Enhancing our Patients Compliance with their Medical Regimen

1
Enhancing our Patients Compliance with their
Medical Regimen

• Phil Mendys, Pharm D, FAHA, CPP,
• Co-Director, UNC Lipid and
• Prevention Clinic

2
Disclosures

• Dr. Mendys is an employee of Pfizer and works as
  a Senior Director in Medical Affairs.
• Dr. Mendys carries both academic and clinical
  appointments at the University of North Carolina
  in the School of Medicine-Division of Cardiology
  and the School of Pharmacy- Pharmacotherapy and
  Experimental Therapeutics.

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(No Transcript)
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Talk Objectives

• Key Concepts in Medication Adherence
• Making the case for supporting Adherence Programs
  Case Study with Dyslipidemia
• Cardiac Rehabilitation A Perfect Match to
  Improve Patient Outcomes
• Patient Provider Quiz-
• Facts and misperceptions

5
Heart medicine advances helppatients enjoy
active lifeBritish Heart Foundation July 9, 2011

• In the 1960s, there was no treatment for a heart
  attack. If they survived, victims were confined
  to a hospital bed, given painkillers and told to
  take complete restIf they died in their 50s or
  60sit was considered a fact of life

6
The Burden of Chronic Disease

• poor adherence increases with the duration and
  complexity of treatment regimensduration and
  complex treatment are inherent to chronic
  illnesses. Across diseases, adherence is the
  single most important modifiable factor that
  compromises treatment outcome.
• - World Health
  Organization, 2003

7
The Five Dimensions of Adherence

• Health System/Health Care Team Factors
• Patient-related Factors
• Social/Economic Factors
• Condition-related Factors
• Therapy-related Factors

HCT health care team
World Health Organization. World Health
Organization Geneva, Switzerland. 2003.
8
Health Care System Factors That Affect Adherence
Extent to which the health care system
facilitates or impedes providers
adherence-related activities Organizational
structures and processes

• Resources and set policies that support optimal
  practices
• Provision of preventive services
• Integration of other health care professionals as
  part of the treatment
• To augment role of primary providers
• To provide more intensive intervention when
  needed
• Mandatory provisions that allow
• Educating providers about guidelines
• Training in treatment strategies (including
  patient counseling)
• Providing office support mechanisms
• Cost

Koeck C. BMJ. 19983171267-1268 Ockene IS, et
al. J Am Coll Cardiol. 200240630-640.
9
Case Study Cholesterol ManagementWhen to Start
Cholesterol Lowering Therapy in Patients with
Coronary Heart DiseaseA Statement for Healthcare
Professionals From the AHA Task Force on Risk
Reduction

• several studies suggest that plasma lipoprotein
  measurements can be made immediately upon
  admission to the hospital for acute coronary
  syndromes to establish a baseline cholesterol
  levels.
• If LDL cholesterol gt 130 at time of discharge, a
  cholesterol-reducing drug can reasonably be
  started at time of discharge
• one important issue concerns responsibility for
  initiating cholesterol-lowering therapy in the
  setting of acute coronary eventsdivided
  responsibility often lead to no therapy at all.

Circulation. 1997 951683-85
10
Improved Treatment of Coronary Heart Disease by
Implementation of Cardiac Hospitalization
Atherosclerosis Management Program (CHAMP)
Fonarow G., et.al. Am J Cardiol 2001 87819-22
11
Provider Factors

• Counseling skills
• Involvement of patients in decision-making/plan
  of care
• Time constraints
• Knowledge, awareness, adherence to clinical
  practice guidelines
• Individual vs team-provider approach

12
Recognizing Predictors of poor adherence
N Engl J Med 2005353487-97.
13
What Drives Health Care Team to Improve
Adherence?

