Customize
Quick Links
Specialties

Accreditation/Credit Designation

Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians' Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 2.0 Contact Hours.

Acknowledgment of Commercial Support

This activity is supported by educational grants from Actelion Pharmaceuticals US, Inc; Novartis Pharmaceuticals Corporation; Sanofi US; and Regeneron Pharmaceuticals.

CARDIO-ENDO-RENAL COLLABORATIVE (CERC) Clinical Connections™

Release Date: December 14, 2018
Expiration Date: December 14, 2019
Media: Internet - based

Activity Overview

CARDIO-ENDO-RENAL COLLABORATIVE (CERC) Clinical Connections™ focuses on the theme of Novel Approaches to Integrated Cardiometabolic Disease Management. This activity encompasses advancements in novel therapies and technologies, lifestyle medicine, multidisciplinary approaches that are driving improvements in outcomes and quality, and cardiovascular (CVD)/metabolic disease prevention. CERC Clinical Connections™ highlights clinical updates and strategies aimed directly at the intersection of metabolic and CVD prevention. Clinically relevant topics in cardiometabolic health include CVD prevention, dyslipidemia, heart failure, and pulmonary arterial hypertension. This clinical connection will provide healthcare professionals clinical insight and advance their understanding of chronic cardiometabolic diseases and associated comorbidities.

Acknowledgment of Commercial Support

This activity is supported by educational grants from Actelion Pharmaceuticals US, Inc; Novartis Pharmaceuticals Corporation; Sanofi US; and Regeneron Pharmaceuticals.

Instructions for This Activity and Receiving Credit

  • You will need to login to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “educational content/video files” will be available for your reference.
  • In order to receive a CME/CE certificate, participants must complete the activity.
  • Complete the posttest and pass with a score of 70% or higher, complete the evaluation and then click on request for credit. Participants may immediately download a CME/CE certificate upon completion of these steps.

Target Audience

This educational activity is directed toward cardiologists, endocrinologists, specialty nurse practitioners, specialty physician assistants, certified diabetes educators, other specialty allied health professionals, nephrologists, and other healthcare professionals.

Learning Objectives

At the conclusion of this activity, you should be better prepared to:

  1. Recognize the reduction of cardiovascular risk associated with anti-inflammatory therapy in patients with a well-established inflammatory risk assessment
  2. Evaluate individualization of chronic heart failure treatment based on patient-specific factors to reduce morbidity/mortality with the use of guideline-recommended therapy
  3. Translate clinical trial data to clinical practice for successful implementation, when appropriate, of a PCSK9 inhibitor to current therapeutic regimens for patients exhibiting statin intolerance or minimal change in LDL-C levels, despite use of maximally tolerated dose of statins
  4. Identify pulmonary arterial hypertension to prevent delays in diagnosis, and to promptly apply evidence-based, guideline-recommended therapy to improve symptoms and quality of life

Faculty, Staff, and Planners' Disclosures

Faculty

James A. Underberg, MD, MS, FACPM, FACP, FNYAM, FASPC, FNLA
Lipidology & Cardiovascular Disease Prevention
Clinical Assistant Professor of Medicine
NYU Medical School & NYU Center for CV Prevention
Director, Bellevue Hospital Lipid Clinic
Past-President, National Lipid Association
New York, NY

Disclosure: Grant/Research Support: Aegerion, Pfizer; Consultant: Amgen, Amarin; Speakers Bureau: Amgen, Amarin, Akcea, Alexion, Sanofi, Regeneron; Advisory Board: Amgen, Sanofi, Regeneron, Akcea, Aegerion, Alexion, Ambry

Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASH
Professor of Medicine
Tulane University School of Medicine
Tulane Heart and Vascular Institute
New Orleans, LA
 

Disclosure: Consultant: Amgen, Sanofi, Boehringer Ingelheim, Janssen, Quantum Genomics

Paul M. Ridker, MD, MPH, FACC, FAHA
Eugene Braunwald Professor of Medicine
Harvard Medical School
Director, Center for Cardiovascular Disease Prevention
Brigham and Women's Hospital
Boston, MA

Disclosure: Grant/Research Support: National Heart, Lung, and Blood Institute, National Cancer Institute, American Heart Association, Doris Duke Charitable Foundation, Leducq Foundation, Donald W. Reynolds Foundation, James and Polly Annenberg La Vea Charitable Trusts, AstraZeneca, Novartis, Pfizer, Kowa, Amgen; Consultant: Quintiles, Novartis, Corvidia, lnflazome, Eisai, Sanofi, Janssen; Other: Investigational/off-label use of drugs/device disclosures: canakinumab and methotrexate. Dr. Ridker is listed as a co-inventor on patents held by the Brigham and Women's Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease that have been licensed to Siemens and AstraZeneca.

