Patient: _______________________________ Diagnosis: _____________________________

Rx ()

Risk Intervention

Recommendations

 

Smoking:

Goal-Complete cessation

Strongly encourage patient and family to stop smoking.

Provide counselling, nicotine replacement, and formal cessation programs as appropriate.

 

Lipid Management:

Primary goal *             LDL < 2.5 mmol/L

Start hypolipidemic diet in all patients: 30% fat,<7%saturated fat,< 200mg/day cholesterol. 10 % LDL achievable with diet. Assess fasting lipid profile. Baseline lipid profile < 24 after acute event. In post -MI patients, lipid profile may take 4 to 6 weeks to stabilize. Add drug therapy according to the following guide:

 

Secondary goal *

TC/HDL < 4

Tertiary goal *

Metabolic Syndrome

TG < 1.7 mmol/L

 HDL 1.0mmol/L(men)/

1.3mmol/L (women)

CWG on Hypercholesterolemia and other Dyslipidemias

LIPID Profile

1st Line Therapy

2nd Line Therapy

LDL

Statin

Resin

LDL & TG

Statin

Niacin or Fibrate

LDL & TG & HDL

Fibrate or Niacin

Combination Therapy

* Primary goal: For patients CHD Risk equivalent: any of CAD, TIA, CVA, AAA, PVD/bruits, DM with one additional categorical risk factor or for patients with very high 10-year risk for hard CV events ( 20%).

          Target initial therapy with the medication dose required to achieve target LDL < 2.5 mmol/L.

          For 10 yr CV risk for hard endpoints 10-20%, LDL target is 3.5 mmol/L.

          For 10 yr CV risk for hard endpoints < 10%, LDL target is 4.5 mmol/L.

          Initiate lipid lowering early in high-risk patients (in conjunction with dietary modification).

For specific medications and dosing strategy see Lipid Optimization Tool

 

Blood pressure control:

Goal

135/85 mm Hg

 

2002 CHS

www.chs.md

Guidelines released May  2003

          Initiate lifestyle modification in all patients with blood pressure > 140 systolic or > 90 diastolic over 3 visits with target organ damage (TOD) or 5 visits with no TOD. Initiate Rx immediately if BP > 180/105.

          Initial Rx for systolic/diastolic HTN in absence of compelling indication: Low dose thiazide; ACE-I /ARB; long-acting DHP-CCB; b-blocker. No age distinction in initial therapy.

          Use Rx individualized to patient requirements if associated risk factors, target organ damage or concomitant disease/condition

          Isolated systolic HTN: LDD/long-acting DHP-CCB/ARB

          Avoid b-blocker or a-blocker as initial Rx HTN 60yr.

          ACE-I not recommended for blacks without another compelling indication.

          Type 2 diabetes with micro-albuminuria, proteinuria or nephropathy ACE-I/ARBs are 1st line Rx

 

Diabetes

 

2003 CDA

Guidelines released Dec  2003

 

          Dx DM: FBG 7.0 mmol/L or 2 hr PCG11.1 mmol/L.(Normal: A1C ≤ 6;  FG 4-6 mmol/L; 2 hr PCG 5-8 mmol/L. IFG 6.1-6.9 mmol/L. IGT 2 hr PCG 7.8-11 mmol/L).

          Target euglycemia ASAP. Initiate dietweight loss (5-10%), diabetes education & exercise program. Target A1C ≤ 7; FG 4-7 mmol/L; 2 hr PCG 5-10 mmol/L. Rx oral hypoglycemic for FBG 7.0 mmol/L & A1C 7-9.Consider initial combination Rx for A1C ≥9 mmol/L.

          Aggressive BP control. Target <130/80 Rx ACE-i , ARB, cardio-selective b-blocker, thiazide diuretic, long acting CCB. BP target 125/75 for diabetic nephropathy eliminated. (differs from CHS)

 

Physical activity:

Minimum goal

30 minutes 3 to 5 times/week

          Assess risk, preferably with exercise test, to guide prescription.

          Encourage minimum of 30-40 minutes of moderate intensity activity 3 to 5 times weekly            (walking, jogging, cycling or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, using stairs, gardening, household work)

          Max benefits 5 to 6 hours per week. Medically supervised programs for moderate to high-risk patients.

 

Obesity/weight

management:

Start intensive diet and appropriate physical activity intervention, as outlined above, in patients >120% of ideal weight for height. Particularly emphasise need for weight loss in patients with hypertension, elevated triglycerides or elevated glucose levels. Ideal body weight BMI < 25.

