心血管预防指南英文

Guidelines 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, 2008CVD and other major causes of death: both sexes.(United States: 2004). Source: NCHS and NHLBI. Causes of Death-US57% of deaths due to CV diseasesSetting 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 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 blockers Influenza vaccinationLifestyle 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 womenOne-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 treatmentBlood 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 thiazidesNew 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 LDL130mg/dlMedian FU 4.9yearsMean LDL 77 vs 101New 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% (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;294:2437-454439 (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 SimvastatinNew 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;294:2437-45New 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 2008;51:1448-5410001 pts with CHD9656 with renal data3107 CKD (GFR60ml/min/1.73m2vs 6549 normal GFRLipid 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, ezetimibeDiabetes Management Lifestyle modification and pharmacotherapy Goal: HbA1c7%Antithrombotic Therapy Lifelong aspirin 75-162mg/dAspirin 100-325mg/d within 48h of SVG, higher dose for 1 yearAspirin 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 flutterAngiotensin-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 revascularizationRenin-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 dis