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Guidelines For Cardiovascular PreventionGuidelines For Cardiovascular PreventionDr Chan, Ngai Yin, MBBS(HK), MRCP(UK), FRCP(Edin), FACC, FAHA,Associate Consultant,Director, Cardiac Pacing Services,Princess Margaret Hospital10th South China International Congress in Cardiology, Guangzhou, China, April 12, 2021CVD and other major causes of death: both sexes.(United States: 2004). Source: NCHS and NHLBI. Causes of Death-US57% of deaths due to CV diseasesSetting the Goal:A History•In 1998, the AHA Board of Directors adopted a 2021 Impact Goal:•By 2021, to reduce coronary heart disease, stroke and risk by 25%.•Risk factors to be measured included:•Tobacco Usage•High Blood Pressure•High Cholesterol•Physical Inactivity•In 2001, Obesity and Diabetes were added as risk factors.•Our goal is to achieve a 0% growth rate in •Obesity and Diabetes by 2021.Coronary Heart Disease Mortality22.8%↓Stroke Mortality18.8%↓AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update•Lifestyle modification•Blood pressure control•Lipid management•Diabetes management•Antithrombotic treatment•Renin-Angiotensin-Aldosterone system blockade•β –blockers•Influenza vaccinationLifestyle modification•Smoking•-complete cessation, avoid environmental exposure•Physical activity•-30 minutes, 7 days per week (minimum 5 days per week)•Weight management•-BMI 18.5-24.9kg/m2, waist circumference <40 inches for men, <35 inches for womenOne-for-all Community-Based Phase 2.5 Cardiac Rehabilitation for Low-risk Patients•Patients with implantable devices•Class I and II heart failure patients•Patients with coronary artery disease after complete revascularization•Patients with stable angina with satisfactory medical control•Patients with valvular heart disease after surgical treatmentBlood Pressure Control•Goal: <140/90mmHg or <130/80mmHg if patient has diabetes or chronic kidney disease•Lifestyle modification•As tolerated, add BP medication, treating initially with β –blockers and/or ACEI, with addition of other drugs such as thiazidesNew Lipid Target (1)LaRosa JC, Grundy SM, Waters DD et al. Intensive lipid lowering with atorvastatinIn patients with stable coronary disease. NEJM 2005;352:1425-3510001 pts with CHDAnd LDL<130mg/dlMedian FU 4.9yearsMean LDL 77 vs 101New Lipid Target (2)LaRosa JC, Grundy SM, Waters DD et al. Intensive lipid lowering with atorvastatinIn patients with stable coronary disease. NEJM 2005;352:1425-35Primary endpoint:First major CV event, defined asDeath from CHD,Nonfatal MICardiac arrest survivorFatal or nonfatal strokeLiver derangement:1.2% vs 0.2% (p<0.001)New Lipid Target (3)Pedersen TR, Faergeman O, Kastelein JJ et al. High-dose atorvastatin vs usual-dose Simvastatin for secondary prevention after myocardial infarction. JAMA 2005;294:2437-454439 (high dose) vs 4449 ptsWith history of MIPrimary endpoint:Major coronary event defined asCoronary death, nonfatal AMI, orCardiac arrest survivorNo difference in CV or All-cause mortality80mg Atorvastatin20mg SimvastatinNew Lipid Target (4)Pedersen TR, Faergeman O, Kastelein JJ et al. High-dose atorvastatin vs usual-dose Simvastatin for secondary prevention after myocardial infarction. JAMA 2005;294:2437-45New Lipid Target (4)Shephard J, Kastelein JJP, Bittner V et al. Intensive lipid lowering with atrovastatin in patientsWith coronary heart disease and chronic kidney disease. JACC 2021;51:1448-5410001 pts with CHD9656 with renal data3107 CKD (GFR<60ml/min/1.73m2vs 6549 normal GFRLipid Management•Diet therapy•LDL-C <100mg/dL, further reduction of LDL-C to <70mg/dL is reasonable•If TG 200-499mg/dL, non-HDL-C should be <130mg/dL•If TG ≥500mg/dL, prevent pancreatitis with fibrate or niacin before LDL lowering•Lipid-lowering medications: statin, fibrate, niacin, bile acid sequestrants, ezetimibeDiabetes Management•Lifestyle modification and pharmacotherapy•Goal: HbA1c<7%Antithrombotic Therapy•Lifelong aspirin 75-162mg/d• Aspirin 100-325mg/d within 48h of SVG, higher dose for 1 year• Aspirin 325mg/d postPCI (1 month BMS, 3 months SES, 6 months PES)•+Clopidogrel 75mg/d up to 12 months for ACS, postPCI (≥1 month BMS, ≥3 months SES, ≥6 months PES)•Warfarin with INR 2-3 for PAF, CAF or flutterAngiotensin-Converting-Enzyme Inhibition in Stable Coronary Artery DiseaseBraunwald E, Domanski MJ, Fowler SE et al. Angiotensin-converting enzymeInhibition in stable coronary artery disease. NEJM 2004;351:2058-69P=0.438290 pts randomized4mg trandolapril or placeboPrimary endpoint:Death from CV causes, MI,Or coronary revascularizationRenin-Angiotensin-Aldosterone System Blockade•ACEI•-LVEF≤40%, HT, DM, or CKD•-Low-risk, normal LVEF, optional•ARB•-ACEI intolerant•-Combination with ACEI in systolic heart failure•Aldosterone blockade•-post-MI patients, on ACEI and ß –blocker, either DM or heart failure, LVEF≤40%β -Blockers•MI, ACS, or LVD with or without heart failure symptoms (I, A)•All other patients with coronary or other vascular disease or diabetes (IIa, C)Framingham Heart Study2489 men and 2856 women30-74 yo12 years FU383 men and 227 womenDeveloped CHD12 European cohort205178 subjects18 years FU7934 CV deathsCardiovascular Diseases-Mortality Rate in Hong KongMortality ratePer 100,000???。