CVD Treatment Guidelines and MNT

CVD Treatment Guidelines and MNT - Cardiovascular Disease...

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Unformatted text preview: Cardiovascular Disease: Cardiovascular Disease: Prevention and Treatment Dietary Factors that Affect Dietary Factors that Affect Blood Lipids Saturated Fatty Acids Saturated Fatty Acids Elevate blood cholesterol in all lipoprotein fractions (LDL and HDL) when substituted for CHO or other fatty acids Dose­response between SFA and LDL­C – For every 1% of energy intake increase in sfa, plasma cholesterol increases 2.7% Most hypercholesterolemic sfas are lauric (C12:0) myristic (C14:0) and palmitic (C16:0) (palmitic is 60% of sfa intake) Stearic (C18:0) is neutral Saturated Fatty Acids Saturated Fatty Acids The most hypercholesterolemic fats are palm kernel, coconut and palm oils, lard, and butter SFAs also associated with CAD progression: milk, cheese, butter, lamb, bakery goods, fast foods, snacks Average American intake is 11% of kcals Polyunsaturated Fatty Polyunsaturated Fatty Acids If CHO is replaced by linoleic acid (C18:2) LDL­C ↓ and HDL­C ↑ When SFA is replaced by PUFA in a low fat diet, both LDL and HDL ↓ Eliminating SFA is twice as effective in lowering cholesterol as ↑ PUFA A 1% increase in PUFA ↓ TC by 1.4 mg/dl Polyunsaturated Fatty Polyunsaturated Fatty Acids Major source of omega­6 PUFAs are vegetable oils, salad dressings, and margarines made with the oil U.S. population intake 7% of calories Large amounts may increase LDL oxidation Omega­3 Polyunsaturated Omega­3 Polyunsaturated Fatty Acids: EPA, DHA Found in fish oils, fish oil capsules, and ocean fish (eicosapentaenoic and docosahexaenoic acid) Do not affect TC; may ↑ LDL­C (5­10%) and decrease TG (25­30%) especially in patients with high TG Anticoagulant effect Decrease vasoconstriction Improve endothelial dysfunction Reduce inflammation Omega­3 Fatty Acids: ALA Omega­3 Fatty Acids: ALA Alpha­linolenic acid An essential fatty acid Shorter­chain found in various plant sources such as flax, canola, walnuts, and soy Benefits less clear; may protect against CVD by reducing inflammation Omega­3 Fatty Acids Omega­3 Fatty Acids Consumption of fish and fish oils rich in EPA, DHA will lower cholesterol, LDL, and TG and reduce sudden cardiac death One fatty fish meal/week resulted in 50% decrease in risk of cardiac arrest 1 g supplement of omega­3 daily reduced risk of CVD, nonfatal MI, nonfatal stroke Cis­Monounsaturated Fat Cis­Monounsaturated Fat Naturally occurring monounsaturated fat Found in olive oil, canola oil, avocado, olives, pecans, peanuts, and other nuts Oleic acid is the most prevalent MFA in the US diet Cis­Monounsaturated Fat Cis­Monounsaturated Fat When fat is replaced by CHO, it lowers HDL as well as LDL­C When sfa is replaced by mfa, lowers LDL­C without lowering HDL­C When substituted for carbohydrate, mfa reduces serum triglyceride levels Can recommend a higher fat diet if much of the fat comes from mfa Cis­Monounsaturated Fat Cis­Monounsaturated Fat Mediterranean diet: high in fat, especially MFA (olive oil), fish, nuts, low in red meat associated with ↓ risk of CVD Emphasizes fruits, root vegetables, flax, canola High fat diets should be used with caution Mediterranean vs Standard Mediterranean vs Standard AHA Low Fat Diet Subjects: 202 post­MI patients 50 put on AHA lowfat diet (30% fat) 51 on Mediterranean (40% fat; fish 3­5 times/week, olive oil, avocado) Both limited to 7% SFA and 200 mg cholesterol/day Both groups received two individual diet counseling sessions in the first month and six group sessions over the next two years. 