Diapositiva 1

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Campagna Educazionale ANMCO Difendiamo il cuore
Lefficacia della prevenzione secondaria tra
Ospedale e Territorio
23 Febbraio 2008
Enrico Puccioni Unità Operativa di
Cardiologia Spedali Riuniti, Livorno
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MORTALITA SCA

• Intraosped. 6 mesi
  
• STEMI 7 12
• NSTEMI 5 13

Savonitto S JAMA 1999 281 707-13
Terkelsen CJ Eur H J 2005 26 18-26
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Risk of a Second Vascular Event
Sudden death defined as death documented within
1 hour and attributed to coronary heart disease
(CHD) Includes only fatal MI and other CHD
death does not include non-fatal MI
1. Adult Treatment Panel II. Circulation 1994
89133363. 2. Kannel WB. J Cardiovasc Risk 1994
1 3339. 3. Wilterdink JI, Easton JD. Arch
Neurol1992 49 85763. 4. Criqui MH et al. N
Engl J Med 1992 326 3816.
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Secondary Prevention

• Ask, advise, assess, and assist patients to stop
  smoking I (B)
• Daily physical activity 30 min 7 d/wk, minimum 5
  d/wk I (B)
• Weight management
• Statin goal
• LDL-C lt 100 mg/dL I (A)
• consider LDL-C lt 70 mg/dL IIa (A)
• Blood pressure management
• Diabetes management

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Secondary Prevention and Long Term Management
Goals Class I Recommendations

• Status of tobacco use should be asked at every
  visit.
• Every tobacco user and family member who smoke
  should be advised to quit at every visit.
• The tobacco users willingness to quit should be
  assessed.
• The tobacco user should be assisted by counseling
  and developing a plan for quitting.
• Follow-up, referral to special programs, or
  pharmacotherapy (including nicotine replacement
  and pharmacological rx) should be arranged.
• Exposure to environmental tobacco smoke at home
  and work should be avoided.

Smoking Goal Complete cessation. No exposure
to environmental tobacco smoke.
RIDUZ. RISCHIO re-IMA -25 Mortalità -45
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
RIDUZIONE RISCHIO EVENTI - 25
Physical activity Goal 30 min 7 d per wk
minimum 5 d per wk

• For all patients, encouraging 30 to 60 min 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 (e.g., walking breaks at
  work, gardening, household work).
• Advising medical supervised programs (cardiac
  rehabilitation) for high-risk patients (e.g.,
  recent acute coronary syndrome or
  revascularization, HF) is recommended.
• Encouraging resistance training 2 d per week may
  be reasonable (Class IIb LOE C)

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Secondary Prevention and Long Term Management
It is useful to assess body mass index and/or
waist circumference on each visit and
consistently encourage weight maintenance/reductio
n through an appropriate balance of physical
activity, caloric intake, and formal behavioral
programs when indicated to maintain/achieve a
body mass index between 18.5 and 24.9 kg/m2. The
initial goal of weight loss therapy should be
to reduce body weight by approximately 10
from baseline. With success, further weight loss
can be attempted if indicated through further
assessment. If waist circumference (measured
horizontally at the iliac crest) is 102 cm in
women and 89 cm in men, it is useful to
initiate lifestyle changes and consider treatment
strategies for metabolic syndrome as indicated.
Weight management Goal BMI 18.5-24.9
kg/m2 Waist circumf. Women lt 102 cm Men lt 89
cm
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Lipid management Goal LDL-C ltlt than 100 mg/dL

• LDL-C should be lt 100 mg/dL.
• Further reduction to lt 70 mg /dL is reasonable.
  (Class IIa LOE A)
• If baseline LDL-C is 100 mg/dL, LDL-lowering
  drug rx should be initiated.
• If on-treatment LDL-C is 100 mg/dL intensify
  LDL-lowering drug rx (may require LDL-lowering
  combination).
• If baseline LDL-C is 70 to 100 mg/dL, it is
  reasonable to treat to LDL-C lt 70 mg/dL. (Class
  IIa LOE B)