• Knowledge of the broad determinants of
  nonadherence
• Ability to assess, detect, and understand the
  potential for nonadherence
• Understand how patients might progress to
  adherence
• Develop specific strategies for addressing
  adherence
• Tailor interventions to the needs of individual
  patients

World Health Organization. World Health
Organization Geneva, Switzerland, 2003.
14
A Tool to Improve Adherence
15
Patient Factors

• Knowledge, attitudes, skills
• Organic factors (memory, cognitive-information
  processing)
• Self-efficacy
• Decision-making processes discounting
• Co-morbidities/complexity of therapeutic regimen
• Individual resources

16
Patient Reasons for Nonadherence
Just forget
Dont think its necessary all the time
Hate taking drugs
Dont like being dependent
Drugs give me side effects
Dont think drugs are working
Too expensive
Dont like being told what to take
Supply will last longer
Other
Prospective, open-label, interview-based study in
metropolitan New York area pharmacies (N821).
Cheng JWM, et al. Pharmacotherapy.
200121828-841.
17
Health Literacy and Heart Disease

• Over the past 50 years, we have learn a lot about
  the relationships between risk factors and the
  cause of cardiovascular illness, but we have much
  work yet to do in the area of preventing heart
  disease.
• Ones ability to read, listen, and comprehend
  health information is a vital element of
  maintaining and improving health, including the
  prevention of chronic illness.
• Evidence has shown that improved knowledge of
  ones condition may improve patient adherence to
  lifestyle changes and the use of preventive
  medication, however-

Vascular Health and Risk Management 20062(4)
18
Literacy Skills and Calculated 10-Year Risk of
Coronary Heart Disease
Literacy skills 1. reading comprehension,2.num
eracy 3. oral language (speaking) 4. aural
language (listening)
J Gen Intern Med DOI 10.1007/s11606-010-1488-5,
published online Aug 10, 2010
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A meta-analysis of the association between
adherence to drug therapy and mortality

• good adherence was associated with lower
  mortality
• association between good adherence to placebo and
  mortality supports the existence of the healthy
  adherer effect
• adherence to drug therapy may be a surrogate
  marker for overall healthy behavior.

BMJ 20063331-6
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What Drives Patients to Improve Adherence?

• People learn best by active participation
• Individuals need to have adequate information
• Individuals need to believe in their ability to
  make changes (self-efficacy) and have positive
  expected outcomes
• Individuals need skills, support, resources
• Interventions need to be tailored to the
  individual or organization and its social context

Bandura A. Social Foundations of Thought and
Action A Social Cognitive Theory. Englewood
Cliffs, NJ Prentice Hall 1986.
21
Adherence Social/Economic Factors

• Formal/informal support from members of the
  community
• Awareness level of policy makers and health
  managers
• Application of adherence materials to different
  socioeconomic settings
• Health system programs promoting
  adherence/self-management
• Socioeconomic status, literacy/education,
  employment, living conditions, distance from
  treatment center, transportation, medication
  cost, environment, culture/beliefs about
  illness/treatment, fear of health care system,
  and family dysfunction
• Poverty and chronic disease interrelationships,
  compounding non-adherence

World Health Organization. World Health
Organization Geneva, Switzerland. 2003.
22
Societal Factors

• Examples
• Obesity
• Food used to be expensive now its cheap
• Physical activity used to be cheap now its
  expensive
• Smoking
• Was associated with style and freedom of choice
  now its considered unhealthy and socially
  incorrect

23
Adherence Condition-related Factors

• Illness-related demands faced by the patient,
  affecting patients risk perception and the
  priority placed on adherence
• Severity of symptoms and level of disability
• Severity of the disease and rate of disease
  progression
• Availability of effective treatments
• Co-morbidities, such as depression
• Drug and alcohol abuse

World Health Organization. World Health
Organization Geneva, Switzerland. 2003.
24
Better Knowledge Improves Adherence to
Lifestyle Changes and
Medication in Patients With CHD

• Men and women, lt71 years, who had a cardiac event
  (n509)
• 392 interviewed, examined, and received a
  questionnaire
• 347 completed questionnaire about their general
  knowledge of CHD risk factors, compliance to
  lifestyle changes, and drug adherence
• Statistically significant correlation between CHD
  risk factor knowledge and compliance to certain
  lifestyle changes (weight, physical activity,
  stress management, diet, attaining lipid level
  goals, likelihood of taking prescribed
  antihypertensives)
• No correlation between this knowledge and blood
  glucose or blood pressure levels nor smoking
  habits or treatment patterns for prescribed
  lipid- and blood glucose-lowering drugs
• Knowledge correlated to patient behavior with
  respect to some risk factors, which should be
  recognized in prevention programs

