Cardiovascular Disease Prevention. Autumn Primary Care Conference November 13, 2009

Cardiovascular Disease Prevention Autumn Primary Care Conference November 13, 2009 John A. Merenich, MD, FACP Medical Director, CO KP Lipid Resource ...
Author: Jewel Watkins
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Cardiovascular Disease Prevention Autumn Primary Care Conference November 13, 2009

John A. Merenich, MD, FACP Medical Director, CO KP Lipid Resource Team & Clinical Pharmacy Cardiac Risk Service Medical Director, CO Clinical Informatics & Decision Support Clinical Lead, National KP Integrated Cardiovascular Disease Initiative

Associate Clinical Professor of Medicine, U Colorado 1

Objectives Use shared decision making and collaborative care planning to apply components of integrated CVD management to individual patient total cardiovascular health. Identify and develop possible solutions to patient adherence issues. Implement population-based strategies to increase the number of panel members with a CV risk assessment. Determine, based on application of the latest evidence, appropriate LDL goals, glycemic control, aspirin use, and hsCRP use for panel patients at risk for CV disease.

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Methodol ogy Utilize case studies Call on clinical content experts for their views and recommendations Highlight the wide range of tools already available Focus on key clinical issues The need for Integrated CVD for individuals & populations Global CVD assessment to identify those at highest risk Statins as a cornerstone of therapy for most high risk groups The effectiveness of statins + niacin when combo therapy needed Update on hsCRP, aspirin therapy role in primary prevention, and glucose control/CVD in patients with diabetes Medication ADHERENCE!!!!

Prob lem f ormulati ons Cardiovascular disease remains a major source of morbidity, mortality, and cost for our patients, system, and payors/employers

KP Northern Cal iforni a and Col orado CA D Cos t D at a

Prob lem f ormulati ons Cardiovascular disease remains a major source of morbidity, mortality, and cost for patients, our system, and payors/employers Focus on “secondary prevention” is arbitrary (especially as relates to pathophysiology) and limits our ability to reduce outcomes CVD must be approached “end to end”

The Progressive Development of Cardiovascular Disease Risk Factors Endothelial Dysfunction Atherosclerosis CAD Myocardial Ischemia Coronary Thrombosis Myocardial Infarction Arrhythmia & Loss of Muscle Remodeling Ventricular Dilation Congestive Heart Failure End stage Heart Disease

The Prevention Continuum: ICVD Currently Targets High Risk and Stable Disease Members Integrated CVD Program

Target Population

Intervention

Healthy/ Low Risk

AtRisk

Health Promotion

Primary Prevention

Adapted from Source: Halverson, Isham

High Risk

End Stable Stage Prevalent Disease Disease

Secondary PreventionImplementation Current Focus

Prob lem f ormulati ons Cardiovascular disease remains a major source of morbidity, mortality, and cost for patients, our system, and payors/employers Focus on “secondary prevention” is arbitrary and limits our ability to reduce outcomes CVD must be approached “end to end”

CVD health is not just lipid management Residual risk Population attributable risk

RESIDUAL RISK: Percentage of patients experiencing major coronary events in several large outcomes studies

Libby, P. J Am Coll Cardiol 2005;46:1225-1228

INTERHEART: Summar y 1. 2.

3.

Nine simple risk factors are strongly associated with AMI worldwide. These risk factors are even more important in the young, and their effects are consistent in men and women, across all ethnic groups and all regions. Abnormal Apo-B/ApoA-1 ratio and smoking are the most important risk factors and account for >2/3 of the PAR. All 9 risk factors account for >90% of the PAR globally and in most regions.

IMPLICATIONS: Implementing preventive strategies based on our current knowledge would avert the majority of premature CHD worldwide.

INTERHEART: Risk Factor Impact by Age

Smoking Fruit/Veg Exercise Alcohol Hypertension Diabetes Abd Obesity All Psych ApoB/ApoA-1 All 9 RF

Odds Ratio Young Old 3.33 2.44* 0.69 0.72 0.95 0.79 1.00 0.85 2.24 1.72* 2.96 2.05* 1.79 1.50 2.87 2.43 4.35 2.50* 216.47 81.99*

P for interactions: *p

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