Basma Y. Kentab

Aggressive comprehensive risk factor management:

• Improves survival, • Reduces recurrent events and• Reduces need for interventional procedures, • Improves the quality of life

Why Is It Necessary??

AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update

Secondary Prevention Definition

Therapy to reduce recurrent cardiovascular events and decrease cardiovascular mortality in patients with

established atherosclerotic vascular disease

Secondary Prevention Patient Population

Established coronary and other atherosclerotic vascular disease, including:

• Peripheral arterial disease, • Atherosclerotic aortic disease• Carotid artery disease

Components of Secondary Prevention

Cigarette smoking cessation

Blood pressure control

Lipid management to goal

Physical activity

Weight management to goal

Diabetes management to goal

Antiplatelet agents / anticoagulants

Renin angiotensin aldosterone system blockers

Beta blockers

Influenza vaccination

Cigarette Smoking Recommendations

Goal: Complete Cessation and No Exposure to Environmental Tobacco Smoke

•Ask about tobacco use status at every visit.

•Advise every tobacco user to quit.

•Assess the tobacco user’s willingness to quit.

•Assist by counseling and developing a plan for quitting.

•Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion)

•Urge avoidance of exposure to environmental tobacco smoke at work and home.

Blood Pressure Control

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

Blood pressure ≥ 120/80 mm Hg :

Initiate or maintain lifestyle modification: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits vegetables and low fat dairy products

Blood pressure ≥ 140/90 mm Hg (or ≥ 130/80 for chronic kidney disease or diabetes)

As tolerated, add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors with addition of other drugs such as thiazides as needed to achieve goal blood pressure

Lipid Management

Lipid Management Goal

LDL-C should be less than 100 mg/dL

Further reduction to LDL-C to < 70 mg/dL is reasonable

If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*

*Non-HDL-C = total cholesterol minus HDL-C

Lipid Management

Start dietary therapy (<7% of total calories as saturated fat and <200 mg/d cholesterol)

Adding plant stanol/sterols (2 gm/day) and fiber (>10 mg/day) will further lower LDL

Promote daily physical activity and weight management.

Encourage increased consumption of omega-3 fatty acids in fish or 1 g/day omega-3 fatty acids in capsule form for risk reduction.

For All Patients

Lipid Management

Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event.

For patients hospitalized, initiate lipid-lowering medication as recommended below prior to discharge:

• If baseline LDL-C > 100 mg/dL, initiate LDL-lowering drug therapy

• If on-treatment LDL-C > 100 mg/dL, intensify LDL-lowering drug therapy (may require LDL lowering drug combination)

• If baseline is LDL-C 70 to 100 mg/dL, it is reasonable to treat to LDL < 70 mg/dL

Lipid Management

• If TG are 200-499 mg/dL, non-HDL-C should be < 130 mg/dL

• Further reduction of non-HDL to < 100 mg/dL is reasonable

• Therapeutic options to reduce non-HDL-C: - More intense LDL-C lowering therapy or- Niacin (after LDL-C lowering therapy) - Fibrate (after LDL-C lowering therapy)

• If TG are > 500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy. Achieve non-HDL-C < 130 mg/dL, if possible

Physical Activity Recommendations

Goal: 30 minutes 7 days/week, minimum 5 days/week

Assess risk with a physical activity history and/or an exercise test, to guide prescription

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

Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF)

Weight Management Recommendations

Goal: BMI 18.5 to 24.9 kg/m2Waist Circumference: Men: < 40 inches Women: < 35 inches Assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through appropriate balance of physical activity, caloric intake, and formal behavioral programs

If waist circumference (measured at the iliac crest) >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 10 percent from baseline. With success, further weight loss can be attempted if indicated.

Diabetes Mellitus Recommendations

Goal: Hb A1c < 7%

Lifestyle and pharmacotherapy to achieve near normal HbA1C (<7%).

Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended).

Coordinate diabetic care with patient’s primary care physician or endocrinologist.

Antiplatelet Agents / Anticoagulation Recommendations

Aspirin Recommendations

Start and continue indefinitely aspirin 75 to 162 mg/d in all patients unless contraindicated

For patients undergoing CABG, aspirin (100 to 325 mg/d) should be started within 48 hours after surgery to reduce saphenous vein graft closure

Post-PCI-stented patients should receive 325 mg per day of aspirin for 1 month for bare metal stent, 3 months for sirolimus-eluting stent and 6 months for paclitaxel-eluting stent

Clopidogrel Recommendations

Start and continue clopidogrel 75 mg/d in combination with aspirin :

– for post ACS or post PCI with stent placement patients for up to 12 months

–for post PCI-stented patients• >1 month for bare metal stent, • >3 months for sirolimus-eluting stent • >6 months for paclitaxel-eluting stent

Anticoagulation Recommendations

Manage warfarin to international normalized ratio 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, LV thrombus.)

Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely

Renin-Angiotensin-Aldosterone System Blockers Recommendations

ACE inhibitor Recommendations

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

Consider for all other patients

Among lower risk patients with normal LVEF where cardiovascular risk factors are well controlled and where revascularization has been performed, their use may be considered optional

Angiotensen Receptor Blockers Recommendations

Use in patients who are intolerant of ACE inhibitors with HF or post MI with LVEF less than or equal to 40%.

Consider in other patients who are ACE inhibitor intolerant.

Consider use in combination with ACE inhibitors in systolic dysfunction HF.

Aldosterone Antagonists Recommendations

Use in post MI patients, without significant renal dysfunction or hyperkalemia, who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF < 40% and either diabetes or heart failure

Contraindications include abnormal renal function (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) and hyperkalemia (K+ >5.0 meq/L)

β-Blockers Recommendations

Start and continue indefinitely in all post MI, ACS, LV dysfunction with or without HF symptoms, unless contraindicated.

Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated.

Influenza Vaccination

Patients with cardiovascular disease should have influenza vaccination