1. 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

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

3. 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?

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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)

13. 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.

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. Beta-Blockers Coreg/Carvedilol Lopressor/Metoprolol Toprol XL
starting dose 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

23. 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

24. 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 mg as a single dose or two divided doses
Dose titration dependant on renal function, potassium level and blood pressure

25. 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

26. 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

27. 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

28. 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

29. 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 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

30. 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 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

31. 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

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

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

34. 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

35. 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

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

37. 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)

38. 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

39. 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.

40. 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

41. Thank you for your attention!