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IntegratingAggressiveCVRiskManagementinPrimaryCareHighprevalenceofmultipleCVriskfactors

inUSadultsCDC.MMWR.2005;54:113-40.BehavioralRiskFactorSurveillanceSystem,2003≥2ofhypertension,hypercholesterolemia,diabetes,smoking,physicalinactivity,obesity40.0%–46.2%36.0%–39.9%33.0%–35.9%27.0%–32.9%INTERHEART:ExponentialriseinCVdiseasewithaddedriskfactorsOdds

ratiofor

1stMI*

(99%CI)6451216122561283284Smk

(1)DM

(2)HTN

(3)ApoB/

A1ratio

(4)1+2+3All4All4

+ObesAll4

+PsAll9risk

factors2.92.41.93.313.042.368.5182.9333.7YusufSetal.Lancet.2004;364:937-52.Smk=smoking;DM=diabetes;HTN=hypertension;

Obes=obesity;Ps=psychosocialfactors*Plottedonadoublingscale3-fold26-foldINTERHEART:AnysmokingincreasesCVriskTeoKKetal.Lancet.2006;368:647-58.*vsneversmokedN=27,098from52countries1–23–45–67–89–1011–1213–1415–1617–1819–20OddsratioforfirstMI*Cigarettessmoked(n/day)Never≥21-0.751248LifetimeCVDriskestimateandrisk

factorburden70605040302010050607080906950463656050403020100Men

(n=3564)Women(n=4362)AdjustedcumulativeincidenceofCVD

(%)5060708090≥2MajorRFs1MajorRF≥1ElevatedRF≥1NotoptimalRFAlloptimalRFs705039278Attainedage(years)Lloyd-JonesDMetal.Circulation.2006;113:791-8.2-foldinhigheragegroupAdditiveriskofagewithhypertension+hypercholesterolemiaWongNDetal.AmJCardiol.2006;98:204-8.

NHANES2001-2002;N=286426.552.743.121.4ClinicalmanifestationsofobesityInsulin

resistanceGlucotoxicityLipotoxicityAdiponectinLeptinAtherosclerosisCourtesyofSelwynAP,WeissmanPN.2006.Type2diabetesand

glycemicdisordersFFAsDyslipidemiaLowHDLSmall,denseLDLHypertriglyceridemiaHypertensionEndothelialdysfunction/

inflammation(hsCRP)Impairedthrombolysis

PAI-1MetabolicconsequencesofvisceralobesityVisceral/abdominalobesityCorrelatesmorestronglywithinsulinresistancethanlowerbodyobesityIsassociatedwithplasmalevelsoffattyacidsandaccompanyingTG Insulinresistance Alteredhepaticfataccumulationandmetabolism Dyslipidemia Proinflammatoryadipokines(insulinresistance,riskforCVdisease)VisceralfatcorrelatesmorestronglywithinsulinresistancethansubcutaneousfatGrundySMetal.Circulation.2005;112:2735-52.DesprésJ-Petal.BMJ.2001;322:716-20.VisceralobesityinCVriskCTscansfrommenmatchedforBMIandtotalbodyfatWhite=visceralfatarea(VFA);black=subcutaneousfatDesprésJ-P.EurHeartJSuppl.2006;8(supplB):B4-12.SubcutaneousobesityFatmass:19.8kgVFA:96cm2Visceralobesity

Fatmass:19.8kgVFA:155cm2Visceralobesity

drivesCVriskprogressionindependentofBMIMeasurementofwaistcircumferencemayofferamoreuseful

surrogatemarkerofvisceraladipositythanwaist-hipratioOptimalmarker(s)forvisceraladiposityDesprésJPetal.BMJ.2001;322:716-720.MeasuringwaistcircumferenceIliaccrestCDCProjections–2005to2050:DiabetesfocusNarayanKMVetal.DiabetesCare.2006;29:2114-6.*Revisedprojection“appearsmorealarmingthanpreviouslyestimated”32.1millionnewdiabetespatientsby2050*174%220%470%423%606%inblacks≥75yr20502005Individualswithdiabetes(millions)Diabetes

2005-2050(%)Multipleriskfactors:UndertreatedandpoorlycontrolledWongNDetal.AmJCardiol.2006;98:204-8.

