After ACS/Complex PCI Optimizing Patient Outcomes From Medicines to Rehab… How do we make it happen? Donna L. Hunn Adult Nurse Practitioner Accreditation Clinical Manager Society of Chest Pain Centers

After achieving an excellent angiographic result... What’s next?

Secondary Prevention after ACS What is secondary prevention? How does it benefit the patient? What have we learned from the clinical trials? What do the practice guidelines tell us? What are the CMS core measures? Whose responsibility is it?

AHA/ACC The AHA/ACC consensus statement supports the merits of aggressive risk-reduction therapies in improving survival, reducing recurrent events and the need for interventional procedures, and improving quality of life in patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease.

Classification of Recommendations and Level of Evidence Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective Class II: Conditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment

Classification of Recommendations Class II a Weight of evidence/opinion is in favor of usefulness/efficacy Class II b Usefulness/efficacy is less well established by evidence/opinion Class III Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful

Level of Evidence Level of Evidence A: Data derived from multiple randomized clinical or meta-analysis Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies Level of Evidence C: Only consensus opinion of experts, case studies, or standard of care

ACC/AHA Practice Guidelines Secondary Prevention Class I/Level of Evidence A Patients who survive the acute phase of STEMI should have plans initiated for secondary prevention therapies

2011 ACCF/AHA SCAI Guideline for Percutaneous Coronary Intervention: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiograpy Interventions

AHA/ACCF Secondary Prevention and Risk Reduction and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: A Guideline From the American Heart Association and American College of Cardiology Foundation

Post Procedural Antiplatelet Therapy Class I After PCI, use of aspirin should be continued indefinitely (LOE: A) Duration of P2Y12 inhibitor therapy after stent implantation BMS or DES during PCI for ACS at least 12 months Clopidogrel 75 mg daily Prasugrel 10 mg daily Ticagrelor 90 mg twice daily (LOE: B)

Post Procedural Antiplatelet Therapy Class I Patients should be counseled on the importance of compliance with DAPT and that therapy should not be discontinued before discussion with their cardiologist. (Level of Evidence: C)

DAPT Compliance and Stent Thrombosis Class III HARM (Level of Evidence: B) PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with DAPT for the appropriate duration of treatment based on the type of stent implanted.

Benefits of Antiplatelet Therapy Reduction in all cause mortality Reduction in vascular mortality Decrease risk of non-fatal reinfarction Decrease risk of non-fatal stroke Decrease risk of any serious vascular event myocardial infarction stroke vascular death

Stent Thrombosis The most common cause of acute stent thrombosis is nonadherence to DAPT Resistance to Aspirin orThienopyridines Prothrombotic States Congenital or acquired thrombophylic states

Risks of Smoking Leading preventable cause of CAD and death in the industrialized world. Adverse effects on platelet function and production of carboxyhemoglobin Causes acute endothelial dysfunction

Smoking Goal Complete Cessation No exposure to environmental tobacco smoke Intervention Recommendations Assess tobacco use Strongly encourage patient and family to stop smoking and to avoid secondhand smoke Provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and formal smoking cessation

Benefits of Cessation Decrease mortality Reduce risk of reinfarction Reduce risk of sudden death Reduce post-infarction angina

Blood Pressure Control Goal less than 140/90 mmHg less than 130/80 mmHg if chronic kidney disease or diabetes Intervention Recommendations If blood pressure is 120/80 mmHg or greater Lifestyle modifications weight control physical activity alcohol moderation moderate sodium restriction emphasis on fruits, vegetable, and low-fat dairy products

Blood Pressure Control If blood pressure is 140/90 mmHg or greater or 130/80 mmHg or greater for individuals with chronic kidney disease or diabetes: Add blood pressure-reducing medications beta-blockers inhibitors of the renin-angiotensin-aldosterone system

Beta-Blockers Decrease Heart Rate Decrease Blood Pressure Decrease myocardial contractility Improve ventricular diastolic relaxation Reduce myocardial oxygen consumption Extensive clinical trial evidence show decreased post MI mortality, specifically sudden cardiac death

Beta-Blockers Coreg/Carvedilol Lopressor/Metoprolol Toprol XL starting dose 3.125 mg bid target dose 25 mg bid Lopressor/Metoprolol starting dose 12.5 mg q 6 hours target dose 100 mg bid Toprol XL target dose 200 mg daily Dose titration dependant on heart rate and blood pressure