101 controls given advice in the hospital Tuttle et al, presented at ACC meeting, New Orleans, 3­07 Mediterranean vs Standard Mediterranean vs Standard AHA Low Fat Diet After 4 years 83% of those on either therapeutic diet had survived without problems; cholesterol profile improved in both groups People on either diet had one­third the risk of suffering another heart attack, a stroke, death or other heart problem as controls Those on Mediterranean diet found it harder to stick to (↑ fish, olive oil) 53% of control patients survived without problems; cholesterol profile did not improve Trans­Monounsaturated Trans­Monounsaturated Fats Produced in the hydrogenation process Commonly used in the food industry to harden unsaturated oils and soft margarines 50% of trans­fatty acids come from animal foods (beef, butter, milk fats) Major foods sources in US are stick margarine, shortening, commercial frying fats, high fat baked goods Trans Fatty Acids Trans Fatty Acids Elaidic acid (trans­isomer of oleic acid) raises blood cholesterol compared with PUFA Has less of a cholesterol raising effect than sfa Lowers HDL Margarine vs Butter Margarine vs Butter The combined amount of saturated fat and trans fat in butter is higher than that in margarine Soft or liquid margarine is the preferred spread Average intake of trans fats is 7­8% of total fat intake Choose lowfat desserts, dairy products, meats will lower trans fatty acid intakes Fat Type Per Serving Fat Type Per Serving Product Total Sfa g Butter Stick marg Spread marg Tub marg 7.2 Trans fat g .3 Combi ned 7.5 choles terol 31.1 11 2.1 2.8 4.9 0 9.7 1.8 2.7 4.5 0 6.7 1.2 .6 1.8 0 fat g 10.8 Source: FDA Effects of Various Dietary Fat Effects of Various Dietary Fat Sources on TC:HDL Ratio Mensink RP et al. AJCN 2003;77:1146-1155. Total Fat Content of Diet Total Fat Content of Diet High fat diets are associated with obesity, which increases the risk of CHD Low fat diets (<25% of kcals from fat) raise triglycerides and lower HDL; however these changes are not associated with ↑ risk Low fat diets lower LDL only when they are low in sfa AHA: total fat <30% of kcals ATP III: 25%­35% of kcals from fat Dietary Cholesterol Dietary Cholesterol Dietary cholesterol raises total and LDL­ cholesterol, but less than sfa A 25 mg increase in dietary cholesterol raises serum cholesterol 1 mg/dl At 500 mg intake, increments are even less; appears to be a threshold for response TLC guidelines: <200 mg/day AHA guidelines: <300 mg/day Dietary Cholesterol Dietary Cholesterol Response to dietary cholesterol is highly variable; hyper­responders may have poor rates of conversion of cholesterol to bile acids Dietary intakes of cholesterol have been declining since the 1960s Intake acts synergistically with sfa; positively related to CHD risk Fiber Fiber Soluble fibers (pectins, gums, mucilages, algal polysaccharides, some hemicelluloses) in legumes, oats, fruit and psyllium lower serum cholesterol and LDL­C Quantity needed varies by food (more legumes than pectins or gums) Fiber Fiber Average decline in LDL­C is 14% for hypercholesterolemics and 10% for normocholesterolemics when soluble fiber is added to a low fat diet Fiber may bind bile acids, which lowers serum cholesterol to replete the bile acid pool Fiber Fiber Insoluble fibers have no effect (celluloses and lignin) Of total fiber (25­30 grams) 6 to 10 grams should be from soluble fiber Can be achieved with 5 or more servings of fruits or vegetables a day and 6 or more servings of whole grains and high­fiber cereals Alcohol Alcohol Affects total triglyceride and HDL­C Effects on TG are dose dependent and are greater in persons with TG>150 mg/dl Moderate alcohol consumption has been associated with decreased risk of MI and CHD mortality in white men Alcohol raises both HDL2 and HDL3 subfractions Current intake in US is 2% of total kcals No increase is recommended to decrease CHD risk Coffee Coffee Mixed results in studies on effect of coffee on lipids Heavy intake of regular coffee (720 ml) causes minor increases in TC (9 mg/dl) LDL­C (6 mg/dl) and HDL­C (4 mg/dl) Boiled coffee (European) produces