Download Reducing risk in heart disease

National Heart Foundation of Australia and
Cardiac Society of Australia and New Zealand
Reducing risk in
heart disease
An expert guide to clinical practice for secondary
prevention of coronary heart disease – summary
Updated 2012
This summary guide is based on the full guide document: Reducing risk in heart disease: an expert guide to clinical
practice for secondary prevention of coronary heart disease (updated 2012). Call the Health Information Service
on 1300 36 27 87 or visit www.heartfoundation.org.au for a copy.
Endorsed by:
Reducing risk in heart disease
An expert guide to clinical practice for secondary
prevention of coronary heart disease – summary
Lifestyle/behavioural risk factors and management
Smoking
Goal: Complete cessation of smoking and avoidance of second-hand smoke.
Nutrition
Goals: Establishment and maintenance of healthy eating patterns including:
• saturated fatty acid < 7% and trans fatty acid < 1% of total energy intake1
• consumption of 1 g eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) and > 2 g alpha linolenic
acid (ALA) daily
• limiting salt intake to ≤ 4 g/day (1550 mg sodium).
Alcohol
Goal: Consumption of a low-risk amount of alcohol by patients who drink.
Physical activity
Goal: Progress, over time, to at least 30 minutes of moderate-intensity* physical activity on most, if not all,
days of the week (150 minutes/week minimum).
Healthy weight
Goals:†
• Waist measurement < 94 cm (men) and < 80 cm (women)
• Body mass index (BMI) = 18.5–24.9 kg/m2
Biomedical risk factors/medical management
Lipids
Goals:
• Low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L‡
• High-density lipoprotein cholesterol (HDL-C) > 1.0 mmol/L
• Triglyceride (TG) < 2.0 mmol/L
• Non–high-density lipoprotein cholesterol (NHDL-C) < 2.5 mmol/L§
Blood pressure
Goal: Patients with coronary heart disease (CHD) achieve and maintain a blood pressure (BP) of < 130/80 mmHg.2,**
Diabetes
Goal:
maintain optimal blood sugar level (BSL) (HbA1c ≤ 7%).3
* Moderate-intensity physical activity causes a moderate, noticeable increase in depth and rate of breathing, while still leaving you able to talk comfortably. Examples include
† Goals are based mainly on evidence of increased risk of death in European populations. They may not be appropriate for all age groups and ethnic groups.
‡ This target is for high-risk patients who have had a coronary event.
§ NHDL-C is calculated by subtracting HDL-C from total cholesterol (TC). It combines LDL-C, very low density lipoprotein cholesterol (VLDL-C), intermediate density
lipoprotein (IDL-C) and lipoprotein (a) (LP(a)). The NHDL-C does not assume normal lipoprotein composition, does not require a fasting specimen, and may be a better
indicator than LDL-C in patients with high TG (such as patients with diabetes).4
**This includes patients with or without diabetes and/or stroke/transient ischaemic attack (TIA) and/or microalubuminuria (men > 2.5 mg/mmol, women > 3.5 mg/mmol).
Pharmacological management
Antiplatelet agents5
• All patients should take 75–150 mg/day of aspirin unless contraindicated.
• Addition of clopidogrel may be relevant in patients with recurrent ischaemic events, post-stent implantation.
• Prasugrel and ticagrelor are alternatives to clopidogrel in patients with acute coronary syndromes (ACS).
Anticoagulants
• Use warfarin in patients at high risk of thromboembolism post–myocardial infarction (MI).
• Monitor closely for signs of bleeding, particularly when combined with antiplatelets.
ACE inhibitors (ACEIs)/Angiotensin II receptor antagonists (ARAs) 6
• We recommend ACEIs in all patients, especially those at high risk, unless contraindicated. Start early post-MI.
• Consider ARAs for patients who develop unacceptable side effects on ACEIs.
Beta-blockers6
• We recommend beta-blockers in all patients post-MI, especially in high-risk patients, unless contraindicated.
Statins7
• We recommend statins in all patients with CHD, unless contraindicated.
• For hospitalised patients, therapy should start during admission.
Aldosterone antagonists6,8
• Eplerenone may be used early post-MI in patients with left ventricular systolic dysfunction and symptoms of
heart failure.