Roxana Sulica, MD
Associate Professor, Department of Medicine
Director, Pulmonary Hypertension Program
NYU Langone Health
New York, NY
 

Disclosure: Grant/Research Support: Reata; Consultant: Actelion, Bayer, Arena, United Therapeutics

The staff of Physicians' Education Resource®, LLC, (PER®) have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.

PER Pulse™ Recaps

1 of 4
Insight from James Underberg, MD – PER Pulse Recap:
Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management

Join renowned medical experts in the management of cardio-metabolic disorders, James Underberg, MD, Keith Ferdinand, MD, Paul Ridker, MD, and Roxana Sulica, MD, in the online continuing medical education (CME) activity, Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management. You will engage with the faculty through expert interviews to gain insight into emerging therapies and their impact on the treatment paradigm; investigate best practices for management of associated risks leading to an increase in cardiovascular disease (CVD); and explore the role of biomarkers as a target for reduction of atherosclerosis.

This first of 4 PER Pulse Recaps will focus on the application of evidence-based clinical decision-making performance relative to applying emerging clinical trial data to the treatment paradigm of CVD, dyslipidemia, and heart failure.

Dr. Underberg characterized the potentially practice-changing implications for the management of patients with dyslipidemia:

“PCSK9s are approved to be used in patients, on top of maximally tolerated therapy.”
— James Underberg, MD

For the management of dyslipidemia, the current guidelines primarily recommend a change in lifestyle, then the use of statins followed by non-statin therapies. The use of PCSK9 inhibitors (PCSK9is) for the treatment of dyslipidemia is an active area of research with emerging recent evidence to improve outcomes for patients with hypercholesterolemia. PCSK9is are FDA-approved to provide additional lipid lowering in adults receiving maximum tolerated dose (MTD) statin therapy to treat heterozygous familial hyperlipidemia or clinical atherosclerotic cardiovascular disease (ASCVD). The guidelines reached similar conclusions that candidates for a PCSK9i include patients with:1

  • Clinical ASCVD who do not reach their LDL-C target on a MTD statin
  • Statin intolerance and high risk who need additional lipid-lowering therapy
  • Familial hypercholesterolemia with elevated LDL-C and risk factors

One of the most common scenarios in which a PCSK9i is considered is for the patient with clinical ASCVD and comorbidity who is not reaching lipid goals on a MTD statin. For a patient whose LDL-C remains above 70 mg/dL or who has recent ACS <3 months, you might consider adding a non-statin, such as ezetimibe.1 If you need to lower LDL-C by more than 25%, then it is logical to reach for a PCSK9i.

Patients with ASCVD and statin intolerance appear to be a very high-risk population. However, statin intolerance is not an FDA-approved indication for PCSK9is. When navigating the PCSK9i prior-authorization approval process, Dr. Underberg agreed that it may help to characterize statin intolerance differently.

Reference

  1. Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70(14):1785-1822. doi: 10.1016/j.jacc.2017.07.745.

2 of 4
Insight from Keith Ferdinand, MD – PER Pulse Recap:
Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management

As a follow-up to the online continuing medical education (CME) activity, Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management, this second of 4 PER Pulse Recaps will focus on the application of evidence-based clinical decision-making performance relative to applying emerging clinical trial data to the treatment paradigm of cardiovascular disease (CVD), dyslipidemia, and heart failure (HF).