Alm-Roijer C, et al. Eur J Cardiovasc Nurs.
20043321-330.
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Adherence Therapy-related factors

• Complexity of the medical regimen, concomitant
  medications
• Frequency and duration of treatment
• Previous treatment failures
• Frequent changes in treatment
• Immediacy of beneficial effects and side effects,
  availability of medical support to deal with them

World Health Organization. World Health
Organization Geneva, Switzerland. 2003.
26
Nonadherence to Statin Treatment begins early
Adherence continues to drop over time,
particularly when treating the asymptomatic
patient
Adapted from cohort study using linked
population-based administration data from
Ontario, Canada (N85,020). Jackevicius et al.
JAMA. 2002288462-467.
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Adherence Measurements

• Patient self-reports or questionnaires
• Clinician perception
• Pill counts
• Electronic monitoring devices
• Biochemical measurement or pharmacologic tracers
• Electronic prescription refill records (refill
  rates)

Most adherence research is observational, rather
than Conducted in a trial setting, to better
reflect real-world patient behavior.
Sikka R, et al. Am J Manag Care. 200511449-457
World Health Organization. World Health
Organization Geneva, Switzerland, 2003.
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Meta-analysis of trials of interventionsto
improve medication adherence

• Medication non-adherence has a profound negative
  impact on every
• aspect of health care. For decades we have
  searched for that one perfect solution to the
  problem however, there does not seem to be any
  one
• intervention that robustly enhances adherence,
  perhaps because so many
• variables affect a patients decision to take a
  drug. A combined approach intuitively may best
  address patients needs, but more data must be
  collected through standardized research methods.
  Studies focusing on the relationship between
  adherence and health outcome measures, specific
  interventions, and cost-effectiveness and between
  adherence and various combinations of
  interventions are needed
• Conclusion
• Meta-analysis of studies of interventions to
  improve medication adherence
• revealed an increase in adherence of 411. No
  single strategy appeared to be best.

Am J Health-Syst PharmVol 60 Apr 1, 2003
29
Thus, a Multifaceted Approach to Patient
Treatment is Required
Payers
(employers/HP/PBM)
Pharmacy
IVR
AdhereRx
AdhereRx
HAL, CAVEAT Pilot
HAL, HEART
Physician
Physician
AdhereRx
CareMark Refill Reminder
Pharmacy First
House CallPoster
Starters
Physician
Physician
Pharmacy bag
Pharmacy bag
CVS Mailer
newsletter
newsletter
direction to
direction to
patient
patient
Patient
Refill Reminder
Refill Reminder
Starters
Starters
Letters
Letters
Follow
-
up
Follow
-
up
Follow
--
up
Follow
-
-up
with patient
with patient
with patient
with patient
Starters
House Call Radio
800 IVR
800 IVR
Family/
Nurse
DTC Print
DTC Print
Peers
Website
Web
DTC TV
DTC TV
Direct Mail
My Heart Wise
Outbound Direct Mail
Direct to Consumer
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The challenge of non-adherence

• More than 50 of patients with diabetes,
  hypertension, tobacco addiction, hyperlipidemia,
  congestive heart failure, asthma, depression, and
  chronic atrial fibrillation are currently managed
  inadequately.1-9
• 18,000 Americans die each year from heart attacks
  because they did not receive preventive
  medications, although they were eligible for
  them.10-11
• Low adherence to prescribed treatments is common
  typical adherence rates for prescribed
  medications are 50 with a range of 0100.12
• 1/3 or more of ambulatory patients take
  prescribed doses at intervals that frequently are
  longer than prescribedhours, days, sometimes
  weeks.13
• Within 6 months, 60 of patients discontinue
  their CV prevention medications.