greater elevations than filtered coffee Coffee Coffee Large population studies have failed to find associations between coffee consumption and CHD incidence or mortality Coffee drinkers consume more saturated fat and cholesterol, smoked more cigarettes, and were less likely to exercise Antioxidants Antioxidants Antioxidants have been studied for possible role in preventing oxidation of LDL­C Epidemiological studies suggest vitamin E and carotenoids are inversely related to CVD, but randomized trials have not supported this Vitamin E: no primary or secondary prevention trials show positive effect B­carotene supplements appear to have no benefits Use food sources Calcium Calcium Supplementation produces small decreases in LDL­C in hypercholesterolemic men May form insoluble soaps with fatty acids Soy Protein Soy Protein Substituting soy protein lowers TC (9%) and LDL­C (13%) and TG (11%) with no effect on HDL­C Effect in addition to a Step 1 diet; occurs only in persons with hypercholesterolemia Dose response Daily intake of 25 g of soy will lower LDL­C by 4 to 8% in hypercholesterolemic persons Stanols/Sterols Stanols/Sterols Isolated from soybean oils or pine tree oil Lowers blood cholesterol Esterified and made into margarines Consuming 2­3 grams/day lowers cholesterol by 9­20% in persons with hypercholesterolemia Inhibits absorption of dietary cholesterol Stanols/Sterols Stanols/Sterols Nuts Nuts Tree nuts can reduce risk of CHD via lipid­ lowering effects; Peanuts also cardioprotective Almonds, hazelnuts, pecans, pistachio nuts, and walnuts modestly reduce serum cholesterol Nuts are a rich source of fiber, vitamin E, magnesium, and MUFA and PUFA ALA in walnuts, arginine, and antioxidant and antithrombotic effects May reduce insulin resistance Nuts Nuts Epidemiological evidence suggests an inverse relationship between nut consumption and CHD risk and type 2 diabetes Nurses’ Health Study: women who ate 5+ servings lowered risk of CHD by 45% Nuts Nuts Recommend 1 to 2 ounces of nuts (1 to 2 large handfuls) in place of other sources of energy Choose unsalted, roasted, or raw nuts AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Risk Reduction These recommendations apply to the general public for primary prevention and can be used clinically New focus on weight management More focus on practical strategies for implementation AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Risk Reduction Balance calorie intake and physical activity to achieve or maintain a healthy body weight. Consume a diet rich in vegetables and fruits Choose whole­grain, high­fiber foods Consume fish, especially oily fish, at least twice a week Circulation 2006;114:82­96 AHA 2006 Diet/Lifestyle AHA 2006 Diet/Lifestyle Recommendations for CVD Risk Reduction Limit your intake of SFA to <7% of energy, trans fat to <1% of energy, cholesterol to <300 mg/day by – Choosing lean meats and vegetable alternatives – Selecting fat­free (skim), 1%­fat, and lowfat dairy products, and – Minimizing intake of partially hydrogenated fats Circulation 2006;114:82­96 AHA 2006 Diet and Lifestyle AHA 2006 Diet and Lifestyle Recommendations for CVD Risk Reduction Minimize your intake of beverages and foods with added sugars Choose and prepare foods with little or no salt If you consume alcohol, do so in moderation When you eat food that is prepared outside of the home, follow the AHA Diet and Lifestyle Recommendations Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Know your calorie needs to achieve and maintain a healthy weight Know the calorie content of the foods and beverages you consume Track your weight, physical activity, and calorie intake Prepare and eat smaller portions Track and, when possible, decrease screen time Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Incorporate physical movement into habitual activities Do not smoke or use tobacco