1. American College of Cardiology, Puerto Rico Chapter Guidelines Applied to Practice (GAP)

2. February 6, 2006 Eduardo J. Viruet M.D., F.A.C.C. Eduardo J. Viruet M.D., F.A.C.C. American College of Cardiology Puerto Rico Chapter Guías de Cardiología Aplicadas a la Práctica Casos Clínicos

3. 68-year-old man with history of dyslipidemia, arterial hypertension and Diabetes Mellitus II 68-year-old man with history of dyslipidemia, arterial hypertension and Diabetes Mellitus II Chest discomfort associated to strenuous physical activity Chest discomfort associated to strenuous physical activity LDL levels = 170 mg/dl LDL levels = 170 mg/dl What is the adequate initial therapy? What preventive measures should be taken ?

4. Pharmacotherapy for Chronic Stable Angina Pectoris Pharmacotherapy to Prevent MI and Death Pharmacotherapy to Reduce Ischemia and Relieve Symptoms

5. Pharmacotherapy for Chronic Stable Angina Pectoris Therapy to Prevent MI and Death Aspirin Aspirin Beta Blockers Beta Blockers Statins Statins ACE inhibitors ACE inhibitors

6. Pharmacotherapy for Chronic Stable Angina Pectoris Therapy to Reduce Ischemia and Relieve Symptoms Nitrates Beta Blockers Beta Blockers Calcium channel Blockers Calcium channel Blockers

7. Pharmacotherapy for Chronic Stable Angina Pectoris ABCDE Formula – ASA and antianginal – Beta-blockers and blood pressure – Cholesterol and cigarettes – Diet and diabetes mellitus – Education and exercise

8. Goal: Complete Cessation and No Exposure to Environmental Tobacco Smoke Cigarette Smoking Recommendations Ask about tobacco use status at every visit. Advise every tobacco user to quit. Assess the tobacco user’s willingness to quit. Assist by counseling and developing a plan for quitting. Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion. Urge avoidance of exposure to environmental tobacco smoke at work and home.

9. Goal: <140/90 mm Hg or <130/80 if diabetes or chronic kidney disease Blood Pressure Control Recommendations Blood pressure 120/80 mm Hg or greater:  Initiate or maintain lifestyle modification: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits vegetables and low fat dairy products Blood pressure 140/90 mm Hg or greater (or 130/80 or greater for chronic kidney disease or diabetes)  As tolerated, add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors with addition of other drugs such as thiazides as needed to achieve goal blood pressure

10. Physical Activity Recommendations Assess risk with a physical activity history and/or an exercise test, to guide prescription Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF) Goal: 30 minutes 7 days/week, minimum 5 days/week

11. Lipid Management Goal LDL-C should be less than 100 mg/dL Further reduction to LDL-C to < 70 mg/dL is reasonable *Non-HDL-C = total cholesterol minus HDL-C If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*

12. Risk CategoryLDL-C and non-HDL- C Goal Initiate TLC Consider Drug Therapy High risk: CHD or CHD risk equivalents (10-year risk >20%) and <100 mg/dL if TG > 200 mg/dL, non-HDL-C should be < 130 mg/dL  100 mg/dL >100 mg/dL (<100 mg/dL: consider drug options) Very high risk: ACS or established CHD plus: multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors <70 mg/dL, non-HDL-C < 100 mg/dL All patients>100 mg/dL (<100 mg/dL: consider drug options) Grundy, S. et al. Circulation 2004;110:227-39. Lipid Management Goals: NCEP ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol, TLC=Therapeutic lifestyle changes

13. Lipid Management Recommendations If baseline LDL-C > 100 mg/dL, initiate LDL-lowering drug therapy If on-treatment LDL-C > 100 mg/dL, intensify LDL- lowering drug therapy (may require LDL lowering drug combination) If baseline is LDL-C 70 to 100 mg/dL, it is reasonable to treat to LDL < 70 mg/dL Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event. For patients hospitalized, initiate lipid-lowering medication as recommended below prior to discharge according to the following schedule: When LDL lowering medications are used, obtain at least a 30-40% reduction in LDL-C levels.

14. Lipid Management Recommendations If TG are 200-499 mg/dL, non-HDL-C should be < 130 mg/dL Further reduction of non-HDL to < 100 mg/dL is reasonable Therapeutic options to reduce non-HDL-C: More intense LDL-C lowering therapy I (B) or Niacin (after LDL-C lowering therapy) IIa (B) or Fibrate (after LDL-C lowering therapy) IIa (B) If TG are > 500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy. Achieve non-HDL-C < 130 mg/dL, if possible

15. Weight Management Recommendations Goal: BMI 18.5 to 24.9 kg/m2 Waist Circumference: Men: < 40 inches Women: < 35 inches Assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/ reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated. If waist circumference (measured at the iliac crest) >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. With success, further weight loss can be attempted if indicated. *BMI is calculated as the weight in kilograms divided by the body surface area in meters 2. Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.