Angiotensin-Converting Enzyme Inhibitors Decrease oxidative stress Improve fibrinolytic balance Reduce platelet activity Lower plasminogen activator inhibitor levels Decrease migration of macrophages Reduce proliferation of vascular smooth muscle Reduce MI size Retard detrimental LV remodeling Reduce incidence of sudden cardiac death

Angiotensin-Converting Enzyme Inhibitors Altace/Ramipril starting dose 2.5 mg daily target dose 10 mg daily Lotensin/Benazepril starting dose 5-10 mg daily target dose 20-80 mg as a single dose or two divided doses Dose titration dependant on renal function, potassium level and blood pressure

Angiotensin Receptor Blockers Indicated in patients who are intolerant of ACE inhibitors and with either clinical or radiological signs of heart failure or LVEF < 40

Aldosterone Blockers To be considered in patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF less than or equal to 40, and have either diabetes or heart failure

Lipid Management TG less than 200mg/dL Primary Goal: LDL-C substantially less than 100 mg/dL Start dietary therapy in all patients (less than 7% of total calories as saturated fat and less than 200 mg/d cholesterol) Promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids

Lipid Management TG less than 200mg/dL Intervention/Recommendation Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI Add drug therapy according to guidelines: LDL-C less than 100 mg/dL (baseline or on treatment): Statins should be used to lower LDL-C LDL-C greater than or equal to 100 mg/dL (baseline or on treatment): Intensify LDL-C-lowering therapy with drug treatment, giving preference to statins

Lipid Management TG 200mg/dL or greater Primary Goal: Non-HDL-C substantially less than 130 mg/dL Intervention/Recommendations: If TG > 150 mg/dL or HDL-C is less than 40 mg/dL: Emphasize weight management and physical activity Advise Smoking Cessation If TG is 200-499 mg/dL: after LDL-C lowering therapy, consider adding fibrate or niacin If TG > 500 mg/dL consider fibrate or niacin before LDL-C-lowering therapy consider omega-3 fatty acids as adjunct therapy for high TG

Physical Activity Goal: At least 30 minutes, 7 days per week Minimum 5 days per week Intervention Recommendations Assess risk, by a physical activity history and/or an exercise test to guide prognosis and prescription Encourage minimum of 30-60 minutes of activity, preferably daily but at least 5 times weekly walking, jogging, cycling, or other aerobic activity supplemented by an increase in daily lifestyle activities

Physical Activity Cardiac rehabilitation All eligible patients with ACS/post CABG/post PCI Particularly those with multiple modifiable risk factors and/or those moderate-high risk patients in whom supervised exercise training is warranted

Cardiac Rehabilitation Involves multifactorial longterm interventions: Education Counseling Behavioral intervention Risk factor modification Exercise prescription Reduces mortality Reduces symptoms Improves well-being

Weight Management Goal BMI 18.5- 24.9 kg/m2 Waist Circumference: Women: less than 35 inches Men: less than 40 inches

Weight Management Intervention Recommendations Calculate BMI and waist circumference as part of evaluation Monitor response of BMI and waist circumference to therapy If waist circumference is >35 inches in women or >40 inches in men: initiate lifestyle changes and treatment strategies for metabolic syndrome

Diabetes Management Goal Intervention Recommendations HbA1C less than 7% Intervention Recommendations Coordinate care with PCP/endocrinologist Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose as indicated by HbA1C. Lifestyle Modification: Physical activity Weight management Blood pressure control Lipid Management

Influenza Vaccination Class I Patients with cardiovascular disease should have an annual Influenza vaccination (Level of Evidence: B)

Depression Class IIa Post CABG or Post MI Reasonable to screen for depression Utilize case management Collaborate with PCP/Mental Health Specialist (Level of Evidence: B)

Acute MI National Hospital Inpatient Quality Measures Aspirin at Arrival Aspirin Prescribed at Discharge ACEI or ARB for LVSD Adult Smoking Cessation Advice/Counseling Beta-Blocker Prescribed at Discharge Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival Primary PCI Received Within 30 Minutes of Hospital Arrival

Euroaspire III Data Highlight Ongoing Failures in Primary and Secondary Prevention May 7, 2010 (Prague, Czech Republic) - The latest results from European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroASPIRE III) survey should hammer home the message that despite all of the drugs available to ward off primary and secondary cardiovascular events, an exploding population of people both with and without a history of coronary events is failing to reach risk-factor targets.

Whose Responsibility Is It? Cardiologist/PCP Hospitalist Nurse Practitioner/PA Nurse Case manager Social worker Homecare Dietician Mental health specialist Diabetic educator Exercise physiologist Pharmacist

Thank you for your attention!