Cardiac Prescribing Forum Educational Event

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Cardiac Prescribing ForumEducational Event

• 5th December 2007

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Agenda
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Aims

• To highlight new national guidance with regard to
  prescribing issues
• NICE post-MI Secondary prevention guideline
• To present consensus guidelines from the agreed
  through the CPF for the SE sector
• Cholesterol and statins
• Clopidogrel
• To discuss potential work areas for the CPF for
  the next 12 months

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CG48 NICE MI Secondary Prevention Guidelines

• Helen Williams
• Specialist Cardiac Pharmacist
• Lambeth Southwark PCTs
• and Kings College Hospital, London
• Member of NICE GDG for MI Secondary Prevention

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Overview

• Highlight key recommendations
• Discuss specific issues
• Smoking cessation
• Fish oils and omega-3 fatty acid supplements
• Drug therapy the Key Four
• Clopidogrel in STEMI and NSTEMI
• Aldosterone antagonists

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Communication of diagnosis and advice

• After an acute MI, every discharge summary should
  include confirmation of the diagnosis of acute
  MI, results of investigations, future management
  plans and advice on secondary prevention.

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Lifestyle Advice

• Patients should be advised to
• Be physically active for 2030 minutes a day.
  Patients who are not achieving this should be
  advised to increase their activity in a gradual
  way
• Quit smoking
• Eat a Mediterranean-style diet

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Quitting Smoking

• The cardiac effects of smoking are reversed
  within 23 years of quitting
• Five years after quitting, a smokers CV risk, is
  the same as if they had never smoked.
• Level II / III smoking cessation services
• Cardiac rehabilitation services
• Use of new drugs, such as varenicline (NICE
  TA123)
• Consistent smoking cessation advice from HCPs

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Mediterranean Diet

• Patients should be advised to eat a
  Mediterranean-style diet (more bread, fruit,
  vegetables and fish less meat and replace
  butter and cheese with products based on
  vegetable and plant oils
• A Mediterranean diet, as defined above, reduced
  mortality in a prior-MI group from 6.6 to 2.6
  (ARR 4) at 27 months

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Fish Oils

• Patients should be advised to eat at least two to
  four portions of oily fish per week

• If they are not achieving this and have had an
  MI within the past 3 months, consider providing
  at least 1 g daily of omega-3-acid ethyl esters
  treatment licensed for secondary prevention post
  MI for up to 4 years.

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Oily Fish

• Evidence Statement
• In patients after MI, advice to increase
  consumption of oily fish reduced all-cause
  mortality (1)
• DART-1 1989
• Epidemiological data
• Aim 2-4 portions per week
• ?realistic in a UK population

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Fish Oils

• Patients should be advised to eat at least two to
  four portions of oily fish per week

• If they are not achieving this and have
  had an MI within the past 3 months, consider
  providing at least 1 g daily of omega-3-acid
  ethyl esters treatment licensed for secondary
  prevention post MI for up to 4 years.

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Omega-3 fatty acid supplements

• Evidence statement
• The only large trial of supplementation with 1g
  omega 3 polyunsaturated fatty acids has shown a
  reduction in mortality and cardiovascular
  morbidity, although there was a low uptake of
  statins and other secondary prevention drugs at
  baseline in this study (1) GISSI-P 1999

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Omega-3 fatty acids (Omacor)

• Fish oil supplementation
• Eicosapentaenoic acid (EPA) docosahexaenoic
  acid (DHA)
• GISSI-P study (1997)
• Open label study
• Omega-3 fatty acid supplementation post-MI
  reduced total mortality by 20 (ARR 2.1) over
  3.5 years
• Dose 1g/day

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How do we achieve this in practice?

• Assess dietary intake immediately post-MI
• Advise increased fish consumption (2-4 portions
  per week if necessary)
• Consider Omega-3 FA supplements (Omacor) if
  patient is unable or states unwilling to increase
  fish intake
• Reassess before the end of cardiac rehabilitation
• Check if adequate dietary intake of omega-3 FA
  achieved
• If not, consider omega-3FA supplementation
  (Omacor)

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Other Lifestyle.