Heart failure is a morbidity affecting nearly 5.7 million Americans, and is the leading cause of hospitalization of individuals over the age of 65 in the United States. The prevalence of HF continues to rise despite the availability of guideline-recommended therapies.1

The 2013 ACC/AHA/HFSA guidelines for HF include new therapies indicated for stage C HF with reduced ejection fraction (HFrEF), updates on the evaluation of the patients with HF using biomarkers, as well as more specific recommendations for pharmacologic treatment based on HF stages.2

According to the new recommendations, an angiotensin-converting-enzyme inhibitor (ACEi), angiotensin receptor blocker (ARB), or angiotensin receptor-neprilysin inhibitor (ARNi) should be used with a beta-blocker and an aldosterone antagonist for patients with chronic symptomatic HFrEF. ACEis or ARBs should be replaced by ARNis when patients with mild-to-moderate heart disease are stable, have adequate blood pressure, and are tolerating standard therapies well. However, ARNis should not be used with ACEis or in patients with a history of angioedema.2

The current treatment regimen for HF has shown improvement in survival and quality of life; however, the rise in hospitalization and mortality remains substantial.3 The guidelines include ivabradine and sacubitril/valsartan therapy, 2 additional agents focused on reducing hospitalization rates in patients with HFrEF.1 According to the HFSA, ivabradine may be beneficial in reducing hospitalizations in patients with symptomatic stable, chronic HFrEF who are receiving guideline-directed evaluation and management, including a beta-blocker at a maximum tolerated dose, and who are in sinus rhythm with a heart rate of ≥70 beats per minute at rest.4 Sacubitril/valsartan is indicated to reduce the risk of CV death and hospitalizations in patients with chronic HF (NYHA Class II-IV) and reduced EF. It is intended to be used in place of an ACEi or other ARB and is usually administered in conjunction with other HF therapies.5

“Medical therapy is also therapeutic lifestyle changes. Exercise has a Class I evidence to improve well-being and functional capacity.”
— Keith Ferdinand, MD

References

  1. Ortman J, Velkoff VA, Hogan H, An Aging Nation: The Older Population in the United States, US Census Bureau. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed June 2018.
  2. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-e327. doi: 10.1161/CIR.0b013e31829e8776.
  3. Allen LA, Tomic KE, Smith DM, et al. Rates and predictors of 30-day readmission among commercially insured and Medicaid-enrolled patients hospitalized with systolic heart failure. Circ Heart Fail. 2012;5(6):672-579. doi: 10.1161/CIRCHEARTFAILURE.112.967356.
  4. Corlanor (ivabradine) Prescribing Information. http://pi.amgen.com/united_states/corlanor/corlanor_pi_hcp.pdf. Thousand Oaks, CA: Amgen. Revised January 2017. Accessed November 27, 2018.
  5. Entresto (sacubitril and valsartan) Prescribing Information. http://www.pharma.us.novartis.com/product/pi/pdf/entresto.pdf. East Hanover, NJ: Novartis Pharmaceuticals Corporation. Revised November 2017. Accessed November 27, 2018.

3 of 4
Insight from Paul Ridker, MD – PER Pulse Recap:
Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management

As a follow-up to the online continuing medical education (CME) activity, Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management, this third of 4 PER Pulse Recaps will focus on best practices for management of toxicities associated with immunotherapy. Below are some highlights from the activity.

Cardiovascular disease (CVD) has classically been considered to be a disease of hyperlipidemia.1 However, despite the widespread use of statins, which dramatically lower atherogenic cholesterol levels, a substantial proportion of statin-treated patients remain at residual risk of CVD, suggesting that inflammation plays an independent role in the development of CVD and acute coronary syndromes.2

The interleukin-1 (IL-1) family has been detected in human atherosclerotic plaques.2 IL-1α and IL-1β correlate with the progression of plaques with minimal expression of IL-1α and IL-1β in healthy coronary arteries, increased expression in simple atherosclerotic plaques, and high expression in complicated plaques.2

The downstream anti-inflammatory effects of IL-1 inhibition have been substantiated in clinical trials.3 CANTOS, a phase IIb trial of canakinumab, where a monoclonal antibody that specifically targets IL-1β, demonstrated inhibition of IL-1β, IL-6, and C-reactive protein (CRP) production for a period of several months. Low-dose methotrexate and colchicine are also being explored for their activity in the CRP, IL-6, and IL-1 axis.3

“After being put on all aggressive care including high-dose statin therapy, if CRP still remains greater than 2 mg/L, that’s residual inflammatory risk.”
— Paul Ridker, MD

References

  1. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352:1685-1695. DOI: 10.1056/NEJMra043430.
  2. Ridker PM, Luscher T. Anti-inflammatory therapies for cardiovascular disease. Eur Heart J. 2014;35(27):1782-1791. doi: 10.1093/eurheartj/ehu203.
  3. Libby P. Interleukin-1 beta as a target for atherosclerosis therapy: biological basis of CANTOS and beyond. J Am Coll Cardiol. 2017;70:2278-2289. doi: 10.1016/j.jacc.2017.09.028.

