diabetes mellitus has the following lipid profile: Total serum cholesterol of 178 mg/dL LDL cholesterol level of 98 mg/dL HDL cholesterol of 35 mg/dL Triglyceride level of 492 mg/dL UCSF, Department of Medicine, CME 10 5

UCSF, Department of Medicine, CME Case 3 l Has been compliant with a low-fat, low- cholesterol, diabetic diet. l Glycohemoglobin A 1C = 6.6% on oral therapy. UCSF, Department of Medicine, CME 11 Case 3: Which of the following is the recommended initial drug therapy for this patient? 1. A fibrate 2. Niacin 3. A statin 4. Ezetimide 5. A bile acid resin UCSF, Department of Medicine, CME 12 6

UCSF, Department of Medicine, CME Major Risk Factors for CV Disease l 4 major modifiable traditional CV risk factors: l Smoking l Diabetes Mellitus l Hypertension l Hyperlipidemia l 80-90% patients with CAD have ≥ 1 CAD RF; >95% with a fatal CAD event had ≥ 1 CAD RF. JAMA, August 20, 2003, vol 290, pp.891-97, 898-904. UCSF, Department of Medicine, CME 13 Hyperlipidemia in Diabetics l Diabetes mellitus is a coronary artery disease equivalent, and risk factor targets for patients with diabetes are the same as those in patients with established coronary disease. l This is irrespective of age or other risk factors. UCSF, Department of Medicine, CME 14 7

UCSF, Department of Medicine, CME Log-Linear Relationship Between LDL-C Levels and Relative Risk for CHD 3.7 2.9 2.2 Relative Risk for Coronary 1.7 Heart Disease (Log Scale) 1.3 1.0 40 70 100 130 160 190 LDL-Cholesterol (mg/dL) UCSF, Department of Medicine, CME 15 Grundy, S. et al., Circulation 2004;110:227-39. ATP III LDL-C Goals Consider Risk Category LDL-C Goal Initiate TLC Drug Therapy High risk: <100 mg/dL ≥ 100 mg/dL >100 mg/dL CHD or CHD risk equivalents (optional goal: (<100 mg/dL: (10-year risk >20%) <70 mg/dL) consider drug options) Moderately high risk: <130 mg/dL ≥ 130 mg/dL >130 mg/dL 2+ risk factors (100-129 mg/dL: (10-year risk 10% to 20%) consider drug options) Moderate risk: <130 mg/dL ≥ 130 mg/dL >160 mg/dL 2+ risk factors (10 year risk <10%) Lower risk: <160 mg/dL ≥ 160 mg/dL >190 mg/dL 0-1 risk factor (160-189 mg/dL: LDL-lowering drug optional) UCSF, Department of Medicine, CME 16 Grundy, S. et al., Circulation 2004;110:227-39. 8

UCSF, Department of Medicine, CME 2013 ACC/AHA Guidelines on the Assessment of Atherosclerotic Cardiovascular Risk l New Pooled Cohort Equations for atherosclerotic cardiovascular disease (ASCVD) risk assessment l Statin therapy recommended in 4 groups, with de-emphasis of other drug classes (e.g. fibrates, niacin, ezetimibe) l No LDL-C or non-HDL-C treatment targets 2013 ACC/AHA Guidelines :No Cholesterol Treatment Target Goals l Appropriate intensity of statin therapy is recommended to reduce the risk of ASCVD by lowering LDL-C and non- HDL-C l “Treat to target” and “lower is best” strategies are no longer advocated l More clinical trials are needed 9

UCSF, Department of Medicine, CME Pooled Cohort Equations for Risk Assessment l Equations predict 10-year risk of stroke & myocardial infarction l Former guidelines focused only on heart attacks l Highlights the large burden of disability from nonfatal events l Separate equations for nonwhite populations l Importance of race/ethnicity in risk of ASCVD Statin Therapy Recommended in Four Groups 1. Individuals with known ASCVD 2. Individuals with LDL-C ≥ 190 mg/dL 3. Individuals 40 to 75 years of age with diabetes and LDL-C 70-189 mg/dL 4. Individuals 40 to 75 years of age with estimated 10-year ASCVD risk ≥ 7.5% and LDL-C 70-189 mg/dL 10

UCSF, Department of Medicine, CME Treatment Threshold: 7.5% l Lowered from former threshold of 20% risk of MI over 10 years or > 10% with multiple risk factors l Based on NHANES data: l Men l 50% of all African-American men and 30% of white men in 50s l Almost all men in 70s l Women l 70% African-American women and 60% white women in 60s Treatment Options l Statins: Preferred agent;modest effects on TG, HDL. l Fibrates ↓ TG 20-50%, ↑ HDL 10-20%. l VA-HIT Study: Gemfibrozil reduced MI/ cardiac death. l ACCORD study (added to statin) negative l Niacin: ↓ TG 20-50%, ↑ HDL 20-35%. l Negative AIM HIGH study l Omega-3 fatty acids: ↓ TG 20-30%, ↑ HDL 1-3%. l Ezetimibe is an intestinal brush border cholesterol absorption inhibitor. Lacking outcomes data. UCSF, Department of Medicine, CME 22 11

UCSF, Department of Medicine, CME Case 4: 72 y.o. woman with NSTEMI l A 72-year-old woman comes to the emergency department with several episodes of substernal chest pressure over the past 24 hours. She has had four episodes of chest pressure occurring at rest and lasting 20-40 minutes. l History of hypertension, diabetes, and current smoking. l Medications include aspirin 325 mg daily; hydrochlorothiazide 25 mg daily; and glyburide 5 mg twice daily. UCSF, Department of Medicine, CME 23 Case (cont’d) l Vital signs: pulse is 80/min and regular, blood pressure is 145/75 mmHg. Chest with basilar crackles and cardiac examination reveals a + S4. l ECG shows 2-mm ST-segment depression in leads V 3 -V 6 . l Serum troponin I is elevated at 3.7 ng/ mL. UCSF, Department of Medicine, CME 24 12

UCSF, Department of Medicine, CME Case 4 Therapy with aspirin, sublingual nitroglycerin, and a β –blocker is begun. The patient is admitted to the coronary care unit. Which of the following should you do next? 1. Schedule an exercise stress test within 48 hours. 2. Begin intravenous heparin. 3. Begin intravenous heparin and eptifibatide, and schedule an exercise stress test within 48 hours. 4. Begin intravenous heparin and eptifibatide, and schedule coronary angiography within 48 hours. UCSF, Department of Medicine, CME 25 Spectrum of Acute Coronary Syndromes Non-Q Q wave Stable Unstable Angina wave MI MI Angina Non ST ST Elevation MI Elevation ACS ECG - ST ↑ ECG - ST ↓ CK-MB Troponin I or T CRP 13