David Vancraeynest Congrès UCL de médecine générale Mai 2014

Congrès UCL de médecine générale
Mai 2014
David Vancraeynest
Cardiologie
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
It is THROMBOSIS, superimposed on ruptured
plaque that precipitates life-threatening clinical
events
ACS
Stroke
Approximately one third of STEMI
patients die within 24 hours of onset
of ischemia.
The morbidity and mortality is lower
in UA/NSTEMI patients, but is still
substantial, and about 15% of
patients die or experience a
reinfarction within 30 days of
diagnosis.
Circulation. 2004;110(9):e82-e292
Deaths by cause, Men
Europe(2012)
Deaths by cause, Women
Europe(2012)
European CVD statistics, ed. 2012
Circulation 2013;127:e6-e245
Percentage of the Decrease in Deaths from Coronary Heart Disease
Treatments, Risk factors changes or both?
European Heart Journal (2012) 33, 1635–1701
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
Aspirin is protective in patient at increased risk of
occlusive vascular events
including those with an acute myocardial infarction, unstable or
stable angina, previous myocardial infarction, stroke or peripheral
arterial disease: NOT SPECIFIC
Low dose aspirin (75-150 mg daily) is an effective
antiplatelet regimen for long term use
BMJ. 2002;324:71– 86
Platelet Inhibitors
Aspirin 75 mg
Aspirin + Clopidogrel
Both Aspirin (RR of 40%) and
Clopidogrel (RR of add’l 20%) should
be initiated early and continued long
term
SPECIFIC POST-ACS
Aspirin 75 mg
+ Clopidogrel
Lancet. 2001;358:527–533
Platelet Inhibitors:
Aspirin + Clopidogrel
death from cardiovascular causes
nonfatal myocardial infarction
Nonfatal stroke
Vs
Aspirin + Prasugrel
Major Bleeding
TRITON-TIMI 38
N Engl J Med 2007;357:2001-15
Platelet Inhibitors:
Aspirin + Clopidogrel
Vs
Aspirin + Ticagrelor
N Engl J Med 2009;361:1045-57
ACE Inhibitors:
When ejection fraction is
reduced (<40%)
When hypertension is
present
When diabete is present
When renal failure is
present
When stable CAD is
present…
Lancet 2003; 362: 782–88
The addition of Eplerenone to optimal medical therapy
reduces mortality among patients with acute myocardial
infarction complicated by left ventricular dysfunction
EPHESUS
N Engl J Med 2003;348:1309-21
The first randomised trials of BBlockade in
secondary prevention after myocardial infarction
were published in the 1960s
Firm evidence shows that long term BBlockade
remains an effective and well tolerated treatment
that reduces mortality and morbidity in unselected
patients after myocardial infarction
BMJ 1999;318:1730–7
Statins reduce cardiovascular morbidity and mortality as well
as the need for coronary artery interventions.
Statins at doses that effectively reduce LDL cholesterol by
50% also seem to halt progression or even contribute to
regression of coronary atherosclerosis: drugs of first choice.
The highest priority for treatment are patients with CVD
irrespective of their lipid levels.
In these patients at very high CVD risk the LDL cholesterol
goal is less than 70 mg/dL
Intensive statin therapy early after ACS
leads to a reduction in clinical events at
30 days, consistent with greater early
pleiotropic effects
J Am Coll Cardiol 2005;46:1405–10
In this study of patients with previous MI,
intensive lowering of LDL-C did not result
in a significant reduction in the primary
outcome of major coronary events
JAMA 2005;294:2437-2445
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
Lifestyle
Modifications
Smoking
Hypertension
Goal: Complete cessation
Goal: <140/90 mmHg
Lifestyle
Modifications
Physical
Activity
Goal: HbA1c: <7%
Goal: 30 min, 7 days /week
Weight
Goal: BMI: 19-24.9
Diabetes
Lipids
Goal: LDL-cholesterol <70mg/dL
Lifestyle
Modifications
Smoking cessation intervention programs can have a substantial effect on
subsequent mortality, even when successful in a minority of participants
Lung Health Study Research Group, Ann Intern Med. 2005;142:233-239
ACCORD Trial
The usual treatment target for HbA1c has
been increased from <6.5% to <7.0% in the
European Guidelines of CV prevention.
N Engl J Med 2008;358:2545-59
With the exception of the extra protective
effect of β blockers given shortly after a
myocardial infarction all the classes of blood
pressure lowering drugs have a similar effect in
reducing CHD events and stroke for a given
reduction in blood pressure
BMJ 2009;338:b1665
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
« Exercise is one of the most important behavioural
interventions that can have a major beneficial impact
on the likelihood to develop, suffer symptomatically
or die from cardiovascular disease »
Prevalence of Acute
Coronary Syndrome
Quality of Life
Mortality
Dyslipidemia
Exercise
Hypertension
Obesity
Angina
Diabete
Rheumatology 2008, 47:239
Cardiac patient
Assess ability
Assess motivation
Exercise test
Exercise program
Tailored to the
individual
3-5 times weekly
60-80% of VO2
Evidence of residual
ischemia ?
Workload ?
Peak VO2 ?
Readmission
Mortality
Cardiac rehabilitation participation is associated with a markedly reduced risk of
readmission and death after incident myocardial infarction
Am J Cardiol 2014, in press
Introduction
Le traitement pharmacologique
La prise en charge des facteurs de risque
Tabac
Diabète et le contrôle glycémique
Hypertension artérielle et le contrôle tensionnel
Cholestérol
La pratique du sport / La réadaptation pour cardiaque
Facteurs psychosociaux
Smoking
Hypertension
Goal: Complete cessation
Goal: <140/90 mmHg
Physical
Activity
Diabetes
Goal: HbA1c <7%
Goal: 30 min, 7 days/week
Weight
Goal: BMI 19-24.9
Lipids
Goal: LDL-cholesterol <70mg/dL
Professional
activity
Social
environment
Cultural
environment
Depression
Familial
environment
Education
Pharmacotherapy:
Aspirin 75-160 mg for the rest of life
P2Y12 Receptor Inhibitor for 1 year
Statin for the rest of life
BBlocker for 3 years or more
ACE Inhibitor and Aldosteron Blocker if EF<40%
Lifestyle Modifications:
Salt – Fruit – Vegetables – Fatty acids - Physical activities
Patient / Physician Relationship