4 of 4
Insight from Roxana Sulica, MD – PER Pulse Recap:
Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management

As a follow-up to the online continuing medical education (CME) activity, Novel Multidisciplinary Approaches to Integrated Cardiometabolic Disease Management, this final of 4 PER Pulse Recaps will focus on the application of evidence-based clinical decision-making performance relative to applying emerging clinical trial data to the treatment paradigm of cardiovascular disease (CVD), dyslipidemia, and heart failure (HF).

Pulmonary arterial hypertension (PAH) is frequently overlooked until the disease is in its more advanced stages, including right HF and associated complications. Initial symptoms are nonspecific and include fatigue, shortness of breath, and near syncope.1 In the absence of effective therapy, prognosis of PAH is very poor: Median survival is 2.8 years from diagnosis, with over 50% of untreated patients dying within 5 years. Patients with progressive shortness of breath on exertion, a loud P2 and TR murmur, cardiomegaly on CXR, right axis deviation right ventricular hypertrophy on ECG, and pulmonary function tests with isolated decrease in gas diffusion should be screened for PAH, and diagnosis confirmed via echocardiogram.2

Currently, PAH has no cure, but its management has evolved over the past decade, and endpoints of clinical trials of PAH therapies have shifted from short-term functional changes to examine long-term outcomes. Optimal therapy is individualized and must be selected according to PAH severity, comorbid conditions, route of administration of pharmacologic therapies and their adverse effects, overall treatment goals, and clinician preference. The sooner treatment is employed, the greater the likelihood of beneficial outcomes.

Four major categories of therapy are now approved for treatment of PAH (Table).


The nitric oxide signaling pathway has been targeted therapeutically in Group 1 PAH. First-line therapies for patients with mild-to-moderate PAH include phosphodiesterase type 5 inhibitors, endothelin receptor antagonists, the guanylate cyclase activator, riociguat, and calcium channel blockers. Escalation to combination therapy is indicated for patients with an inadequate response to initial therapy.

Augmentation of the prostacyclin signaling pathway as a successful therapeutic strategy for the treatment of PAH is recommended. Drugs in this class include epoprostenol, treprostinil, iloprost, and the prostacyclin receptor agonist, selexipag. These aim at lowering pulmonary vascular resistance, increasing cardiac output, improving exercise capacity, and reducing episodes of clinical worsening when used at clinically effective doses.3,4 Epoprostenol has also been shown to improve survival in idiopathic PAH. Current guidelines recommend intravenous prostacyclins for patients with functional class III and IV PAH.

“We have guidelines specifying the level of risk of each patient; risk of progression and risk of death”
- Roxana Sulica, M.D

References

  1. Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry. Chest. 2010;137:376-387. doi: 10.1378/chest.09-1140.
  2. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association Developed in Collaboration With the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. Am Coll Cardiol. 2009;53:1573-1619. DOI: 10.1016/j.jacc.2009.01.004.
  3. Archer SL, Weir EK, Wilkins MR. Basic science of pulmonary arterial hypertension for clinicians: new concepts and experimental therapies. Circulation. 2010;121:2045-2066. doi: 10.1161/CIRCULATIONAHA.108.847707.
  4. Jing ZC, Parikh K, Pulido T, et al. Efficacy and safety of oral treprostinil monotherapy for the treatment of pulmonary arterial hypertension: a randomized, controlled trial. Circulation. 2013;127:624-633. doi: 10.1161/CIRCULATIONAHA.112.124388.

Login or Register to Start Activity

Please use the form below to Register or Log In to begin Activity.

*Required Fields






Become a Member

Forgot Password?
Calendar of Events
SUNMONTUESWEDTHURSFRISAT
   1234
567891011
12131415161718
19202122232425
262728293031
Filter By