Methods of Tertiary prevention

1. Methods of Tertiary prevention Samar Musmar,MD,FAAFP Assistant Dean for clinical affairs Head ,Department of Medicine and Community

2. Opportunities of prevention • First sign of illness—excellent opp • Sooner disability li mitation tx –better prevention • Infect dse—early tx—prev of inf in community • Symptoms used as guide for prevention • Preventive measures more convincing when symptomatic • Oneset of symptoms—window of opputunities—teachable moments

3. Disability limitation • Med or surgical tx of dse—minimize or prevent impairment(short or long term) • CAD—coronary angioplasty or CABG • Therapy vs symptomatic stage prevention • Therpay—undo threat or damage from existing dse • Symptomatic stage prevention—halt or limit future dse progression(1ry,2ry,3ry)

4. Coronary artery dse • Goals: • if occlusion—prevent death & permanent damage • Occlusion+,- ---slow stop or reverse progression

5. CAD—risk factors • Male gender • Fx hx—MI before age 60 • Cigarette smoking--++bl clotting,++CO in bl,decrease in O2 delivery • DM—tight control,ACE++,other risk factors • HTN—severe • Sedentary life style—vigorous activity—20 min x3/w • Wight-body-- fat distribution—insulin resistance • Dyslipidemia

6. Interaction of risk factors • Framingham study—multiple risk factors—synergism • E.g 45 year old female—dse within 8 years depends on:smoking,gluc intolerance,LVH,HTN severe,chol high • Lowest risk—2.2% none of above • Highest risk—77.8% all of above • Intermediate risk—depends on one of risk factors • Chol—3.8,HTN—3.8,LVH—2.7,gluc int—1.8,smoking 1.7

7. 3ry prev CAD • Therapy— • Symtomatic stage prev: • Goals:--prevent restenosis,slow progression of atherosclerosis • Behavioral modification • Other measures—other known risk factors—HTN,DM,dyslipidemia

8. Dyslipidemia • Complete lipid profile:TC,LDL,HDL,TG • TC—screening(nonfasting)200,240 • HDL –50 F,35M • LDL—100,130,160 • TG—150,200 • Total non HDL chol level 200 • TC/HDL ratio • TG-HDL relationship • Homocystiene level--++diet folic acid,B12, pyrodoxine • Therapy and symptomatic stage prev—tx, • 1ry prev—life style modif • CAD sympt-- life style modif+drug therapy (statins)

9. HTN • JNC VII—defin of HTN • Risk groups : pregnant women,women on OCP’s,racial • Assessment—screening(comm or occupational),case finding,or when develops complications (visual,renal,CHF,MI) • Early tx and detection of HTN—decrease—50% mortality and (stroke and CAD) • Therapy and sympt stage prev-- JNC VII—NL, mild,mod,severe • Essential and nonessential • Aims of tx—tx and prevent –end organ damage • Life style mod • DASH --diet

10. HTN • LIFE STYLE MOD—NO effect—meds • HOPE(Heart Outcome Prevention Evaluation)—ACE use—prevent death by MI & stroke

11. DM • Type I/typeII—insulin resistance • Prevent TOD—DCCT(Diabees Control &Complication trial1993),UKPDS(UK Prospective diabetes Study2000) • DCCT—tight control type I—reduces incidence of microvascular dse & macrovascular dse • UKPDS—same with type II • +frequent eye examination(retina) • +Use of ACE—decrease microalbuminuria • +Moderate to high physical activity • Other combined meds—decrease insulin resistance ,decrease progreassion

12. Rehabilitation • Goals :strengthen remaining functions,help pts to function in alternative ways • Must begin early • CVA—early PT • Most successful program –tailored to meet needs of pt physical ,social and emotional needs • PT, OT, speech therapy • Psych & emotional counsilling • Spiritual counsilling

13. Categories of disability • Categories for reason of work compensation • Permanent total disability • Permanent partial disability • Temporary total disability • Permanent partial disability • death