1. Institute of Medicine, 2003c 2. Clark et al.,
2000 3. Joint National Committee on Prevention,
1997 4. Legorreta et al., 2000 5. McBride et
al., 1998 6. Ni et al., 1998 7. Perez-Stable
and Fuentes-Afflick, 1998 8. Samsa et al., 2000
9. Young et al., 200110. Chassin, 1997 11.
Institute of Medicine, 2003a. 12. Sackett and
Snow, 1979 13. Houston, et al. 1997.
31
Patients Nonadherent to Statin Therapy Are Twice
as Likely to Experience Subsequent MI
Nonadherent
Adherent
P.047
P.001
P.73
4.1
4.1
4.0
3.5
2.1
1.5
Total
Patients lt65 Years
Patients 65 Years
Adherence defined as fill frequency 80 (n661).
Nonadherence defined as fill frequency 60
(n395).
Blackburn DF, et al. Pharmacotherapy.
2005251035-1043.
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As Adherence Goes Down, Health Care Costs and
Hospitalizations Go Up
1-19 Adherence Level
80-100 Adherence Level
100
Sokol MC, et al. Med Care. 200543521-530.
33
The great statin debate -

Do they have magical
properties?

• Dr. Topol Do you believe that statins have
  pleiotropic effects or magical properties?
• Dr. Califf Absolutely
• Dr. Topol Do you think its related to
  inflammatory markers, effect on endothelial
  function, or some unique effect on the vascular
  wall?
• Dr. Califf Nope
• Dr. Topol Is it about early treatment, early
  benefit or intensity?
• Dr. Califf Nah
• Dr. Topol What then do you attribute the magic
  of statins?
• Dr. Califf When patients actually take them.

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UNC LIPID AND PREVENTION CLINIC
35
Patient Knowledge of Coronary Risk
ProfileImproves the Effectiveness of
Dyslipidemia Therapy
24
Communicating risk is consistent with many of the
recommendations to improve adherence, including
enhancing self-monitoring and using the support
of family and friends. Informing patients of
their coronary risk may also increase the
effectiveness of primary prevention by
identifying individuals most likely to benefit
from treatment while reassuring those at low
risk.
21
18
15
High Risk
8-y Cardiovascular Risk,
12
Moderate Risk
9
6
3
Low Risk
0
Sep2002
Dec2002
Mar2003
Jun2003
Sep2003
Dec2003
Month
As a result of these changes, your cardiovascular
age has dropped from 60.8 y to 53.8 y. Your 8-y
cardiovascular risk has dropped from 24.5 to 7.5
Grover SA, et al. Arch Intern Med.
20071672296-2303.
36
Misperception among physicians and patients
regarding the risks and benefits of statin
treatment the potential role of
direct-to-consumer advertisingRachel H. Kon, MD,
Mark W. Russo, MD, Bridget Ory, MD, Phil Mendys,
PharmD,Ross J. Simpson, Jr., MD, PhD
37
Physician Follow-up/Provider Continuity
Associated With Long-term Adherence
Statin Therapy Start Date
Statin Therapy Restart Date
Statin Therapy Stop Date
No Statin Use in Past Year
Statin Rx 1
Statin Rx 2
Statin Rx 3
ControlPeriod
HazardPeriod
Statin Rx n 1
14 d
14 d
90-d Gap inStatin Coverage

• Statin use is dynamic many patients have long
  periods of nonadherence
• An estimated 48 restarted treatment within 1
  year 60 restarted within 2 years
• Continuity of care combined with increased
  follow-up and cholesterol testing could promote
  long-term adherence by shortening or eliminating
  long gaps in statin use

Brookhart MA, et al. Arch Intern Med.
2007167847-852.
38
Point-of-Care Lipid Testing

• Address gap in testing to treatment
• Improves option to titrate, adjust Rx
• Gets additional patient engagement
• Improves goal attainment

39
Statin Titration and Goal AttainmentStart with
the end in mind!
14 of patients not at goal on initial dose
reached Goal by 6 months
At Goal on Starting Dose
48
2829 high risk patients
At Goal
(N203)
52
Titrated
Not At Goal
Not At Goal
(N1464)
NOT Titrated
(N448)
(N813)
AJC, Vol 92 July 1, 2003
40
The relationship of vitamin D deficiency to
statin myopathy

• Both statins and vitamin D affect skeletal muscle
  metabolism and function. There is preliminary
  data to suggest that vitamin D deficiency is
  associated with increased statin-associated
  skeletal muscle complaints, but no definitive
  evidence that vitamin D contributes to statin
  myalgia or is effective in its treatment. Vitamin
  D supplementation reduced myalgic symptoms in
  some statin treated patients although a placebo
  effect cannot be excluded. Consequently, it is
  reasonable to determine vitamin D levels in
  statin-myalgic patients and to provide vitamin D
  supplementation in doses of 4002000 IU to those
  with low vitamin D levels (lt32 ng/mL) until
  definitive placebo controlled trials of this
  therapy are available.

