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1、Overview of Atherothrombotic Therapy: Secondary Prevention2002 ACC/AHA UA/NSTEMI* Guideline Update: Risk Factor ModificationClass ISmoking cessation Achieving optimal weight Daily exerciseAHA diet BP control to 130 mg/dLLipid-lowering agent if LDL-C after diet is 100 mg/dLA fibrate or niacin if HDL-

2、C 140 mm Hg is a much more important CVD risk factor than diastolic DBP.The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg.Individuals with a SBP of 120 to 139 mm Hg or a DBP of 80 to 89 mm Hg should be considered prehypertensive and require health-promoting lifes

3、tyle modifications to prevent CVD.SBP, systolic blood pressure; CVD, cardiovascular disease; DBP, diabolic blood pressure.Chobanian AV, et al. JAMA. 2003;289:2560-2572.Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined

4、 with drugs from other classesMost patients with hypertension will require 2 or more antihypertensive medications to achieve goal BP (140/90 mm Hg, or 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be a thiazide-type diureticTh

5、e most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivatedThe Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood PressureSBP, systolic blood pressure; CVD, cardiovascular dis

6、ease; DBP, diabolic blood pressure.Chobanian AV, et al. JAMA. 2003;289:2560-2572.Classification and Management of Adult Blood PressureBPClassificationSBP, mm HgDBP, mm HgLifestyleModificationNormal12080EncouragePrehypertension120-13980-89YesStage 1hypertension149-15990-99YesStage 2hypertension160100

7、YesChobanian A V, et al. JAMA. 2003;289:2560-2572. (with permission)Algorithm for Treatment of HypertensionChobanian AV, et al. JAMA. 2003;289:2560-2572. (with permission)Lifestyle ModificationsNot at Goal BP(140/90 mm HG or 130 mg/dL Lipid-lowering agents if LDL-C level after diet is 100 mg/dL1. AC

8、E inhibitors for patients with CHF, LV dysfunction (EF 0.40), hypertension, or diabetesACC, American College of Cardiology; AHA, American Heart Association; UA, unstable angina; NSTEMI, nonST-segment elevation myocardial infarction; ACS, acute coronary syndrome; LDL-C, low-density lipoprotein choles

9、terol; ACE, angiotensin-converting enzyme; CHF, coronary heart failure; LV, left-ventricular; EF, ejection-fraction.Braunwald E, et al. J Am Cardiol.2000;36:970-1062.Category % ORAcute MIAcute stroke Prior MI Prior stroke/TIAOther high riskCoronary artery disease(unstable angina, heart failure)Perip

10、heral arterial disease(intermittent claudication) 22 2 %High risk of embolism (atrial fibrillation)Other (diabetes mellitus)All trials1.00.50.01.52.0Control BetterAntiplatelet BetterAntithrombotic Trialists Collaboration (ATC): Efficacy of Antiplatelet Therapy on Vascular Events* Vascular events = M

11、I, stroke, or vascular death.OR, odds reduction; MI, myocardial infarction; TIA, tranient ischemic attack.Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86. (with permission)Aspirin Alone BetterCombined With AspirinAntithrombotic Trialists Collaboration1Dipyridamole6NSTiclopidine 20NSIV GP

12、 IIb/IIIa-Inhibitor 19P .0001Subtotal15P .0001OR Comparison* (%) P ValueCURE2Clopidogrel20P =.000091.00.50.01.52.0Effects of Various Antiplatelet Agents Combined With Aspirin vs Aspirin Alone* In combination with aspirin vs aspirin alone. CURE, Clopidogrel in Unstable angina to prevent Recurrent Eve

13、nts. 1 Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86. 2The CURE Trial Investigators. N Engl J Med. 2001;342:494-502. ATC: Efficacy of Aspirin at Various Doses in Reducing Vascular Events* in High-Risk Patients* Vascular events included nonfatal MI, nonfatal stroke, and death from vascu

14、lar causes. Treatment effect P.0001. Adapted with permission from the BMJ Publishing Group. ATC, Antithrombotic Trialists Collaboration, MI, myocardial infarctionAdapted from Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86.0.51.01.52.0500-1500 mg 34 19160-325 mg 19 2675-150 mg 12 3275 mg

15、 3 13Any aspirin 65 23Antiplatelet BetterAntiplatelet WorseAspirin Dose No. of Trials OR (%)Odds Ratio0Aspirin Resistance and the Risk ofCardiovacular Events in High Risk Patients5529 pts from HOPE study with baseline urine samplesCase (n=488)Pts with CV events after randomizationControls (n=488)Pts

16、 without CV events after randomizationUrinary 11-dehydro Thromboxane B2(ng/mmol creatinine)00.511.5233.81.01.31.41.8MI, stroke or CV death (P=.01)Odd RatioHypothesis: Incomplete inhibition of thromboxane B2 increases risk of cardiovascular eventAdapted from Eikelboom JW, et al. Circulation. 2002;105

17、:1650-1655.Cholesterol Reduction Reduces Incidence of Vascular Events in Diabetes0510152025300123456Log rank P.0001Simvastatin-allocatedPlacebo-allocatedFollow-up (years)Major vascular events (%)Heart Protection Study Collaborative Group. LANCET. 2003;361:2005-2016. (with permission)Cholesterol Redu

18、ction in Diabetes With or Without Arterial Disease010203040Heart Protection Study Collaborative Group. Lancet. 2003;361:2005-2016. (with permission)DiabetesOcclusive Arterial Both ArterialAloneDisease AloneDisease andDiabetes9%13%20%25%31%36%Risk reduction (SE):Proportional32.9% (9.1)24.5% (3.1)18.4

19、% (5.7)Absolute/100044 (12)62 (8)66 (21)P-Value.00032X upper limit of normal 3 (1%) 2 (1%)2 (1%)2 (1%)3 (1%)ALP 1-5X upper limit of normal 10 (2%) 10 (3%)12 (4%)11 (4%)19 (6%)Wallentin L, et al. Lancet. 2003;362:789-797. (with permission)van Es, et al. Lancet. 2002;360:109-113. (with permission)ASPE

20、CT IIWARIS IIWarfarin With or Without Aspirin Post ACS/MIDeath,MI,CVA Hurlen M, et al. NEJM. 2002;347:969-974. (with permission)Cumulative Treatment Failure (%)Logrank test: P=.03CoumadinAspirinCombinationPatients at riskComb.AspirinCoumadin3253252331881591055433628223318615910056332293243197161102600.140.120.100.080.060.040.020Event-free SurvivalFollow up