Short-acting nitrates5
• All patients should be prescribed a short-acting nitrate, unless contraindicated, and provided with a written
action plan for chest pain.
Initiating and sustaining behaviour change
Secondary prevention/cardiac rehabilitation (SP/CR) programs
Goal:
Warning signs of heart attack: action plan9,10
Goal: Everyone with CHD is prescribed a short-acting nitrate, unless contraindicated, and given an action plan to
follow if they experience warning signs of heart attack.
Psychosocial factors and assessment
Psychological management11
Goal: Assess all patients for comorbid depression. Initiate psychological and medical management if appropriate.
Social support
Goal: Assess all patients for their level of social support.
Further information
Executive writing group
Key contributors
Professor Patricia Davidson (chair)
Professor Nigel Stocks
Dr Anu Aggarwal
Ms Jill Waddell
Ms Rebecca Lee
Professor Derek Chew
Associate Professor David Sullivan
Ms Shanthi Thuraisingham
All members of the writing group were asked to declare any conflicts of interest at the commencement of the
project and at each teleconference. Professor Nigel Stocks received consultancy fees from AstraZeneca
(ACCOUNT study) and Novartis (VIPER-BP study). No other conflicts of interest were declared by members of
the writing group. This guide will be reviewed regularly and modified when necessary to take into account
new research, new technologies, and the results of evaluation of guideline outcomes.
References
1.National Heart Foundation of Australia. Position statement: Dietary fats and dietary sterols for cardiovascular health. Melbourne: National
Heart Foundation of Australia, 2009.
2.National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of
hypertension 2008. Updated 2010. Melbourne: National Heart Foundation of Australia, 2010.
3.Colagiuri S, Dickinson S, Girgis S, et al. National evidence based guideline for blood glucose control in type 2 diabetes. Canberra:
Diabetes Australia and the National Health and Medical Research Council, 2009.
4.Hirsch GA, Vaid N, Blumenthal RS. The significance of measuring non-HDL-cholesterol. Available from: www.medscape.com/
viewarticle/438773. Accessed 4 January 2012.
5.Chew DP, Aroney CN, Aylward PE, et al. 2011 Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and
New Zealand Guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
6.National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Guidelines for the management of acute
coronary syndromes 2006. Med J Aust 2006; 184 (Suppl.):S1–S32.
7.Tonkin A, Barter P, Best J, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: position
statement on lipid management 2005. Heart Lung Circ 2005; 14(4):275–291.
8.National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expert
Writing Panel). Guidelines for the prevention, detection and management of chronic heart failure in Australia. Updated July 2011.
Melbourne: National Heart Foundation of Australia, 2011.
9.National Heart Foundation of Australia. Heart attack warning signs: checklist of important information to discuss with patients.
Melbourne: National Heart Foundation of Australia, 2011.
10.National Heart Foundation of Australia. Heart attack warning signs: fact sheet about reducing delays in patient response. Melbourne:
National Heart Foundation of Australia, 2011.
11.Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and
treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing,
Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes
Research: endorsed by the American Psychiatric Association. Circulation 2008; 118(17):1768–1765.
© 2012 National Heart Foundation of Australia ABN 98 008 419 761
This work is copyright. No part of this publication may be reproduced in any form or language without prior written permission from the National
Heart Foundation of Australia (national office). Enquiries concerning permissions should be directed to [email protected].
ISBN 978-1-74345-022-2
PRO-139
Disclaimer: This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The
statements and recommendations it contains are, unless labelled as ‘expert opinion’, based on independent review of the available evidence.
Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in
consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the Heart Foundation and its
employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and
completeness. The information is obtained and developed from a variety of sources including, but not limited to, collaborations with third parties
and information provided by third parties under licence. It is not an endorsement of any organisation, product or service. This material may be
found in third parties’ programs or materials (including, but not limited to, show bags or advertising kits). This does not imply an endorsement or
recommendation by the National Heart Foundation of Australia for such third parties’ organisations, products or services, including their materials
or information. Any use of National Heart Foundation of Australia materials or information by another person or organisation is at the user’s own
risk. The entire contents of this material are subject to copyright protection.
For heart health information
1300 36 27 87
www.heartfoundation.org.au