心血管预防指南.pptx

Guidelines For Cardiovascular PreventionDr Chan,Ngai Yin,MBBS(HK),MRCP(UK),FRCP(Edin),FACC,FAHA,Associate Consultant,Director,Cardiac Pacing Services,Princess Margaret Hospital10th South China International Congress in Cardiology,Guangzhou,China,April 12,2008CVD and other major causes of death:both sexes.(United States:2004).Source:NCHS and NHLBI.Causes of Death-US57%of deaths due to CV diseasesSetting the Goal:A HistoryIn 1998,the AHA Board of Directors adopted a 2010 Impact Goal:By 2010,to reduce coronary heart disease,stroke and risk by 25%.Risk factors to be measured included:Tobacco UsageHigh Blood PressureHigh CholesterolPhysical InactivityIn 2001,Obesity and Diabetes were added as risk factors.Our goal is to achieve a 0%growth rate in Obesity and Diabetes by 2010.Coronary Heart Disease Mortality22.8%Stroke Mortality18.8%AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease:2006 UpdateLifestyle modificationBlood pressure controlLipid managementDiabetes managementAntithrombotic treatmentRenin-Angiotensin-Aldosterone system blockade blockersInfluenza vaccinationLifestyle modificationSmoking-complete cessation,avoid environmental exposurePhysical activity-30 minutes,7 days per week(minimum 5 days per week)Weight management-BMI 18.5-24.9kg/m2,waist circumference 40 inches for men,35 inches for womenOne-for-all Community-Based Phase 2.5 Cardiac Rehabilitation for Low-risk PatientsPatients with implantable devicesClass I and II heart failure patientsPatients with coronary artery disease after complete revascularizationPatients with stable angina with satisfactory medical controlPatients with valvular heart disease after surgical treatmentBlood Pressure ControlGoal:140/90mmHg or 130/80mmHg if patient has diabetes or chronic kidney diseaseLifestyle modificationAs tolerated,add BP medication,treating initially with blockers and/or ACEI,with addition of other drugs such as thiazidesNew Lipid Target(1)LaRosa JC,Grundy SM,Waters DD et al.Intensive lipid lowering with atorvastatinIn patients with stable coronary disease.NEJM 2005;352:1425-3510001 pts with CHDAnd LDL130mg/dlMedian FU 4.9yearsMean LDL 77 vs 101New Lipid Target(2)LaRosa JC,Grundy SM,Waters DD et al.Intensive lipid lowering with atorvastatinIn patients with stable coronary disease.NEJM 2005;352:1425-35Primary endpoint:First major CV event,defined asDeath from CHD,Nonfatal MICardiac arrest survivorFatal or nonfatal strokeLiver derangement:1.2%vs 0.2%(p0.001)New Lipid Target(3)Pedersen TR,Faergeman O,Kastelein JJ et al.High-dose atorvastatin vs usual-dose Simvastatin for secondary prevention after myocardial infarction.JAMA 2005;294:2437-454439(high dose)vs 4449 ptsWith history of MIPrimary endpoint:Major coronary event defined asCoronary death,nonfatal AMI,orCardiac arrest survivorNo difference in CV or All-cause mortality80mg Atorvastatin20mg SimvastatinNew Lipid Target(4)Pedersen TR,Faergeman O,Kastelein JJ et al.High-dose atorvastatin vs usual-dose Simvastatin for secondary prevention after myocardial infarction.JAMA 2005;294:2437-45New Lipid Target(4)Shephard J,Kastelein JJP,Bittner V et al.Intensive lipid lowering with atrovastatin in patientsWith coronary heart disease and chronic kidney disease.JACC 2008;51:1448-5410001 pts with CHD9656 with renal data3107 CKD(GFR60ml/min/1.73m2vs 6549 normal GFRLipid ManagementDiet therapyLDL-C 100mg/dL,further reduction of LDL-C to 70mg/dL is reasonableIf TG 200-499mg/dL,non-HDL-C should be 130mg/dLIf TG 500mg/dL,prevent pancreatitis with fibrate or niacin before LDL loweringLipid-lowering medications:statin,fibrate,niacin,bile acid sequestrants,ezetimibeDiabetes ManagementLifestyle modification and pharmacotherapyGoal:HbA1c7%Antithrombotic TherapyLifelong aspirin 75-162mg/d Aspirin 100-325mg/d within 48h of SVG,higher dose for 1 year Aspirin 325mg/d postPCI(1 month BMS,3 months SES,6 months PES)+Clopidogrel 75mg/d up to 12 months for ACS,postPCI(1 month BMS,3 months SES,6 months PES)Warfarin with INR 2-3 for PAF,CAF or flutterAngiotensin-Converting-Enzyme Inhibition in Stable Coronary Artery DiseaseBraunwald E,Domanski MJ,Fowler SE et al.Angiotensin-converting enzymeInhibition in stable coronary artery disease.NEJM 2004;351:2058-69P=0.438290 pts randomized4mg trandolapril or placeboPrimary endpoint:Death from CV causes,MI,Or coronary revascularizationRenin-Angiotensin-Aldosterone System BlockadeACEI-LVEF40%,HT,DM,or CKD-Low-risk,normal LVEF,optionalARB-ACEI intolerant-Combination with ACEI in systolic heart failureAldosterone blockade-post-MI patients,on ACEI and blocker,either DM or heart failure,LVEF40%-BlockersMI,ACS,or LVD with or without heart failure symptoms(I,A)All other patients with coronary or other vascular disease or diabetes(IIa,C)Framingham Heart Study2489 men and 2856 women30-74 yo12 years FU383 men and 227 womenDeveloped CHD12 European cohort205178 subjects18 years FU7934 CV deathsCardiovascular Diseases-Mortality Rate in Hong KongMortality ratePer 100,000?