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| Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery | | 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%. | | 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. | | There are 12 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; depression management; cardiac rehabilitation and influenza vaccine. Please note that secondary prevention guidelines, especially, those involving medication, may differ between [[Unstable Angina|UA/NSTEMI]]; [[STEMI]]; and [[Chronic Stable Angina]]. Please refer to appropriate page for more specific guidelines. |
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| == Target Population == | | ==[[Coronary heart disease secondary prevention target population | Target Population]]== |
| | ==[[Coronary heart disease secondary prevention patient education | Patient Education]]== |
| | ==[[Coronary heart disease secondary prevention smoking cessation | Smoking Cessation]]== |
| | ==[[Coronary heart disease secondary prevention blood pressure control | Blood Pressure Control]]== |
| | ==[[Coronary heart disease secondary prevention lipid management | Lipid Management]]== |
| | ==[[Coronary heart disease secondary prevention physical activity recommendations | Physical Activity Recommendations]]== |
| | ==[[Coronary heart disease secondary prevention weight management | Weight Management]]== |
| | ==[[Coronary heart disease secondary prevention influenza vaccination | Influenza Vaccination]]== |
| | ==[[Coronary heart disease secondary prevention depression | Depression]]== |
| | ==[[Coronary heart disease secondary prevention beta-blockers | Beta Blockers]]== |
| | ==[[Coronary heart disease secondary prevention diabetes mellitus management | Diabete Mellitus Management]]== |
| | ==[[Coronary heart disease secondary prevention antiplatelet agents/anticoagulants | Antiplatelet Agents/Anticoagulants]]== |
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| Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery
| | ==[[Coronary heart disease secondary prevention renin-angiotensin-aldosterone system blockers |Renin-angiotensin-aldosterone system blockers]]== |
| disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%. | | ==[[Coronary heart disease secondary prevention cardiac rehabilitation | Cardiac Rehabilitation]]== |
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| == Smoking Cessation == | | ==References== |
| | {{reflist|2}} |
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| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT) ===
| | [[Category:Cardiology]] |
| | [[Category:Disease]] |
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| '''Goal:''' Complete Cessation. No Exposure to environmental tobacco smoke.
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| | colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Ask about tobacco use status at every visit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Advise every tobacco user to quit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Assess the tobacco user's willingness to quit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Assist counseling and developing a plan for quitting. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Urge avoidance of exposure to environmental tobacco smoke at work and home. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| |}
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| == Blood Pressure Control ==
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| * If blood pressure is > 120/80 mm Hg:
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| Initiate or maintain lifestyle modification (weight control, EtOH moderation, sodium reduction, increased physical activity, increased fruits, vegetables, low-fat dairy)
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| * If blood pressure > 140/90 mm Hg: As tolerated, add blood pressure medication (betablockers and/or ACE inhibitors initially).
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| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT) ===
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| '''Goal:''' <140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease.
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| '''For all Patients:'''
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| {|class="wikitable" | |
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| | colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) <nowiki>"</nowiki>
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| '''For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes):'''
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])<nowiki>"</nowiki>
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| |}
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| == Lipid Management ==
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| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT)===
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| '''Goal:''' LDL-C <100 mg/dL; If triglycerides are ≥200 mg/dL, non-HDL-C should be <130 mg/dL.
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| '''For all patients:'''
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/d). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further lower LDL-C.<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Promote daily physical activity and weight management. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
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| |}
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| '''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:
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"| <nowiki>"</nowiki>'''a.''' LDL-C should be <100 mg/dL. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|'''b.''' <nowiki>"</nowiki> If baseline LDL-C is ≥100 mg/dL, initiate LDL-lowering drug therapy. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"| <nowiki>"</nowiki>'''c.''' If on-treatment LDL-C is ≥100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"| <nowiki>"</nowiki>'''d.''' If triglycerides are 200 to 499 mg/dL, non-HDL-C should be <130 mg/dL. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"| <nowiki>"</nowiki>'''e.''' Therapeutic options to reduce non HDL - C are more intense LDL - C lowering therapy. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"| <nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]]) <nowiki>"</nowiki>
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| |}
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| |bgcolor="LemonChiffon"| <nowiki>"</nowiki>'''a.''' Reduction of LDL-C to <70 mg/dL is reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:A]]) <nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''b.''' If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''c.''' If triglycerides are 200 to 499 mg/dL, reduction of non-HDL-C to <100 mg/dL is reasonable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''d.''' Therapeutic options to reduce non HDL - C are [[Niacin]] (after LDL-C loweing therapy). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''e.''' Therapeutic options to reduce non HDL - C are [[Fibrate]] therapy (after LDL-C loweing therapy). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]]) <nowiki>"</nowiki>
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| |}
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| == Physical Activity Recommendations ==
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| * Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week.
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| * Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, heart failure)
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| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT) ===
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| {{cquote|
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| '''Goal:''' 30 minutes, 7 days per week (minimum 5 days per week)
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| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] ====
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| '''1.''' For all patients, assess risk with a physical activity history and/or an exercise test, to guide prescription. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| '''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). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| '''3.''' Advise medically supervised programs for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] ====
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| '''1.''' Encourage resistance training 2 days per week. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
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| }}
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| == Weight Management ==
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| * If waist circumference >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.
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| * The initial goal of weight loss therapy should be to reduce body weight by approximately 5-10 percent from baseline.
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| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update (DO NOT EDIT) ===
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| {{cquote|
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| '''Goal:''' Body mass index: 18.5 to 24.9 kg/m2; Waist circumference: men <40 inches, women <35 inches
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| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] ====
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| '''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| '''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| '''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
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| }}
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| == ACE Inhibition ==
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| * Use in all patients with LVEF < 40%, and those with diabetes or chronic kidney disease indefinitely, unless contraindicated
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| * Consider for all other patients
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| == Angiotensin Receptor Blockade ==
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| * Use in patients who are intolerant of ACE inhibitors with heart failure or post MI with LVEF less than or equal to 40%.
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| * Consider in other patients who are ACE inhibitor intolerant.
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| == Diabetes Mellitus ==
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| * Lifestyle and pharmacotherapy to achieve HbA1C <7% may be considered.
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| * Less stringent goal for may be considered (severe hypoglycemia, limited life expectancy, extensive comorbidities)
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| === Anti-platelet therapy ===
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| 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.".<ref name="pmid17636787">{{cite journal |author=Keller T, Squizzato A, Middeldorp S |title=Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD005158 |year=2007 |pmid=17636787 |doi=10.1002/14651858.CD005158.pub2}}</ref>
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| == References ==
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| {{Reflist|2}} | |