products If you consume alcohol, do so in moderation (1 drink/day in women, 2 in men) Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Use the nutrition facts panel and ingredients list when choosing foods to buy Eat fresh, frozen, and canned vegetables and fruits without high­calorie sauces and added salt and sugars Replace high­calorie foods with fruits and vegetables Increase fiber intake by eating beans, whole grain products, fruits and vegetables Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Use liquid vegetable oils in place of solid fats Limit beverages and foods high in added sugars (fructose, sucrose, glucose, maltose, dextrose, corn syrups, concentrated fruit juice, and honey Choose foods made with whole grains Cut back on pastries and high­calorie bakery products (e.g. muffins, doughnuts) Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Select milk and dairy products that are either fat free or lowfat Reduce salt intake by – Comparing the sodium content of similar products and choosing those with less – Choosing processed foods, including cereals and baked goods that are reduced in salt – Limiting condiments, e.g. soy sauce, catsup Circulation 2006;114:82­96 Implementation 2006 AHA Implementation 2006 AHA Diet/Lifestyle Guidelines Use lean cuts of meat and remove skin from poultry before eating Limit processed meats that are high in saturated fat and sodium Grill, bake, or broil fish, meat and poultry Incorporate vegetable­based meat substitutes into favorite recipes Encourage the consumption of whole vegetables and fruits in place of juices Circulation 2006;114:82­96 AHA on Antioxidant AHA on Antioxidant Supplements Antioxidant vitamin supplements or other antioxidants such are selenium are not recommended Although observational studies suggest that high intakes of antioxidant vitamins from food and supplements are associated with lower risk of CVD, intervention trials have not confirmed this Circulation 2006;114:82­96 Antioxidant Supplements Antioxidant Supplements Trials have documented potential harm, e.g. higher risk of lung cancer with beta­carotene supplements in smokers and increased risk of heart failure and total mortality from high dose vitamin E supplements Although supplements are not recommended, food sources of antioxidant nutrients are Circulation 2006;114:82­96 AHA on Soy Protein AHA on Soy Protein Evidence of a direct cardiovascular health benefit from consuming soy protein is minimal However, there may be some benefit if soy protein is used to replace animal and dairy products that contain SFA and cholesterol Circulation 2006;114:82­96 AHA on Folate and Other B AHA on Folate and Other B Vitamins Evidence is inadequate to recommend folate and other B vitamins to reduce heart disease risk Folate intake and B6 and B12 are inversely associated with serum homocysteine levels, which are associated with increased risk of CVD Trials of homocysteine­reducing vitamin therapy have been disappointing Circulation 2006;114:82­96 AHA on Fish Oil AHA on Fish Oil Supplements Fish intake is associated with decreased risk of CVD Patients without documented CHD eat fish, preferably oil fish, twice a week Patients with documented CVD should consume ~1 gram of EPA + DHA per day, preferably from oily fish, though supplements can be considered with physician input Circulation 2006;114:82­96 Fish Oil Supplements Fish Oil Supplements For persons with hypertriglyceridemia, 2 to 4 g of EPA + DHA per day, provided as capsules under a physician’s care are recommended. Circulation 2006;114:82­96 Adult Treatment Panel III Adult Treatment Panel III (NCEP, 2001) First published guidelines 2001 Update published 2004* Raises diabetes as an important risk factor for CHD Uses Framingham projections of 10­year absolute risk to identify patients for more intensive treatment Identifying persons with multiple metabolic risk