Primary CVD Prevention

Question 1

Primary goals in CVD prevention

Answer 1

-Blood pressure control and lipid control account for 40% decline in CVD mortality in the last decade -Other risk factors that need to be controlled: smoking and diabetes -Focus on primary prevention, not curing the problem that already exists.

Question 2

Tools in CVD prevention

Answer 2

-exercise, weight loss, limiting salt/EtOH. -multi-drug therapy and JNC-7 guidelines -community health workers to reach at-risk communities -policy changes

Question 3

Public health benefits of BP control

Answer 3

-by lowering BP we can reduce heart failure and reduce the risk of stroke, MI and CV death at any age -tight systolic BP control leads to reduced risk of microvascular endpoints, fatal/non-fatal strokes, heart failure and fatal/non-fatal MIs -reduction in these outcomes = fewer hospitalizations/costly interventions = better overall health

Question 4

Barriers to CVD risk reduction

Answer 4

• Compliance: poor therapy regimen compliance with blood pressure therapy
  
  • High risk hypertensive patients require multiple drugs (at least 3) and still don’t achieve SBP goals.
  • Only 20% of patients achieve greater than 80% adherence
• Also, keep in mind that patients who have depression may have lower compliance
• patients are individuals w/unique communities & unique challenges

Question 5

Major reasons cited for non-adherence to BP meds (6)

Answer 5

• patients forget (55%)
• don’t think it is necessary (14%)
• hate taking meds (7%)
• don’t like being dependent on meds (7%)
• side effects of drugs (6%)
• too expensive (2%).

Question 6

JNC-7 guidelines in HTN

Answer 6

• start 2 drugs simultaneously if systolic
  
  • BP is > 20 mm Hg or
  • diastolic > 10 mm Hg above goal

Question 7

Major myths in primary CVD precention

Answer 7

1. raising HDLs w/drugs saves lives
2. tight glycemic control in diabetics improves CV outcomes
3. “an aspirin a day keeps the doctor away”

Question 8

Summary of research regarding “HDL-raising” myth

Answer 8

• Bad of statins: increased blood sugar andglycosylated hemoglobin (HbA1c) levels
• Good of statins: removal of routine monitoring of liver enzymes from drug labels
• Bad of statins: potential for generally non-serious and reversible cognitive side effects
• overall: benefits outweigh risk, but primary prevention evidence is slightly less compelling

Question 9

Summary of research regarding “tight glycemic control” myth

Answer 9

• Higher glucose = higher risk
• However, aggressive glucose control may lead to an increase in mortality

Question 10

Summary of research regarding “asprin/day” myth

Answer 10

• Works in CAD, and stroke patients
• Recent randomized trials in DM- no benefit
• Benefits in primary prevention are small & offset by risks of major bleeding
• ASA remains recommended in multiple guidelines, but not FDA approved in primary prevention

Question 11

Conclusions regarding CVD prevention

Answer 11

• Assess global risk in all your patients and treat patients holistically
• Start a statin in high-risk patients with elevated LDL-cholesterol
• Gain patient buy-in and incorporate tools to improve adherence:
• Health care delivery alone is not enough
  
  • ​Community-based programs are beneficial…

Question 12

Tools to improve adherence

Answer 12

– Frequent visits and encouragement,

– Once daily or combination drugs,

– Assess for depression & co-factors (alcohol, drugs, etc.)