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40181 - Are We Nearing the Limits of Office-Based CV...

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Are We Nearing the Limits of Office-Based CV Prevention? Thomas G. Allison, PhD, MPH
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America the Beautiful?
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Continuum of CVD Prevention Public Health Community Programs Primary Prevention Clinic-based Acute Treatment Hospital-based Secondary Prevention Clinic-based
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Case Study 62-year old white male No known CV disease Former smoker BMI = 32.2 kg/m 2 Taking ASA 81 mg/day
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Case Study Type II diabetes x 10 years Hemoglobin A1c = 6.5% Diabetic medications Metformin Glimepiride Rosiglitazone
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Case Study Blood pressure = 134/64 mmHg Blood pressure medications: ACE-inhibitor HCTZ Lipids: Total-C = 165 mg/dL HDL-C = 39 mg/dL LDL-C = 95 mg/dL TG = 155 mg/dL Rx = Simvastatin 40 mg/day
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Questions Should we intensify diabetic therapy? Add insulin? Add Exenatide? Other? Should we attempt to lower systolic blood pressure? Goal < 130 mg/Hg? < 120 mmHg? Add beta blocker? Ca ++ blocker? ARB? Are lipids satisfactory? Higher dose or stronger statin? Add Ezetimibe? Add fibrate? Add niacin?
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The ACCORD Trial The trial with 3 arms but no legs to stand on
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ACCORD Double 2 x 2 Factorial Design Intensive Glycemic Control 5128 Standard Glycemic Control 5123 Lipid BP Placebo Fibrate Intensive Standard 2371 2362 2753 2765 1383 1374 1391 1370 1193 1178 1184 1178 10,251 4733 * 5518 * 94% power for 20% reduction in event rate, assuming standard group rate of 4% / yr and 5.6 yrs follow-up
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ACCORD Baseline Patient Characteristics Number of patients: 10,251 Age: 62 years Duration of diabetes: 10 years Macrovascular disease: >35 % HbA1c: 8.1%
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ACCORD-Glucose Treatment Glycated hemoglobin: < 6.0% versus < 8.0% Duration of follow-up: Median 3.4 yrs Ending therapy: Sulfonylurea: 78% vs. 68% Repaglinide: 50% vs. 18% Metformin: 74% vs. 67% Rosiglitazone: 91% vs. 58% Exenatide: 12% vs. 4% Insulin: 77% vs. 35%
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ACCORD Glucose control Hba1c (%) Time (years)
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