• Beta-carotene, vitamin E or C or folic acid to
  reduce CV risk

• Moderating alcohol intake to within safe limits
• Overweight and obese patients to be offered
  support to lose weight

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Cardiac rehabilitation

• Healthcare professionals,should actively promote
  cardiac rehabilitation
• Cardiac rehabilitation should be equally
  accessible and relevant to all patients after an
  acute MI

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Drug Therapy

• All patients who have had an acute MI should be
  offered treatment with the following drugs
• ACE (angiotensin-converting enzyme) inhibitor
• aspirin
• beta-blocker
• statin

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The Key Four.. (1)

• Importance of combination therapy
• Impact of aspirin, ACEI, beta-blocker and statin
  in 1,358 pts with ACS
• Pts on all FOUR drugs had a 90 reduction in risk
  of death in first 6 months post-discharge
  (p0.0001) compared to those on none of these
  drugs
• Effect of combination therapy is synergistic not
  just additive
• Quadruple therapy should be started prior to or
  soon after an acute coronary event
• Circulation 2004 109 745

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The Key Four. (2)

• Under-utilisation of ACEIs, statins,
  beta-blockers and aspirin is costing 9,000 lives
  in the UK per annum (this far exceeds the number
  that could be saved by encouraging smoking
  cessation).
• Roger Boyle
• Heart Czar
• 2004

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The Key Four..Audit Data

• ASPIRE (1996)
• 8 post-MI pts prescribed lipid-lowering tx at
  discharge
• EUROASPIRE (1997)
• 18 post-MI pts prescribed statin
• EUROASPIRE 2 (2001)
• 58 post-MI pts prescribed statin
• Myocardial National Audit Project (2007)
• in England prescribed post MI secondary
  prevention medication on discharge from hospital
  continues to exceed the targets, remaining at 97
  for aspirin, 91 for beta-blockers and 96 for
  statins
• Heart. 1996 Apr75(4)334-42 Eur Heart J.
  199718(10)1569-82
• Eur Heart J. 2001 Apr22(7)554-72. MINAP
  2007

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Antiplatelet Therapy

• The combination of aspirin and clopidogrel should
  be prescribed
• for 12 months after a non-ST-segment-elevation
  MI
• for at least 4 weeks in patients given the two
  drugs during the first 24 hours after an
  ST-segment-elevation MI

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Clopidogrel Post-NSTEMI

• As per NICE TA80 Clopidogrel in the treatment of
  non-ST-segment-elevation acute coronary syndrome
• Clopidogrel, and aspirin, should be used for
  people with non ST elevation acute coronary
  syndrome at moderate to high risk
• Treatment should be continued for 12 months

CURE (2001) Clopidogrel Plus Aspirin vs Aspirin
Alone post-NSTEMI
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Clopidogrel Post-STEMI

• Two studies CLARITY (2005) and COMMIT (2005) have
  shown that early use of clopidogrel (plus)
  aspirin post-MI reduces CV events including
  mortality
• No data post-STEMI beyond 4 weeks
• Must be started at index episodes and should be
  discontinued at 4 weeks

COMMIT (2005) Clopidogrel Plus Aspirin vs Aspirin
Alone post-STEMI
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Aldosterone antagonists

• Patients with symptoms and signs of heart failure
  will require an early assessment of LV function
• Those with symptoms or signs of heart failure and
  LVSD should be offered a licensed aldosterone
  antagonist within 314 days of the acute MI

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Eplerenone (Ephesus)

• The only large trial of an aldosterone
  antagonist and in early post-MI patients with
  LVSD and clinical heart failure and /or diabetes,
  showed that early treatment with eplerenone
  (initiated within 3 14 days of MI), reduced all
  cause mortlaity, death from CV causes, sudden
  cardiac death and episodes of heart failure

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Cardiological Assessment

• All patients should be offered a cardiological
  assessment to consider whether coronary
  revascularisation is appropriate

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Revascularisation

• CABG surgery reduces fatal and non-fatal MI
  improves survival (1)
• Angiography for those with on-going ischaemia
• Risk stratification benefits vs risks urgency
• CABG or PCI
• In 2006 wide disparity in access to
  revascularisation services in the UK
• 3 - 97 depending on geographical location

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Summary

• All patients to be offered three elements of
  secondary prevention care
• Lifestyle advice
• Cardiac rehabilitation
• Optimal drug therapy
• Aspirin, statin, ACEi, beta-blocker
• Clopidogrel (check durations!)
• Eplerenone

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Cardiac Prescribing ForumEducational Event
5th December 2007
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Cardiac Prescribing ForumWhat Next?
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Suggestions so far..

• Beta-blocker guidance when and how to use
• Nicotine replacement therapy and oral smoking
  cessation drugs
• Atrial Fibrillation increased prescribing
  information to support the NICE recommendations
• ???

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Thank you for coming

• Please complete and return your evaluation forms
• If you are interested in joining the SEL Cardiac
  prescribing forum please contact
  Maurico.lomba_at_lewishampct.nhs.uk