Atherosclerosis 215 (2011) 2329
41
Cardiac rehabilitation

• The perfect fit to improve adherence
• Collaborative Team Approach
• Emphasis on Continuity of Care
• Multi-dimensional
• Systematic Process of Care delivery

42
Patients' perspectives on cardiac rehabilitation,
lifestyle change and taking medicines
implications for service development

• Patients tended to talk about the exercise
  component of cardiac rehabilitation and only talk
  about the information provision component when
  prompted, which suggested they viewed the program
  as being primarily about exercise.
• There was little subsequent contact with health
  services, except routine six-monthly check-ups
  for their coronary heart disease.
• Unmet information needs were common, especially
  about medicines
• Ensuring that individual patients'
  information needs about medicines and lifestyle
  are adequately met remains a key focus for
  cardiac rehabilitation development.

jhsrp.2009.009103v1 15/suppl_2/47
43
The challenge of improving evidence-basedtherapy
adherence in the secondary prevention of coronary
artery disease the next frontier of cardiac
rehabilitation

• Non-adherence to prescribed drug regimens is an
  increasing medical problem affecting physicians
  and patients and contribute to negative outcomes,
  such as the increased risk of subsequent
  cardiovascular events. Analysis of various
  patient populations shows that the choice of
  drug, its tolerability and the duration of
  treatment influence the non-adherence.
  Intervention is required toward patients and
  health-care providers to improve medication
  adherence. This review deals about the prevalence
  of non-adherence to therapy after medical and
  surgical cardiac event, the risk factors
  affecting non-adherence and the strategies to
  implement it. Interventions that may successfully
  improve adherence should include improved
  physician compliance with guidelines, patient
  education and patient reminders, frequent visits
  or telephone calls from staff, simplification of
  the patient's drug regimen by reducing the number
  of pills and daily doses. Since single
  interventions do not appear efficacious, it is
  necessary to establish multiple interventions
  simultaneously addressing a number of barriers to
  adherence.

Monaldi Arch Chest Dis. 2009, reference in Italian
44
Predictors of Smoking CessationAfter a
Myocardial Infarction
While individual smoking cessation counseling was
not associated with smoking cessation post-MI,
hospital-based smoking cessation programs, as
well as referral to cardiac rehabilitation, were
strongly associated with increased smoking
cessation rates.
Arch Intern Med. 2008168(18)1961-1967
45
Long-term Medication Adherence after
MyocardialInfarction Experience of a Community

• CLINICAL SIGNIFICANCE
• ? More than 50 of the patients discontinue each
  of the cardio-protective medications after a
  myocardial infarction over a 3-year period.
• ? Clinical characteristics of the myocardial
  infarction were not associated with long-term
  medication adherence.
• ? Enrollment and use of cardiac rehab is
  associated with better long-term medication
  adherence.

The American Journal of Medicine (2009) 122,
961.e7-961.e12
46
ACCF/AHA/AMAPCPI 2011 Performance Measures for
Adults With Coronary Artery Disease and
Hypertension

• 3.3.2. Medication Adherence
• objection to the use of patient adherence as a
  measure of physician quality is that, although
  prescribing physicians have some influence on
  patient choices, adherence is largely not in the
  individual physicians locus of control.
• reliable information on patient adherence is
  often difficult and expensive to obtain.
• it believed that measures of adherence, such as
  those included in HEDIS (Healthcare Effectiveness
  Data and Information Set), could be used at the
  health plan, employer, or health system levels as
  effective quality improvement tools.

