Medical Management of Atherosclerosis • Scope of the problem
Medical Management of Atherosclerosis Rishad M. Faruqi MD, FRCS (Eng), FRCS (Ed), FACS Dept. of Vascular Surgery Kaiser Permanente Santa Clara Clinical Associate Professor University of CA, San Francisco Clinical Associate Professor Stanford University
Medical Management of Atherosclerosis • Scope of the problem • Management of risk factors and evidence • PHASE program in NCAL • Impact on vascular surgical practice
Medical Management of Atherosclerosis • • • • •
Mortality from cardiovascular disease is declining. Overall incidence of MI has not declined. Increasing incidence of MI in women. Ageing population in developed countries. Cardiovascular disease is the leading cause of death worldwide.
• Management of risk factors. • PHASE program in NCAL • Impact on vascular surgical practice
Medical Management of Atherosclerosis “Heart Heart disease and stroke are the leading causes of death in the United States. Although most cardiovascular disease (CVD) is preventable, proven prevention approaches are not being adequately applied in clinical practice.” practice.” –Elias Zerhouni, MD, Director, National Institutes of Health April, 2004
Medical Management of Atherosclerosis
REACH REGISTRY Reduction of Atherothrombosis for Continued Health Registry (REACH) JAMA. March 21, 20072007-vol 297, No 11;119711;1197-1206
Medical Management of Atherosclerosis • 68,236 patients • Group I with disease (CAD, CVD, PAD): 55,814 • Group II with at least 3 risk factors: factors: 12,422
• • •
5587 physician practices 44 countries From 20032003-2004
Medical Management of Atherosclerosis • CV Death, MI or CVA rate: 4.24% overall • Group I=4.69% – 4.52%(CAD); 5.35%(PAD); 6.47% (CVD)
• Group II=2.15%
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
• Add end point “hospitalization for atheroathero-thrombotic event” event”: – Gp I: 15.20% (CAD); 21.14% (PAD); 14.53% (CVD) • Event rate was directly proportional to the number of vascular beds involved.
Medical Management of Atherosclerosis
What are the main diseases that lead to mortality/morbidity?
Medical Management of Atherosclerosis
• Coronary artery disease • Cerebrovascular disease • Peripheral arterial disease • Aneursym disease
Medical Management of Atherosclerosis
What are the main risk factors?
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis • • • • • •
Age Hyperlipidemia/dyslipidemia Diabetes Mellitus Hypertension Smoking CKD
Medical Management of Atherosclerosis
How can we evaluate risk?
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
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Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
IMPACT OF GENDER ON RISK PROFILE
Male nonnon-smoker or nonnon-diabetic male = Female smoker or diabetic female
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis • Scope of the problem • Management of risk factors and evidence. • PHASE program in NCAL • Impact on vascular surgical practice
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
• LipidLipid-lowering therapy • Antiplatelet/antithrombotic therapy • Antihypertensive therapy
Simvastatin versus placebo in highhigh-risk individuals
Medical Management of Atherosclerosis • • • • • • • •
N=20,536 4040-80 years of age CAD or other occlusive disease Or DM Simvastatin 40 mg versus Placebo Analyzed on an “intention to treat basis” basis” 5 year follow up Mortality, fatal and nonnon-fatal vascular events, cancer and other morbidity.
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis End Point Drug Placebo p value All cause mortality 12.9% 14.7% 0.0003** Coronary Death 5.7% 6.9% 0.0005** Other vasc death 1.9% 2.2% 0.07* Non5.3% 5.7% 0.4 (NS) Non-vasc death First Event MI 8.7% 11.8% 0.0001** First Event CVA 4.3% 5.7% 0.0001** Revascularization 9.1% 11.7% 0.0001** Cancer: No difference Myopathy incidence was 0.01% in the Simvastatin group.
Medical Management of Atherosclerosis
Overall, about a 25 % reduction in MI, CVA and revascularization, regardless of cholesterol level.
Medical Management of Atherosclerosis
Medical Management of Atherosclerosis
SPARCL
Medical Management of Atherosclerosis SPARCL
• Atorvastatin group (all levels are mg/dL):
•Randomized, blinded, international study •4,731 patients stroke or TIA within 11-6 months, LDL 100100-190, no coronary, disease/cardiac SOE • Atorvastatin (80 mg/day) vs. placebo •Fatal or nonfatal stroke over 5 years
Medical Management of Atherosclerosis
Fatal or Nonfatal Stroke (%)
16
Atorvastatin
8 4
HR, 0.84 (95% Cl, 0.710.71-0.99; P = .03) 1
2 3 4 5 Years Since Randomization
112
• Placebo group: – LDL: 134 129 – HDL: 50 51 – Triglycerides: 143
145
Medical Management of Atherosclerosis Simvastatin
Placebo
12
0
– LDL: 133 73 – HDL: 50 52 – Triglycerides: 144
Fatal or NonNon-fatal Stroke
SPARCL
0
Medical Management of Atherosclerosis
Placebo
Adjusted P value
Major Coronary event
81 (3.4%)
120 (5.1%)
Any Coronary event
334 (14.1%)
407 (17.2%)
0.003 0.002
Major CV event
123 (5.2%)
204 (8.6%)
5,000 MDs 17 medical centers 35 OP facilities
Medical Management of Atherosclerosis Secondary Prevention Population Approximately 11% adults in KPKP-NCAL • • • • • • • • •
DM Diabetes CAD Coronary Artery Disease CVA Cerebrovascular Accident or TIA Transient Ischemic Attack AAA Abdominal Aortic Aneurysm PAD Peripheral Arterial Disease CKD Chronic Kidney Disease if age > 50 and – GFR < 30 or – GFR 3030-60, plus proteinuria
Medical Management of Atherosclerosis 4 Drug Interventions Antithrombotic Medication – Treatment with Aspirin 8181-325 mg daily for patients unless contraindicated
– If contraindicated, consider clopidogrel
Lipid Lowering Medications – Treatment with statin is recommended even if LDLLDL-C is