factors as candidates for therapeutic lifestyle changes *Circulation 2004;110:227­239 ATP III ATP III Targets LDL­C first with TLC When LDL­C goals are met, treat metabolic syndrome by increasing physical activity and decreasing energy intake to facilitate weight loss ATP III Risk Factors That ATP III Risk Factors That Modify LDL Goals Cigarette smoking Hypertension >140/90 mmHg or on medication Low HDL­C (<40 mg/dl) Family history of premature CHD (male first degree relative<55; female<65) Age (men >45 years, women >55 years LDL­C Goals and Cutpoints for TLC LDL­C Goals and Cutpoints for TLC and Drug Therapy by Risk Categories LDL Goal (mg/dL) Risk Category CHD or CHD Risk Equivalents (10­year risk >20%) 2+ Risk Factors (10­year risk ≤ 20%) 0–1 Risk Factor LDL Level to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) <100 Optional Goal: ≥ 100 < 70 mg/dl <130 ≥ 130 LDL Level at Which to Consider Drug Therapy (mg/dL) ≥ 130 (100–129: drug optional) 10­year risk 10– 20%: ≥ 130 10­year risk <10%: ≥ 160 ≥ 190 <160 ≥ 160 (160–189: LDL­ lowering drug optional) Therapeutic Lifestyle Changes in Therapeutic Lifestyle Changes in LDL­Lowering Therapy TLC Diet – Reduced intake of cholesterol­raising nutrients (same as previous Step II Diet) Saturated fats <7% of total calories Dietary cholesterol <200 mg per day – LDL­lowering therapeutic options Plant stanols/sterols (2 g per day) Viscous (soluble) fiber (10–25 g per day) Weight reduction Increased physical activity Steps in Steps in Therapeutic Lifestyle Changes Visit I Visit 2 Evaluate LDL 6 wks response Begin Lifestyle Therapies • Emphasize reduction in saturated fat & cholesterol • Encourage moderate physical activity Visit 3 Evaluate LDL 6 wks response If LDL goal not achieved, intensify LDL-Lowering Tx • Reinforce reduction in saturated fat and cholesterol • Consider adding plant stanols/sterols • Increase fiber intake • Consider referral to • Consider referral to a dietitian a dietitian Q 4-6 mo If LDL goal not achieved, consider adding drug Tx • Initiate Tx for Metabolic Syndrome • Intensify weight mgt & physical activity • Consider referral to a dietitian Visit N Monitor Adherence to TLC The Metabolic Syndrome as a The Metabolic Syndrome as a Secondary Target of Therapy Abdominal obesity Atherogenic dyslipidemia – – – Elevated triglycerides Small LDL particles Low HDL cholesterol Raised blood pressure Insulin resistance (± glucose intolerance) Prothrombotic state Proinflammatory state Therapeutic Lifestyle Therapeutic Lifestyle Changes (TLC) TLC Diet – Saturated fat <7% of calories, cholesterol <200 mg/dal – Consider increased viscous (soluble) fiber (10­25 g/day) and plant stanols/sterols (2g/day) Weight management Increased physical activity Nutrient Composition of TLC Diet Nutrient Composition of TLC Diet Nutrient Saturated fat Polyunsaturated fat Monounsaturated fat Total fat Carbohydrate Fiber Protein calories Cholesterol Total calories (energy) expenditure Recommended Intake Less than 7% of total calories Up to 10% of total calories Up to 20% of total calories 25–35% of total calories 50–60% of total calories 20–30 grams per day Approximately 15% of total Less than 200 mg/day Balance energy intake and to maintain desirable body weight ATP III Recommendations ATP III Recommendations Compared with the American Diet American Diet ATP III Total fat % 25­35 32.8 SFA % 11.3 <7 MUFA 12.5 <20 PUFA 6.4 <10 Cholesterol mg 256 <200 Dietary fiber g 20­30 15.1 Carson JA, Grundy SM, VanHorn L, Stone N. MNT in prevention and management of coronary heart disease. In Carson JS et al. Cardiovascular Nutrition. Am Diet Assoc 2004 TLC Diet TLC Diet Food Amount Breads and cereals >6 servings (adjust to meet energy needs) Vegetables and 3­5 servings vegetables fruits 2­4 servings fruits Dairy products 2­3 servings Eggs <2 yolks per week Meat, fish, poultry <5 ounces per day Fats and oils