JACC Vol. 58, No. 3, 2011
47
Adherence as a Health Care Priority
48
Quiz
49
The Framingham risk score estimates 10-year
absolute risk for cardiovascular disease events
and age contributes enormously to the end result,
given that indeed age is the greatest contributor
to absolute cardiovascular risk. However, the
Framingham Risk Score is less robust in the
elderly (age gt 70) as this group becauseA) the
likelihood of CV events decreases after age 70B)
have already had their age-based exposureC)
cholesterol management in this group appears to
provide no benefitD) the risk benefit ratio of
treating these patients limits treatment
considerationsE) none of the above
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY
Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel
III) Full Report Final Report nih.gov
50
The Framingham risk score estimates 10-year
absolute risk for cardiovascular disease events
and age contributes enormously to the end result,
given that indeed age is the greatest contributor
to absolute cardiovascular risk. However, the
Framingham Risk Score is less robust in the
elderly (age gt 70) as this group becauseA) the
likelihood of CV events decreases after age 70B)
have already had their age-based exposureC)
cholesterol management in this group appears to
provide no benefitD) the risk benefit ratio of
treating these patients limits treatment
considerationsE) none of the above
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY
Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel
III) Full Report Final Report nih.gov
51
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• The National Cholesterol Education Panel ATP III
  reaffirms their position that older persons who
  are at coronary disease higher risk and are in
  otherwise good health, are candidates for
  cholesterol-lowering therapy. As reported in the
  Cardiovascular Health Study in 2002, the use of
  statin therapy in study participants at baseline
  who were 65 years or older and free of
  cardiovascular disease, resulted in a
• A) Greater than 50 lower risk of CV events and
  more than 40 lower all cause mortality.
• B) Greater than 50 risk reduction for CV events,
  but only 20 reduction in all cause death.
• C) Equal reduction of risk in CV events and all
  cause mortality
• D) Reduction in risk of CV events, but an
  increase of risk associated with adverse events
  of statin therapy
• E) None of the above

Therapy with hydroxylmethylglutaryl Coenzyme A
Reductase Inhibitors (Statins) and Associated
Risk of Incident Cardiovascular Events in Older
Adults evidence from he Cardiovascular Health
Study Rozen LeMaitre, PhD, MHS et.al. Arch IM
2002 162 1395-1400
52
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• The National Cholesterol Education Panel ATP III
  reaffirms their position that older persons who
  are at coronary disease higher risk and are in
  otherwise good health, are candidates for
  cholesterol-lowering therapy. As reported in the
  Cardiovascular Health Study in 2002, the use of
  statin therapy in study participants at baseline
  who were 65 years or older and free of
  cardiovascular disease, resulted in a
• A) Greater than 50 lower risk of CV events and
  more than 40 lower all cause mortality.
• B) Greater than 50 risk reduction for CV events,
  but only 20 reduction in all cause death.
• C) Equal reduction of risk in CV events and all
  cause mortality
• D) Reduction in risk of CV events, but an
  increase of risk associated with adverse events
  of statin therapy
• E) None of the above

Therapy with hydroxylmethylglutaryl Coenzyme A
Reductase Inhibitors (Statins) and Associated
Risk of Incident Cardiovascular Events in Older
Adults evidence from he Cardiovascular Health
Study Rozen LeMaitre, PhD, MHS et.al. Arch IM
2002 162 1395-1400
53
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• Persons greater than the age of 65 account for
  approximately two out of three first major
  coronary events, and CHD deaths account for about
  ½ of all CHD events. If we accept the premise
  that statin therapy reduces risk for all CHD
  event categories, then the likely mortality
  benefit of statins is reasonably stated at
• A) 40
• B) 33
• C) 70
• D) 50
• E) None of the above

Ref Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult TreatmentPanel III)
Full Report Final Report nih.gov
54
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• Persons greater than the age of 65 account for
  approximately two out of three first major
  coronary events, and CHD deaths account for about
  ½ of all CHD events. If we accept the premise
  that statin therapy reduces risk for all CHD
  event categories, then the likely mortality
  benefit of statins is reasonably stated at
• A) 40
• B) 33
• C) 70
• D) 50
• E) None of the above