 

Antiplatelet agents/

anticoagulants:

 

Start aspirin 80-325 mg per day if not contraindicated. Consider clopidogrel 75mg OD post MI, post CABG, CVA, PVD in ASA intolerant or allergic patients (CAPRIE Trial). Consider clopidogrel 75mg  OD + ASA for ACS: unstable angina/non-ST elevation MI (CURE Trial: duration of therapy 9-12 months)

Consider warfarin for post MI patients not able to take aspirin (maintain INR 2-3).

 

ACE inhibitors

Post-MI/LV Dysfunction:

Start early post-MI in stable high risk patients (anterior MI, previous MI, Killip class II (S3 gallop, rales, radiographic CHF). Continue indefinitely for all with LV dysfunction (EF<40%) or symptoms of CHF.

Use as needed to manage HPT or symptoms in all other patients.

 

ACE inhibitors

Vascular disease/Diabetes

Rx ACE inhibitors in all patients  >55 yrs with evidence of vascular disease or DM and one other risk factor: HOPE Trial-Ramipril 2.510 mg OD or all CAD patients >18 yrs EUROPA Trial-Perindopril 48 mg OD

 

Beta-blockers:

Post-MI

Start acutely or within a few days of event in all post-MI patients (unless contra-indication). Continue indefinitely if residual ischemia, heart failure,LV dysfunction or severe co-morbidity.  Continue indefinitely   in low risk patients (IIa). Rx as needed to manage angina, arrhythmia or HPT.

 

Beta-blockers:

CHF

Rx Beta-blocker to ACE-inhibitor/diuretic/+/- digoxin in stable Class II-IV CHF/LVEF 40%

Bisoprolol 1.25 10 mg OD, carvedilol 3.125 mg BID 25 mg BID (50 mg BID if weight > 85 kg) 

or metoprolol 12.5 mg 75-100 mg BID

 

Homocyst(e)ine

Target 10 mmol/L

Check in patients with premature CAD/CVD/PVD; family history premature atherosclerosis or manifest atherosclerosis & no identifiable risk factors. Folic acid 2.5 mg, B6 25 mg, B12 250 mcg.

 

Estrogens:

HRT not recommended for 10  prevention. Use established preventative strategies. Consider HRT or SERMS for non-cardiac indications. Individualize recommendations consistent with other health risks (VTE, endometrial or breast CA).  HRT not indicated in 20  prevention. D/C HRT in ACS, MI, PTCA,CABG,CHF,Sx.

 

Rx ()

Risk Intervention

Date 

Achieved

Date 

Achieved

Date 

Achieved

Date 

Achieved

Date 

Achieved

Date 

Achieved

 

Ideal body weight:

BMI < 25 __________

Target  ____________

 

 

 

 

 

 

 

Girth: Targets

F< 90 cm M< 100 cm

 

 

 

 

 

 

 

Physical activity:

Minimum goal

30 minutes 3 to 5 times/week (total/wk)

 

 

 

 

 

 

 

Smoking Goal:

Complete cessation

 

 

 

 

 

 

 

Lipid Management:

 

 

 

 

 

 

 

 

Primary goal:

LDL < 2.5 mmol/L

 

 

 

 

 

 

 

Secondary goal_

TC/HDL< 4

 

 

 

 

 

 

 

Metabolic Syndrome

HDL 1.0 mmol/L M

HDL 1.3 mmol/L F

 

 

 

 

 

 

 

TG < 1.7 mmol/L

 

 

 

 

 

 

 

Blood pressure:

Target  135/85 mm Hg  on home BP/ABP

 

 

 

 

 

 

 

Diabetes: Targets

FBS 4-7 mmol/L

2hr PCG 5-10 mmol/L 

A1C 7%

 

 

 

 

 

 

 

MAU: Targets

Spot urine < 20 mg/L

ACR <  2.0 Men 

ACR <  2.8 Women 

 

 

 

 

 

 

 

Antiplatelet agents:

 

 

 

 

 

 

 

Anticoagulants:

Target INR ______

 

 

 

 

 

 

 

ACE inhibitors:

Post-MI

 

 

 

 

 

 

 

ACE inhibitors:

Vascular disease

 

 

 

 

 

 

 

Beta-blockers:

Post-MI

 

 

 

 

 

 

 

Beta-blockers/CHF:

 

 

 

 

 

 

 

Homocyst(e)ine

  10 mmol/L

 

 

 

 

 

 

 

LP(a) < 30 mg/dL

 

 

 

 

 

 

 

hs-CRP< 3.0 mg/L

 

 

 

 

 

 

 

HRT: On/off