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
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Goal: Complete Cessation. No Exposure to environmental tobacco smoke. Class I1. 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)
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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).
Lipid Management
- Assess fasting lipid profile in all patients with CHD, and within 24 hours of an acute cardiovascular or coronary event.
- For hospitalized patients, initiate lipid-lowering medication before discharge.
- LDL-C should be less than 100 mg/dL AND at least a 30% reduction in LDL.
- Further reduction to LDL-C to < 70 mg/dL in very high risk patients is reasonable
- If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL
- Start dietary therapy (<7% of total calories as saturated fat and <200 mg/d cholesterol)
- Add plant stanol/sterols (2 gm/day) and viscous fiber (>10 mg/day)
- Promote daily physical activity and weight management.
- Omega-3 fatty acids in fish or 1 g/day
- Omega-3 fatty acids in capsule form.
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)
Weight Management
- Goal: BMI 18.5 to 24.9 kg/m2
- Waist Circumference:
- Men: < 40 inches
- Women: < 35 inches
- 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.
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.".[1]
References
- ↑ Keller T, Squizzato A, Middeldorp S (2007). "Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease". Cochrane database of systematic reviews (Online) (3): CD005158. doi:10.1002/14651858.CD005158.pub2. PMID 17636787.