Adjust to caloric level TLC: Healthy Cooking TLC: Healthy Cooking Bake, steam, roast, broil, stew or boil instead of frying Remove poultry skin before eating Use a nonstick pan with cooking oil spray or small amount of liquid vegetable oil instead of lard, butter, shortening, other solid fats Trim visible fat before you cook meats Chill meat and poultry broth until fat becomes solid, remove TLC Diet: Eat More TLC Diet: Eat More Fresh, frozen, canned vegetables without added fat, sauce, salt Fresh, frozen, canned or dried fruit Nonfat, ½%, and low­fat milk, buttermilk, yogurt, cheese Unsaturated oils, soft or liquid margarines and spreads, salad dressings, seeds and nuts Lean cuts of meat; extra lean hamburger, fish; meat alternatives made with soy or TVP Whole grain breads and cereals, pasta, rice, potatoes, dried beans and peas, lowfat crackers, pretzels, cookies TLC Diet: Eat Less TLC Diet: Eat Less High­fat bakery products (doughnuts, biscuits, croissants, pies, cookies Chips, cheese puffs, snack mix, regular crackers, buttered popcorn Whole and reduced­fat milk and dairy products, ice cream, cream, half and half, cream cheese, sour cream and cheese TLC Diet: Eat Less TLC Diet: Eat Less Whole eggs, yolks Fatty meat such as ribs, tbone steak, regular hamburger, bacon, sausage, salami, hot dogs, organ meats, liver, brains, sweetbreads, fried meat, poultry and fish Butter, shortening, stick margarine, chocolate, tropical oils, coconut, palm and palm kernel Dealing with Problem Dealing with Problem Foods Reduce the portion size Prepare the food more healthfully Reduce the frequency it is eaten Substitute a more healthful food for the problem food TLC: Healthy Shopping TLC: Healthy Shopping Choose chicken breast or drumstick instead of wing and thigh Select skim milk or 1 percent instead of 2 percent or whole milk Buy lean cuts of meat such as round, sirloin, and loin Buy more vegetables, fruits and grains Read nutrition labels on food packages TLC: Dining Out TLC: Dining Out Choose restaurants that have low fat options available Ask that sauces, gravies, and salad dressings be served on the side Control portions by asking for an appetizer serving or sharing with a friend TLC: Dining Out TLC: Dining Out At fast food restaurants, go for salads, grilled (not fried or breaded) skinless chicken sandwiches, regular­sized hamburgers, or roast beef sandwiches Avoid regular salad dressings and fatty sauces. Limit jumbo or deluxe burgers, sandwiches, french fries, and other foods. Lipid­Lowering Drugs Lipid­Lowering Drugs Added if Diets Are Not Successful After a 6­month trial on each diet, drugs are added to the treatment. Types: s Nicotinic acid and lovastatin s Gemfibrozil, probucol, clofibrate—for high TGs s Cholestyramine and colestipol (bile acid sequestrants)—to lower high cholesterol; may increase TGs HMG CoA Reductase Inhibitors HMG CoA Reductase Inhibitors (Statins) Reduce LDL­C 18–55% & TG 7–30% Raise HDL­C 5–15% Major side effects – Myopathy – Increased liver enzymes Contraindications – – Absolute: liver disease Relative: use with certain drugs HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins) Statin Lovastatin Pravastatin Simvastatin Fluvastatin Atorvastatin Cerivastatin Dose Range 20–80 mg 20–40 mg 20–80 mg 20–80 mg 10–80 mg 0.4–0.8 mg HMG CoA Reductase HMG CoA Reductase Inhibitors (Statins) (continued) Demonstrated Therapeutic Benefits Reduce major coronary events Reduce CHD mortality Reduce coronary procedures (PTCA/CABG) Reduce stroke Reduce total mortality Figure 35. Cholesterol-lowering statin drug visits among adults 45 years of age and over by sex: United States, 1995-2002 80 Men, 65 years and over 60 Women, 65 years and over 40 Men, 45-64 years 20 Women, 45-64 years 0 1 995-96 1 997-98 1 999-2000 2001 -02 Year NOTES: Cholesterol-lowering statin drug visits are physician office and hospital outpatient department visits with cholesterol-lowering statin drugs prescribed, ordered, or provided. See Data Table for data points graphed, specific drugs included, standard errors, and additional notes. SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Survey and National Hospital Ambulatory Medical Care Survey. Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004 Bile Acid Sequestrants Bile Acid Sequestrants Major actions – – – Reduce LDL­C 15–30% Raise HDL­C 3–5% May increase TG Side effects – GI distress/constipation – Decreased absorption of other drugs Contraindications – Dysbetalipoproteinemia – Raised TG (especially >400 mg/dL) Bile Acid Sequestrants Bile Acid Sequestrants Drug Cholestyramine Colestipol Colesevelam Dose Range 4–16 g 5–20 g 2.6–3.8 g Bile Acid Sequestrants Bile Acid Sequestrants (continued) Demonstrated Therapeutic Benefits Reduce major coronary events Reduce CHD mortality Nicotinic Acid Nicotinic Acid Major actions – – – Lowers LDL­C 5–25% Lowers TG 20–50% Raises HDL­C 15–35% Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity Contraindications: liver disease, severe gout, peptic ulcer Nicotinic Acid Nicotinic Acid Drug Form Range Immediate release (crystalline) Extended release Sustained release Dose 1.5–3 g 1–2 g 1–2 g Nicotinic Acid (continued) Nicotinic Acid Demonstrated Therapeutic Benefits Reduces major coronary events Possible reduction in total mortality Fibric Acids Fibric Acids Major actions – – – – Lower LDL­C 5–20% (with normal TG) May raise LDL­C (with high TG) Lower TG 20–50% Raise HDL­C 10–20% Side effects: dyspepsia, gallstones, myopathy Contraindications: Severe renal or hepatic disease Fibric Acids Fibric Acids Drug Gemfibrozil BID Fenofibrate QD Clofibrate BID Dose 600 mg 200 mg 1000 mg Fibric Acids (continued) Fibric Acids Demonstrated Therapeutic Benefits Reduce progression of coronary lesions Reduce major coronary events Secondary Prevention Secondary Prevention Patients with established CHD have 5­7x greater risk of subsequent MI Smoking cessation Reducing BP to <140/90 or 130/85 with CHF, renal insufficiency, DM Reduce LDL­C to <100 mg/dl; non­ HDL levels to <130 mg/dl Secondary Prevention Secondary Prevention (cont) Moderate physical activity for 30 minutes daily 3­4 days a week Weight management to attain BMI<25 A1C<7% Use of 75 to 325 mg aspirin daily unless contraindicated Use of ACE inhibitors and B­blockers indefinitely CVD: Medical Intervention CVD: Medical Intervention Coronary Angioplasty Coronary Angioplasty (PTCA) Percutaneous coronary intervention (PCI) uses a balloon to break up plaque in an occluded artery Performed under local anaesthetic so recovery quicker than with bypass surgery Persons with no more than 2 blockages are candidates Angioplasties Angioplasties 601,000 angioplasties done in 1999; 1.2 million last year Most common problem is restenosis of the artery (10­20%) Require intensive lifestyle management Angioplasties Angioplasties Study by Boden, et al suggests that in low risk pts lifestyle changes and medications are just as effective as PCI Angioplasties did not prevent heart attacks or save lives; angioplasties produced a slight and temporary improvement in chest pain symptoms Angioplasty costs $30,000 to $40,000. The drugs used in the study are almost all available in generic form. Many health insurers including Medicare do not cover MNT for cardiovascular diseases Boden et al, NEJM 2007 Volume 356:1503­1516 PCI with Stent PCI with Stent Coronary Artery Bypass Coronary Artery Bypass Surgery Candidates have more than two occluded arteries Procedures have decreased since 1995 because of ↑ angioplasties Does not cure atherosclerosis; new grafts Does are also susceptible are Restonosis is common within 10 years of Restonosis surgery surgery CABG CABG ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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