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Secondary Prevention and Long Term Management
Goals Class I
Recommendations
Blood pressure control Goal lt130/80 mm Hg
It is recommended to initiate or maintain
lifestyle modification (weight control, ?
physical activity, alcohol moderation, sodium ?,
and emphasis on ? consumption of fresh fruits,
vegetables, and low-fat dairy products). It is
useful as tolerated, to add blood pressure
medication, treating initially with beta-blockers
and/or ACE inhibitors, with the addition of other
drugs such as thiazides as needed to achieve goal
BP.
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Diabetes management Goal HbA1c lt 7
It is recommended to initiate lifestyle
and pharmacotherapy to achieve near-normal
HbA1c. Beginning vigorous modification of other
risk factors (e.g., physical activity, weight
management, BP control, and cholesterol
management as recommended above) is
beneficial. Coordination of diabetic care with
patients primary care physician or
endocrinologist is beneficial.
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Terapia farmacologica efficacia in prevenzione
secondaria
www.istitutoricerche - bestpractice
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Comparison of Prophylactic Drug Use among
Patients Enrolled in EUROASPIRE
EUROASPIRE I (1996) II (2001)
III (2007)
Aspirin/antiplatelet Beta blocker ACE
inhibitors Lipid lowering drugs
81 54 30 32
84 66 43 63
93 86 75 87
European Society of Cardiology Congress 2001
Amsteradm, NL 2007 Vienna, A
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Risk factor comparisons between EUROASPIRE I ,
II and III
EUROASPIRE I, II, III
I (1995-6)
II (2001) III (2007)
20.8
Smoking
19.4 20
- 80
Overweight (BMIgt25 Kg/m2)
-
Obesity (BMIgt30 Kg/m2)
25.3
32.8 33
Body weight incresead 4.9 Kg between Euroaspire I
and III
European Society of Cardiology Congress 2001
Amsteradm, NL 2007 Vienna, A
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Prevalence of raised BP, elevated cholesterol,
and self-reported diabetes mellitus
a. gt140/90 mm Hg or gt130/80 mm Hg among
diabetics b. 4.5 mmol/L or greater c. 2.5 mmol/L
or greater
Wood D. European Society of Cardiology Congress
2007 Vienna, A
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BACK Slides
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ABCDE CHECKLISTA are you on ASPIRIN?
ACEI?B are you on BETA BLOCKERS?C are you
on CHOLESTEROL LOWERING DRUGS?D Dont smoke
DIETE EXERCISE

Cohen JD Theheart.org 29 Mar 2001
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Medication adherence to BP therapy33 non
intensificazione terapia da medico33 non
aderenza alla terapia prescritta67 non
assumevano tutta la terapia prescritta

Peterson E Theheart.org 18 Feb 2008
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Antithrombotic Trialists Collaboration
Efficacy of Antiplatelet Therapy on Vascular
Events1
Control better
Antiplatelet better
Vascular events myocardial infarction, stroke
or vascular death
1. Antithrombotic Trialists Collaboration. BMJ
2002 324 7186.
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Antiplatelet agents ASPIRIN
For all post-PCI STEMI stented patients without
aspirin resistance, allergy, or increased risk of
bleeding, aspirin 162 to 325 mg daily should be
given for at least 1 month after bare-metal stent
implantation, 3 months after sirolimus-eluting
stent implantation, and 6 months after
paclitaxel-eluting stent implantation, after
which long-term aspirin use should be continued
indefinitely at a dose of 75 to 162 mg daily.
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Antiplatelet agents CLOPIDOGREL
For all post-PCI patients who receive a
drug-eluting stent (DES), clopidogrel 75 mg daily
should be given for at least 12 months if
patients are not at high risk of bleeding. For
post-PCI patients receiving a bare metal
stent (BMS), clopidogrel should be given for a
minimum of 1 month and ideally up to 12 months
(unless the patient is at increased risk of
bleeding then it should be given for a minimum
of 2 weeks).
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Secondary Prevention and Long Term Management
Goals Recommendations
Antiplatelet agents CLOPIDOGREL
For all STEMI patients not undergoing
stenting (medical therapy alone or PTCA without
stenting), treatment with clopidogrel should
continue for at least 14 d. (Class I LOE
B) Long-term maintenance therapy (e.g., 1 year)
with clopidogrel (75 mg per day orally) is
reasonable in STEMI patients regardless of
whether they undergo reperfusion with
fibrinolytic therapy or do not receive
reperfusion therapy. (Class IIa LOE C)
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Renin-Angiotensin-Aldosterone System Blockers
ACE Inhibitors
ACE inhibitors should be started and continued
indefinitely in all patients recovering from
STEMI with LVEF 40 and for those with
hypertension, diabetes, or chronic kidney
disease, unless contraindicated. ACE inhibitors
should be started and continued indefinitely in
patients recovering from STEMI who are not lower
risk (lower risk defined as those with normal
LVEF in whom cardiovascular risk factors are well
controlled and revascularization has been
performed), unless contraindicated. Among lower
risk patients recovering from STEMI (i.e., those
with normal LVEF in whom cardiovascular risk
factors are well controlled and revascularization
has been performed) use of ACE inhibitors is
reasonable. (Class IIa LOE B)
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
Renin-Angiotensin-Aldosterone System Blockers
ARBs
Use of ARBs is recommended in patients who are
intolerant of ACE inhibitors and have HF or have
had a STEMI with LVEF 40. It is beneficial
to use ARB therapy in other patients who are
ACE-inhibitor intolerant and have
hypertension. Considering use in combination
with ACE inhibitors in systolic dysfunction HF
may be reasonable.
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Secondary Prevention and Long Term Management
Goals Class I Recommendations
It is beneficial to start and continue beta-
blocker therapy indefinitely in all patients who
have had MI, acute coronary syndrome, or left
ventricular dysfunction with or without HF
symptoms, unless contraindicated.
Beta- Blockers
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Norme comportamentali efficacia in prevenzione
secondaria
www.istitutoricerche - bestpractice