16. Diabetes Mellitus Recommendations Goal: Hb A1c < 7% Lifestyle and pharmacotherapy to achieve near normal HbA1C (<7%). Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended). Coordinate diabetic care with patient’s primary care physician or endocrinologist. ) HbA1c = Glycosylated hemoglobin

17. Guías de Cardiología Aplicadas a la Práctica Casos Clínicos 65-year-old woman with history of Diabetes Mellitus II, and arterial hypertension 65-year-old woman with history of Diabetes Mellitus II, and arterial hypertension Chest discomfort and fatigue at minimal physical activity on optimal medical therapy Chest discomfort and fatigue at minimal physical activity on optimal medical therapy Patients also complains of leg swelling, 2 pillows orthopnea, dyspnea on exercise Patients also complains of leg swelling, 2 pillows orthopnea, dyspnea on exercise What will be the adequate diagnostic test?

18. Invasive Testing in Chronic Stable Angina Recommendations for Coronary Angiography Patients with disabling (Canadian Cardiovascular Society [CCS] classes III and IV) chronic stable angina despite medical therapy Patients with high-risk criteria on clinical assessment or noninvasive testing regardless of anginal severity

19. Invasive Testing in Chronic Stable Angina Recommendations for Coronary Angiography Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia Patients with angina and symptoms and signs of congestive heart failure

20. Guías de Cardiología Aplicadas a la Práctica Casos Clínicos 64 years old male with history of arterial hypertension and chronic smoking 64 years old male with history of arterial hypertension and chronic smoking Complaining of chest pain with moderate physical activity Complaining of chest pain with moderate physical activity Baseline EKG shows CLBBB Baseline EKG shows CLBBB What will be the adequate diagnostic test?

21. Cardiac Stress Imaging in Patients With Chronic Stable Angina Abnormal rest ECG or are using digoxin LBBB or electronically paced ventricular rhythm Prior revascularization (either PCI or CABG) pre-excitation Wolff-Parkinson-White syndrome or more than 1 mm of rest ST depression

22. Guías de Cardiología Aplicadas a la Práctica Casos Clínicos 48 years old male with history of arterial hypertension and dyslipidemia 48 years old male with history of arterial hypertension and dyslipidemia Family history of premature CAD Family history of premature CAD Complains of neck and left shoulder pain with moderate exercise Complains of neck and left shoulder pain with moderate exercise

23. Guías de Cardiología Aplicadas a la Práctica Casos Clínicos EKG with inverted T waves in anterior leads EKG with inverted T waves in anterior leads Exercise stress test with myocardial perfusion showed stress induced large anterior ischemic defect Exercise stress test with myocardial perfusion showed stress induced large anterior ischemic defect What is the next step of therapy?

24. High-risk criteria on noninvasive testing Severe resting left ventricular dysfunction (LVEF < 35%) High-risk treadmill score (score ≤-11) Severe exercise left ventricular dysfunction (exercise LVEF <35%)

25. High-risk criteria on noninvasive testing Stress-induced large perfusion defect Stress-induced multiple perfusion defects of moderate size Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201)

26. High-risk criteria on noninvasive testing Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium- 201) Echocardiographic wall motion abnormality (involving greater than two segments) developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min) Stress echocardiographic evidence of extensive ischemia

27. Guías de Cardiología Aplicadas a la Práctica Casos Clínicos 68 years old female with history of Diabetes Mellitus II and dyslipidemia 68 years old female with history of Diabetes Mellitus II and dyslipidemia History of “heart attack “ in the past History of “heart attack “ in the past EKG shows inferior Q waves EKG shows inferior Q waves Asymptomatic at this moment Asymptomatic at this moment What is the next step of therapy? What is the next step of therapy?

28. Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients Aspirin in the absence of contraindication in patients with prior MI Beta blockers as initial therapy in the absence of contraindications in patients with prior MI

29. Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients Low-density lipoprotein-lowering therapy in patients with documented CAD and LDL cholesterol greater than 130 mg/dL, with a target LDL of less than 100 mg/dL ACE inhibitor in patients with CAD1 who also have diabetes and/or systolic dysfunction

30. American College of Cardiology, Puerto Rico Chapter Guidelines Applied to Practice (GAP)

31. San Juan Intercontinental; Febrero 6: Eduardo J. Viruet MD Casa del Médico, Mayaguez; Febrero 7: Francisco Jaume MD Casa del Médico, Ponce; Febrero 8: Nélida González MD American College of Cardiology Puerto Rico Chapter GAP Casos Clínicos