Coronary heart disease secondary prevention

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

Lipid Management

Secondary prevention

• 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.".