Evidence-Based Guidelines for Cardiovascular Disease

Evidence-Based Guidelines for Cardiovascular Disease Prevention in WomenA Case-Study Approach

This educational offering is supported by Macy’s and Pfizer, national sponsors of the American Heart Association’s Go Red For Women campaign._____________________

An educational grant was also supplied by PacifiCare Foundation.

COURSE CHAIR Nanette K. Wenger, MDProfessor of Medicine (Cardiology)Emory University School of MedicineChief of CardiologyGrady Memorial HospitalAtlanta, GAE-mail: nwenger@emory.edu AUTHORS

Kathy Berra, MSN, ANP, FAANStanford Prevention Research CenterStanford University School of MedicineStanford, CaliforniaE-mail: kberra@stanford.edu Linda Casebeer, PhDAssociate DirectorUniversity of Alabama Division of CMEBirmingham, AlabamaE-mail: casebeer@uab.edu

Sharonne N. Hayes, MD, FACCDirector, Women’s Heart ClinicMayo Clinic College of Medicine Rochester, Minnesota E-mail: hayes.sharonne@mayo.edu

Paula A. Johnson, MD, MPHExecutive Director, Connor’s Center for Women’s Health and Gender BiologyChief, Division of Women’s HealthBrigham and Women’s HospitalBoston, Massachusetts E-mail: pajohnson@partners.org Luella Klein, MDCharles Howard Candler ProfessorDepartment of Gynecology and ObstetricsEmory University School of MedicineDirector, Maternal and Infant ProjectGrady Healthcare SystemAtlanta, Georgia E-mail: cwest03@emory.edu

Cathy A. Sila, MD, FAHAAssociate Director, Cerebrovascular CenterSection of Stroke and Neurologic Intensive CareDepartment of NeurologyCleveland ClinicCleveland, Ohio E-mail: silac@ccf.org

Disclosure StatementAs a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Association of Critical-Care Nurses (AACN) and the American Council on Pharmaceutical Education (ACPE), the American Heart Association must ensure fair balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. Therefore, all faculty and authors participating in continuing education activities sponsored by the American Heart Association must disclose to the audience: (1) any significant financial relationships with the manufacturer(s) of products from the commercial supporter(s) and/or the manufacturer(s) of products or devices discussed, and (2) discussion of unlabeled/unapproved uses of drugs or devices.The following authors have declared financial interest(s) and / or affiliations:•• Kathy Berra, MSN, ANP, FAAN—Research Support: Guidant Foundation

– Speakers Bureau/Honoraria: Pfizer, KOS Pharmaceuticals– Consultant/Advisory Board: Pfizer, KOS Pharmaceuticals

•• Sharonne Hayes, MD, FACC—Consultant/Advisory Board: WomenHeart; Cardiovision 2020•• Nanette Wenger, MD—Research Grant: Bristol-Myers Squibb, Eli Lilly and Company, AstraZeneca

– Speakers Bureau/Honoraria: Aventis Pharmaceuticals, Pfizer, Merck, Bristol-Myers Squibb, Wyeth Ayerst, Eli Lily and Company,

– Consultant/Advisory Board: Eli Lilly Raloxifene Advisory Committee; Heart Disease in Women, MED-ED, Pfizer; Aventis Pharmaceuticals Consultant and Cardiology Advisory Board; Cardiology/Lipidology Advisory Board Merck; Consultant, Women First Healthcare Inc.; Cardiology Consultant, Bristol-Myers Squibb; Ranolazine Advisory Board, CV Therapeutics

•The following authors have declared NO financial interest(s) and or affiliations:•• Linda Casebeer, PhD•• Paula A. Johnson, MD, MPH•• Luella Klein, MD•• Cathy Sila, MD, FAHA

Case 2 “Management of the Patient with Heart Disease”

Case 2“Management of the Patient

with Heart Disease”

Case PresentationMrs. Johnson is a 68-year-old woman who presents for her periodic health examination. She reports that she has had a good year, but is concerned about her risk of breast cancer and wants to schedule her yearly mammogram. Aside from some left hip discomfort for which she takes occasional ibuprofen, she has no other complaints.

Case 2 “Management of the Patient with Heart Disease”

Past Medical History• At age 62, Mrs. Johnson developed unstable angina. At age 62, Mrs. Johnson developed unstable angina.

Coronary angiography showed a 90% mid-right coronary Coronary angiography showed a 90% mid-right coronary artery lesion and a 30% distal left anterior descending artery artery lesion and a 30% distal left anterior descending artery lesion. She had successful stenting of her right coronary lesion. She had successful stenting of her right coronary artery with a good result and has had no recurrent angina. artery with a good result and has had no recurrent angina. She has not seen a cardiologist for four years.She has not seen a cardiologist for four years.

• Mrs. Johnson had a hysterectomy at age 40 for dysfunctional Mrs. Johnson had a hysterectomy at age 40 for dysfunctional uterine bleeding.uterine bleeding.

