心血管预防指南

Guidelines For Cardiovascular Prevention,Dr Chan, Ngai Yin, MBBS(HK), MRCP(UK), FRCP(Edin), FACC, FAHA, Associate Consultant, Director, Cardiac Pacing Services, Princess Margaret Hospital,10th South China International Congress in Cardiology, Guangzhou, China, April 12, 2008,CVD and other major causes of death: both sexes. (United States: 2004). Source: NCHS and NHLBI.,Causes of Death-US,57% of deaths due to CV diseases,Setting the Goal: A History,In 1998, the AHA Board of Directors adopted a 2010 Impact Goal: By 2010, 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 2010.,Coronary Heart Disease Mortality,22.8%,Stroke Mortality,18.8%,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 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 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 atorvastatin In patients with stable coronary disease. NEJM 2005;352:1425-35,10001 pts with CHD And LDL130mg/dl Median FU 4.9years,Mean LDL 77 vs 101,LaRosa JC, Grundy SM, Waters DD et al. Intensive lipid lowering with atorvastatin In patients with stable coronary disease. NEJM 2005;352:1425-35,Primary endpoint: First major CV event, defined as Death from CHD, Nonfatal MI Cardiac arrest survivor Fatal or nonfatal stroke Liver derangement: 1.2% vs 0.2% (p0.001),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;294:2437-45,4439 (high dose) vs 4449 pts With history of MI Primary endpoint: Major coronary event defined as Coronary death, nonfatal AMI, or Cardiac arrest survivor No difference in CV or All-cause mortality,80mg Atorvastatin 20mg 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 patients With coronary heart disease and chronic kidney disease. JACC 2008;51:1448-54,10001 pts with CHD 9656 with renal data 3107 CKD (GFR60ml/min/1.73m2 vs 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: HbA1c7%,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 Disease,Braunwald E, Domanski MJ, Fowler SE et al. Angiotensin-converting enzyme Inhibition in stable coronary artery disease. NEJM 2004;351:2058-69,P=0.43,8290 pts randomized 4mg trandolapril or placebo Primary endpoint: Death from CV causes, MI, Or coronary revascularization,Renin-Angiotensin-Aldosterone System Blockade,ACEI -LVEF40%, 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 blocker, either DM or heart failure, LVEF40%, -Blockers,MI, ACS, or LVD with or without heart failure symptoms (I, A) All other patients with coronary or other vascular disease or dia