NHANES2001-2002;n=638withhypertensionandhypercholesterolemiaSuddencardiacdeath:Toooftenthefirstsign

ofCVdiseaseFoxCSetal.Circulation.2004;110:522-7.50%ofsuddencardiacdeathsoccurinpersons

withnoCVdiseasehistoryCalltoactionIdentifyall

riskfactorsBasetreatment

onglobalriskassessmentTreatmultiple

riskfactorsaggressivelyCVeventsABCsofmultipleriskfactormanagementAAspirin

ACEinhibition

A1CcontrolBBPcontrol

-blockadeCCholesterolmanagementControlweightDDietDon’tsmokeEExercisePlateletactivation

andaggregationHypertensionHyperglycemia/InsulinresistanceDyslipidemiaAdaptedfromCohenJD.Lancet.2001;357:972-3.

BeckmanJAetal.JAMA.2002;287:2570-81.AHAdietandlifestylerecommendationsHealthydietFruits,vegetables,legumes,wholegrains,non-fat/low-fatdairy,fish,poultry,limitedalcoholintakePhysicalactivity≥30minonmostdaysNosmokingAvoiduseofandexposure

totobaccoproductsLichtensteinAHetal.Circulation.2006;114:82-96.CVriskWeightlossimprovesCVriskfactorsSj?str?mLetal.NEnglJMed.2004;351:2683-93.Conventionaltreatment

(n=1660)Gastricsurgery

(n=1845)*At2yearsN=4047withobesity3-Weekdiet+exerciseregimenyieldsfavorablemetabolicchanges*P<0.01?P<0.05RobertsCK.etal.JApplPhysiol.2006;100:1657-65.μU/mLN=31overweight/obesemen;weight8.4lbsBaselineFollow-upPhysicalactivityreducesCVandall-causemortalityFangJetal.AmJHypertens.2005;18:751-8.N=9791;moderatephysicalactivityvslittleornophysicalactivity0.75(0.53–1.05)0.76(0.39–1.49)0.79(0.65–0.97)All-causedeathCVdeathAll-causedeathPrehypertensionCVdeathHypertensionHazardratio1.51.00.5NormalBP02.0All-causedeathCVdeath0.79(0.58–1.09)0.88(0.80–0.98)0.84(0.73–0.97)AdjustedHR(95%CI)Favors

exerciseFavors

noexerciseNHANES1EpidemiologicalFollow-upSurvey(1971–1992)Diet惱ary討prog年rams速can訓(xùn)be籌effe不ctiv戒eye精tdi拒ffic烏ult惜to文main電tainDans你inge睛rML坦et債al.JAMA.20塊05;2釀93:4己3-53屯.N=呈16且0o尖ver雄wei運ght泄or數(shù)ob木ese壓wi則th辯≥1革CV秩ris溉kf野act筍orEmer睬ging他str趨ateg貝ies框inw裹eigh筍tco孝ntro謝lLife荒styl披ein階terv路enti徹ons伴must困inc摟lude墾bot陪hdi姻et閥and浴exer弟ciseEve預(yù)nm抹ode躍rat貧ew斗eig些ht瞞los桌s(幣5%–團(tuán)10%閃)c誤an:Decr推ease幅car念diom隊etab烘olic邀ris遵kfa隔ctor伴sEnc魔our替age戶co仿nti零nue何dh板eal袖th-血pro民mot企ing固be礦hav敏ior鑰sa東nd獻(xiàn)adh揪ere蟲nce燭to則me店dic壇al求the浪rap哥yNove艇lap食proa冶ches檔todec咬rea公sin弱gcar值dio直met疑abo捉lic作ri需sk雕fac指tor葵sa族re博nee純dedEcke察lRH宿et才al.Circ睬ulat叔ion.20緞06;1當(dāng)13:2構(gòu)943-慰6.Gelf焦and愉EV,戴Cann塔onC踩P.J耐Am段Co栗ll欣Car熱dio扣l.200嫂6;4聾7:1潔919唱-26是.Goal默sfo第rop撐tima芳lhe流althAAC味E.Endo機crP去ract.2昌002陰;8(價sup獸pl個1):胸40-益82.LifestyleinterventionDietPhysicalactivitySmokingcessationWeightcontrolAggressivemanagement

