Coronary heart disease secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%. There are 10 aspects of secondary prevention: Smoking cessation; blood pressure control; lipid-lowering; increasing physical activity; weight loss; diabetes control; antiplatelet agents/anticoagulants; RAS blockers; beta-blockers and influenza vaccine.

Target Population

Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%.

Smoking Cessation

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)

Goal: Complete Cessation. No Exposure to environmental tobacco smoke.

Class I

"1. Ask about tobacco use status at every visit. (Level of Evidence: B) "

"2. Advise every tobacco user to quit. (Level of Evidence: B) "

"3. Assess the tobacco user's willingness to quit. (Level of Evidence: B) "

"4. Assist counseling and developing a plan for quitting. (Level of Evidence: B) "

"5. Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion). (Level of Evidence: B) "

"6. Urge avoidance of exposure to environmental tobacco smoke at work and home. (Level of Evidence: B) "

Blood Pressure Control

• If blood pressure is > 120/80 mm Hg:

Initiate or maintain lifestyle modification (weight control, EtOH moderation, sodium reduction, increased physical activity, increased fruits, vegetables, low-fat dairy)

• If blood pressure > 140/90 mm Hg: As tolerated, add blood pressure medication (betablockers and/or ACE inhibitors initially).

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)

Goal: <140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease.

For all Patients:

Class I

"1. Initiate or maintain lifestyle modification—weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. (Level of Evidence: B) "

For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes):

Class I

"1. As tolerated, add blood pressure medication, treating initially with β-blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure. (Level of Evidence: A)"

Lipid Management

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)

Goal: LDL-C <100 mg/dL; If triglycerides are ≥200 mg/dL, non-HDL-C should be <130 mg/dL.

For all patients:

Class I

"1. Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/d). (Level of Evidence: B)"

"2. Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further lower LDL-C."

"3. Promote daily physical activity and weight management. (Level of Evidence: B)"

Class II

"1. Encourage increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Level of Evidence: B)"

For lipid management:Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiate lipid-lowering medication as recommended below before discharge according to the following schedule:

Class I

"a. LDL-C should be <100 mg/dL. (Level of Evidence: A)"

b. " If baseline LDL-C is ≥100 mg/dL, initiate LDL-lowering drug therapy. (Level of Evidence: A) "

"c. If on-treatment LDL-C is ≥100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination). (Level of Evidence: A) "

"d. If triglycerides are 200 to 499 mg/dL, non-HDL-C should be <130 mg/dL. (Level of Evidence:B) "

"e. Therapeutic options to reduce non HDL - C are more intense LDL - C lowering therapy. (Level of Evidence:B) "

"f. If triglycerides are ≥500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C <130 mg/dL if possible. (Level of Evidence:C) "

Class IIa

"a. Reduction of LDL-C to <70 mg/dL is reasonable. (Level of Evidence:A) "

"b. If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. (Level of Evidence:B) "

"c. If triglycerides are 200 to 499 mg/dL, reduction of non-HDL-C to <100 mg/dL is reasonable. (Level of Evidence:B) "

"d. Therapeutic options to reduce non HDL - C are Niacin (after LDL-C loweing therapy). (Level of Evidence:B) "

"e. Therapeutic options to reduce non HDL - C are Fibrate therapy (after LDL-C loweing therapy). (Level of Evidence:B) "

Physical Activity Recommendations

• Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week.
• Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, heart failure)

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)

Goal: 30 minutes, 7 days per week (minimum 5 days per week)

Class I

1. For all patients, assess risk with a physical activity history and/or an exercise test, to guide prescription. (Level of Evidence: B)

2. For all patients, encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, household work). (Level of Evidence: B)

3. Advise medically supervised programs for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure). (Level of Evidence: B)

Class IIb

1. Encourage resistance training 2 days per week. (Level of Evidence: C)

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Weight Management

• If waist circumference >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.
• The initial goal of weight loss therapy should be to reduce body weight by approximately 5-10 percent from baseline.

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)

“

Goal: Body mass index: 18.5 to 24.9 kg/m2; Waist circumference: men <40 inches, women <35 inches Class I 1. Assess body mass index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2. (Level of Evidence: B) 2. If waist circumference (measured horizontally at the iliac crest) is ≥35 inches in women and ≥40 inches in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. (Level of Evidence: B) 3. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. (Level of Evidence: B)

”

ACE Inhibition

• Use in all patients with LVEF < 40%, and those with diabetes or chronic kidney disease indefinitely, unless contraindicated
• Consider for all other patients

Angiotensin Receptor Blockade

• Use in patients who are intolerant of ACE inhibitors with heart failure or post MI with LVEF less than or equal to 40%.
• Consider in other patients who are ACE inhibitor intolerant.

Diabetes Mellitus

• Lifestyle and pharmacotherapy to achieve HbA1C <7% may be considered.
• Less stringent goal for may be considered (severe hypoglycemia, limited life expectancy, extensive comorbidities)

Anti-platelet therapy

A meta-analysis of randomized controlled trials by the international Cochrane Collaboration found "that the use of clopidogrel plus aspirin is associated with a reduction in the risk of cardiovascular events compared with aspirin alone in patients with acute non-ST coronary syndrome. In patients at high risk of cardiovascular disease but not presenting acutely, there is only weak evidence of benefit and hazards of treatment almost match any benefit obtained.".