1. Not Again! Secondary Prevention of Future Cardiovascular Events J. Clay Hays, Jr., MD, FACC

2. 56 yr old insurance man Presents with chest tightness after playing golf. Trying to walk 18 holes Hypertension on diuretics Not diabetic Unsure of lipids Smoker 82 year old mother with CHF, father died of stroke at 79 years old

3. 56 year old man Heart rate 100 beats/ min BP 154/92 511; 230 lbs; BMI 32 Soft right carotid bruit Clear lungs Regular rhythm with soft apical systolic murmur; soft s4

4. 56 year old man Obese Cant feel aorta, no bruits 1+ pedal pulses EKG sinus, nonspecific st-t wave changes Trop 10 What next?

5. Diagnostics 80% circumflex lesion with mild disease elsewhere Placed 3.0x 12mm Taxus drug eluting stent EF 45% with inferior wall hypokinesis 30% right carotid lesion by ultrasound Tchol 205, HDL 27, Trig 425

6. What do you do?

8. ASCVD Coronary Artery Disease Peripheral Arterial Disease Carotid Arterial Disease Atherosclerotic Aortic Disease

9. Benefits of Aggressive Risk Factor Reduction Improves survival Reduces recurrent events Reduces need for further intervention Improves quality of life

10. Smoking Goal Complete Cessation No exposure to environmental tobacco smoke

11. Recommendations Ask about tobacco use at every visit. I(B) Advise user to quit. I(B) Assist with counseling and a plan. I(B) Arrange for followup, referral, or pharmacotherapy. I(B) Avoid exposure at home or work. I(B)

12. Blood Pressure Control Goal <140/90 Or <130/80 if diabetic or chronic kidney disease

13. Recommendations For all patients Weight control Increased activity Alcohol moderation Sodium reduction Increased fruit intake Increased veggies Low fat dairy

14. Recommendations For hypertensive patients Initially treat with B blockers and/or ACEI Add other drugs such as thiazides prn to achieve goal

15. Lipid Management Goal LDL-C < 100 If Triglycerides are >200, non-HDL-C should be < 130 (Total cholesterol – HDL)

16. For all patients Start diet therapy I(B) Reduce saturate fat (<7% of total calories) Reduce trans-fatty acids Reduce to total cholesterol <200 mg/dl Add plant sterols (2g/d) and fiber (>10g/d) Promote daily activity and weight reduction Omega 3 (1g/d), more if trig are up. II(B)

17. For lipid management Assess fasting lipids within 24 hrs for patients with acute events. Initiate medication before discharge according to : LDL should be <100 (IA) and <70 is reasonable (IIaA) See attached table

18. Physical Activity Goal 30 minutes, 7 days per week (Minimum 5 days per week)

19. Physical Activity All patients Assess risk with physical activity history and/or exercise test to guide prescription 30 to 60 mins of moderate intensity I(B) 2 days/ week of resistance training. IIb (C) Medical supervision for high risk patients I(B)

20. Weight Management Goal BMI: 18.5 to 24.9kg/m2 Waist circumference: Men <40 inches, Women < 35 inches

21. Weight management Assess BMI on each visit Encourage diet and exercise I(B) Consider treatment strategies for metabolic syndrome I(B) Initial goal to reduce 10% from baseline weight I(B)

22. Diabetes Management Goal HbA1C <7%

23. Antiplatelet agents Aspirin 75 to 162 mg/d in all patients I(A) For CABG, start ASA within 48 hrs to reduce chance of graft closure. 162 to 325mg for up to one year Clopidogrel 75 mg/d with ASA for up to 1 year after an acute event

24. Plavix and ASA after PCI ASA 325 with Plavix 75 mg/day 1 month with bare metal stents 3 months with Cypher stents 6 months with Taxus stents

25. Warfarin INR 2.0-3.0 Paroxysmal atrial fib Chronic atrial fib or flutter Post MI patient with LV thrombus

26. ACE Inhibitors LV dysfunction <40% Hypertension Diabetes Chronic Kidney disease Optional for patients with normal LV function and good control of other risk factors

27. Angiotensin Receptor Blockers Intolerant to ACEI and have CHF or MI with EF <40% Intolerant to ACEI Combined with ACEI in pts with systolic- dysfunction heart failure

28. Aldosterone Blockade Post MI patients, without renal dysfunction or hyperkalemia, who are on ACEI and B blocker, have EF <40% and have diabetes or CHF. I(A)

29. Beta blockers All patients with MI, Acute coronary syndrome, or LV dysfunction Continue indefinitely Consider in other forms of vascular disease

30. Influenza Vaccination All patients with any form of ASCVD Have you had yours?

31. Questions?