ofcomorbidconditions*LipidmodifyingBPloweringASAforprevention

ofvascularevents*Dyslipidemia,hypertension,earlyrenaldiseaseIntensiveglycemiccontrolA1C≤6.5%Glucose(mg/dL)Preprandial≤110Postprandial≤140Ste悟no-而2:財Rat霉ion絹ale隔fo姿rT則arg列et-哭D(zhuǎn)ri獅ven距Be背hav小ior搞Mo乘dif成ica膛tio廊na奶nd盒Pol姐yph昆arm最acySte抱no-接2:杜Goa葛ls查of酬int喪ens懸ive塑ph徐arm代aco和log提ic灶str積ate架gyTherapyGoalACEinhibitorsAllpatients(ARBs,ifcontraindicated)AspirinAllpatients(150mg/d)BPcontrol<130/80mmHgLipidcontrolTotal-C<175mg/dLTriglycerides<150mg/dLGlucosecontrolA1C<6.5%G?d器eP拳et欣al嚇.NE襖ngl隸J憤Med.20清03;3把48:3蠅83-9犬3.Sten枕o-2浙resu比lts:狗Bet段ter瞎cont困rol燃with牽int往ensi駕vet色hera界pyG?de宜Pe絨tal拆.NEn況glJ謙Med.20組03;3研48:3見83-9遼3.Con犧ven丸tio筍nal喬th筑era群py豬(n預(yù)=8四0)Int閥ens撫ive咬th跨era妙py賤(n懂=8測0)Fol植low票-up筐(y撈ear尋s)Fol苗low匹-up陜(y農(nóng)ear母s)0123456785015025035000123456781101301501700SBP挖(mm切Hg)P<材0.00漂1Tota關(guān)l-C右(mg/躍dL)P<暗0.閉001012345678501502503500AlC均(%哄)P<奸0.00眾1TG丸(m歷g/d鼻L)P=著0.01床5012345678579110Sten串o-2:卷Mul跑tifa梨ctor箏ial推inte裙rven菊tion艷imp混rove混sma湖crov當(dāng)ascu嫩lar棄outc連omesG?de曉Pe振tal刮.NEn饅glJ團(tuán)Med.2藍(lán)003箏;34邊8:3團(tuán)83-詳93.*CV覺deat貿(mào)h,M臭I,s房誠trok沿e,r墳evas騙cula貧riza釋tion吧,am香puta舅tion釀,PA筑Dsu芳rger伴y;?Una宋dju新ste籮dPrim膽ary組com叫posi快te擋outc患o(jì)me*麻(%閘)Foll駕ow-u些p(m向onth撥s)6050403020100Conv員enti捆onalInt剛ens把ive01224364860728496NNT剝=5芒Abso蕩lute銀ris慘kre蔥duct藥ion腳=20粗%53%RRR?

P=0.01N=援160競with擱typ予e2勇diab夾etes蜜and到mic旅roal沙bumi陳nuri壯aSte羞no-域2:叼Int毅ens尚ive透in綁ter懸ven懇tio清ni跌mpr領(lǐng)ove館sv遼asc言ula爭ra醉nd夫neu頭rop廟ath躁ic趟out淋com池esG?d著eP瓦et副al熄.NE壘ngl核J唐Med.20柳03;3剃48:3稻83-9嚼3.0.01.02.0NephropathyRetinopathyAutonomic

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