(Continued on next slide)(Continued on next slide)

Case 2 “Management of the Patient with Heart Disease”

Past Medical History (cont’d.)• Hypertension for 20 years • Smoked half a pack per day for 30 years and quit when her

coronary artery disease was diagnosed six years ago• Hyperlipidemia • Not physically active (in spite of recommendations)• Does not follow any “diet” (in spite of recommendations)

Case 2 “Management of the Patient with Heart Disease”

Family History• One sister has postmenopausal breast cancer. • A brother is diabetic and had myocardial infarction and

coronary artery bypass grafting at age 60. • Her mother died of myocardial infarction at age 64.• Her father died of a stroke at age 72.

Case 2 “Management of the Patient with Heart Disease”

Medications• Aspirin, 81 mg p.o. daily • Hydrochlorothiazide, 25 mg p.o. daily• Amlodipine, 5 mg p.o. daily • Simvastatin, 10 mg p.o. daily• Vitamin E, 400 IU p.o. daily

Case 2 “Management of the Patient with Heart Disease”

Physical Examination• Well-appearing, obese woman in no acute distress • Height: 5 feet 5 inches • Weight: 188 pounds • BMI: 31.3 (Waist circumference: 36 inches) • Blood pressure (left arm, seated): 144/78 mm Hg• Pulse: 78 BPM• Breasts: No masses or discharge • Lungs: Clear

(Continued on next slide)

Case 2 “Management of the Patient with Heart Disease”

Physical Examination (cont’d.)• Heart: Regular rate and rhythm. Normal jugular venous

pressure. Normal first and second heart sounds. No murmur or third heart sound. Fourth heart sound present.

• Abdomen: Nontender, no hepatosplenomegaly, no bruit • Extremities: No edema • Vessels: Femoral and carotid pulses are full and without

bruit

Case 2 “Management of the Patient with Heart Disease”

Laboratory Evaluation• Electrocardiogram: heart rate 82 BPM. Normal sinus

rhythm with nonspecific ST-T wave changes. • Lipids:

Total cholesterol: 209 mg/dL LDL-C: 133 mg/dL HDL-C: 38 mg/dL Triglycerides: 188 mg/dL AST (SGOT): 32 IU/L; ALT (SGPT): 46 IU/L Fasting blood glucose: 122 mg/dL

• Mammogram: Benign calcifications in left breast, otherwise negative.

Case 2 “Management of the Patient with Heart Disease”

Question 1Based on the patient’s clinical data, Mrs. Johnson has a ___10-year risk of experiencing a coronary heart disease event.

A. Greater than 20%B. 10%–20%C. Less than 10%D. None of the above

Case 2 “Management of the Patient with Heart Disease”

Question 2Current guidelines suggest that Mrs. Johnson should be advised:

A. That she has diabetes and should consider insulin therapy.B. To undergo stress echocardiography to exclude silent

ischemia. C. That she has metabolic syndrome.D. None of the above.

Case 2 “Management of the Patient with Heart Disease”

From: Circulation 2005;112:2735-2752

Clinical Identification of the Metabolic Syndrome

Measure (any 3 of 5 constitute diagnosis of metabolic syndrome)

Categorical cutpoints

Elevated waist circumference Men

Women

Waist circumference

>102 cm (>40 in)>88 cm (>35 in)

Elevated triglycerides ≥150 mg/dLReduced HDL-C

MenWomen

<40 mg/dL<50 mg/dL

Elevated blood pressure ≥130/85 mmHgElevated fasting glucose ≥100 mg/dL

Case 2 “Management of the Patient with Heart Disease”

Question 3You advise Mrs. Johnson to increase her physical activity and refer her for nutritional consultation. You also:

A. Recommend increasing her vitamin E to 800 IU per day.B. Tell her to try to achieve a BMI of 20 (lose 68 pounds and

exercise daily). C. Add a multivitamin with at least 500 mg of vitamin C

each day.D. Increase her simvastatin dose to 40 mg per day and make

sure that she is taking it in the evening.

Case 2 “Management of the Patient with Heart Disease”

Question 4Mrs. Johnson tells you that she really wants to minimize the number of medications she is taking and wonders if you would be willing to consider stopping some or all of them. You recommend:

A. She stop taking her vitamin E and hydrochlorothiazide and increase the dose of her amlodipine to 10 mg to achieve better control of her blood pressure.

B. Adding an ACE-inhibitor and stopping the amlodipine. C. Increasing her aspirin dose to 325 mg per day.D. Adding a beta-blocker.E. Both B and D.

Case 2 “Management of the Patient with Heart Disease”

In SummaryFor this 68-year-old woman with established coronary heart disease (CHD) and stenting of her right coronary artery, she should be advised that she meets all five criteria for identification of the metabolic syndrome. Since she is well above her LDL goal of <100 mg/dL, she should increase her simvastatin dose to 40 mg per day and make sure that she is taking it in the evening. You should also treat her with a beta-blocker and an ACE inhibitor. Both drug classes have Class I indications for women with chronic CHD.

Case 2 “Management of the Patient with Heart Disease” Conclusion