Ref Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult TreatmentPanel III)
Full Report Final Report nih.gov
55
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• Choose the one best answer which addresses the
  issues of Therapeutic Lifestyle in older
  patients.
• a) Weight reduction goals and increased physical
  activity are less critical for patients over the
  age of 65.
• b) Patients should be encouraged to reduce intake
  of saturated fats (7 of total calories) and
  cholesterol (200 mg /day). This Step I diet is
  then followed by a more restrictive Step II diet
  to achieve more reasonable treatment goals
• c) the clinician may consider drug therapy at a
  period of 4 to 6 weeks in older patients who are
  not approaching their respective treatment goal.
• d) Plant stanols and soluble fiber should be
  restricted in older patients due to the risk of
  sever GI intolerance.
• e) none of the above.

Lipid Management and the Elderly Mi Michael H.
Davidson, MD, Sara B. Kurlandsky, PhD, Ruth M.
Kleinpell, PhD, RN, Kevin C. Maki, PhD Prev
Cardiol 6(3)128-133, 2003
56
QUESTIONS FOR LIPID MANAGEMENT IN THE ELDERLY

• Choose the one best answer which addresses the
  issues of Therapeutic Lifestyle in older
  patients.
• a) Weight reduction goals and increased physical
  activity are less critical for patients over the
  age of 65.
• b) Patients should be encouraged to reduce intake
  of saturated fats (7 of total calories) and
  cholesterol (200 mg /day). This Step I diet is
  then followed by a more restrictive Step II diet
  to achieve more reasonable treatment goals
• c) the clinician may consider drug therapy at a
  period of 4 to 6 weeks in older patients who are
  not approaching their respective treatment goal.
• d) Plant stanols and soluble fiber should be
  restricted in older patients due to the risk of
  sever GI intolerance.
• e) none of the above.

Lipid Management and the Elderly Mi Michael H.
Davidson, MD, Sara B. Kurlandsky, PhD, Ruth M.
Kleinpell, PhD, RN, Kevin C. Maki, PhD Prev
Cardiol 6(3)128-133, 2003
57
BACK UP SLIDES
58
Poor health literacy a hidden risk factor

• Low health literacy has been associated with
  non-adherence to treatment plans and medical
  regimens, poor patient self-care, high healthcare
  costs, and increased risk of hospitalization and
  mortality. realizing that health literacy affects
  prognosis affords the opportunity to better
  understand the causes of poor outcome and develop
  interventions to address this issue. Many
  cardiovascular diseases have complex mechanisms
  and etiologies and can be difficult for patients
  to understand. low health literacy, therefore,
  presents a particular challenge in treating the
  cardiac patient.

nature reviews cardiology volume 7 Sept 2010
59
Niacin in Patients with Low HDL Cholesterol
Levels Receiving Intensive Statin Therapy- AIM
HIGH
10.1056/nejmoa1107579 nejm.org/NEJM Nov 15, 2011
60
Primary Outcome by Treatment Group and Baseline
Subgroup - ACCORD
The ACCORD Study Group. NEJM 2010
36217,1563-1574.
61
Vitamin D deficiency, myositismyalgia, and
reversible statin intolerance
Current Medical Research Opinion Vol. 27, No.
9, 2011, 16831690
62
Practical support predicts medication adherence
and attendance at cardiac rehabilitation
following acute coronary syndrome
Journal of Psychosomatic Research 65 (2008)
581586
63
Erectile Dysfunction Risk Factors
64
The problem is

• "Men with ED going to a general practitioner or a
  urologist
• need to be referred for a cardiology workup to
  determine
• existing cardiovascular disease and proper
  treatment,
• "ED is an early predictor of cardiovascular
  disease."
• Many men with ED see a general practitioner or a
  urologist to
• get medication for ED, he said.
• "The medication works and the patient doesn't
  show up
• anymore," "These men are being treated for the
  ED, but not the underlying cardiovascular
  disease. A whole segment of men is being placed
  at risk.

Erectile Dysfunction Strong Predictor of Death,
Cardiovascular Outcomes ScienceDaily (Mar. 16,
2010)