Download Coronary heart disease

Secondary prevention in CVD
DR ZIAD NOFAL
CARDIOLOGIST
DAMASCUS HOSPITAL
Coronary heart disease
•
Patients with CHD have increased risks of MI as
well as noncoronary atherosclerotic vascular
disease, such as stroke.
• The magnitude of these increased risks was
quantified in a community-based study of 2160
patients with an acute MI who were followed for
a median of 5.6 years .In the first 30 days, the
rate of first stroke was increased 44-fold
compared to the general population (2.3 per 100
person-months).
Noncoronary atherosclerotic disease
•
As defined by ATP III, noncoronary
atherosclerotic arterial disease includes
patients with :
• carotid artery disease, peripheral artery
disease, or abdominal aortic aneurysm, all of
whom have a 10-year risk of CHD >20 percent.
• Multiple risk factors — Patients without prior CHD but
with multiple risk factors that confer a 10-year risk of CHD
>20 percent are considered to have a CHD risk equivalent.
The 10-year risk of CHD is assessed using the ATP III
modification of the Framingham risk score. These patients
include those with the metabolic syndrome.
• In a random sample of the United States population, using
the ATP III definition, 40 percent of patients age 40 and
over have metabolic syndrome and their average risk of a
first CHD event over 10 years is 16 to 18 percent. Thus,
many patients with metabolic syndrome need to be
managed as aggressively as patients with prior CHD
Events*/100 person-years
Diabetes Mellitus: Risk of Myocardial Infarction
50
DM
No DM
45
40
30
19
20
10
0
20
3.5
Prior CHD
No prior CHD
Patients with DM but no CHD experience a similar rate of MI
as patients without DM but with CHD
CHD=Coronary heart disease, DM=Diabetes
mellitus, MI=Myocardial infarction
*Fatal or non-fatal MI
Haffner SM et al. NEJM 1998;339:229–234
Diabetes has been considered a CHD
risk equivalent because:
a) Most diabetic patients have CAD .
b) Persons with diabetes have a similar risk of
developing CHD than those who already have
CHD (e.g., myocardial infarction).
c) Both a and b
The National Kidney Foundation (NKF) and
(ACC/AHA)guidelines on ST elevation
myocardial infarction recommended that chronic
kidney disease be considered a CHD risk
equivalent, based upon evidence that renal
dysfunction (even of mild degree) is associated
with an increase in CHD risk .
 While these guidelines did not give a precise
definition of significant renal dysfunction, it may
be defined by a serum creatinine concentration
that exceeds 1.5 mg/dL or an estimated
glomerular filtration rate that is less than
60 mL/min per 1.73 m 2

Depression is not a major independent risk factor
in the development of CHD, but occurs frequently in
patients with established CVD and is associated with
increased morbidity and mortality. The AHA advisory
recommends the Patients Health Questionnaire
(PHQ-2) for screening . Using this tool, the provider
asks the patient the following two part question:
 Over the past two weeks, how often have you been
bothered by any of the following problems:
 Little interest or pleasure in doing things.
 Feeling down, depressed, or hopeless.
 A "yes" answer to either part should prompt the
practitioner to arrange for a more comprehensive
evaluation by a qualified professional.

PATIENT EDUCATION
• Patients with SIHD should have an individualized
education plan to optimized care and promote
wellness that includes education on medication
adherence, an explanation of medication
management and cardiovascular risk reduction
strategies in a manner that respects the patient’s
level of understanding, a comprehensive review
of all therapeutic options, a description of
appropriate levels of exercise, introduction to
self-monitoring skills, and information on how to
recognize worsening cardiovascular symptoms
and take appropriate action.
statins
Statin therapy lowers the risk of death by 15 to 20
percent and lowers the risk of non-fatal cardiovascular
events by an even greater degree.
The secondary prevention trials of lipid modification with
statins also demonstrated statistically significant and
clinically important reductions in stroke.
Treat all patients with atherosclerotic CVD with at least a
moderate dose of a statin, irrespective of the baseline
LDL-cholesterol, including those whose baseline LDLcholesterol is below the goals set below.
Short-term effects of MI on blood
lipids
HDL-cholesterol and triglycerides
• t is recommended that, for secondary prevention,
patients who have a persistently low HDL-cholesterol
concentration (<40 mg/dL) after the goal LDLcholesterol concentration has been achieved with a
statin should be started on nonpharmacologic therapy
(eg, exercise, smoking cessation, weight loss in obese
subjects); nicotinic acid or a fibrate can be added if this
is ineffective.
• Many patients with low HDL-cholesterol concentrations
also have elevated triglycerides. The goal for
triglycerides is less than 150 mg/dL which may be
achieved with statins alone or the addition of
adjunctive therapies, such as fish oil or fibrates.
Definition of "very high risk" in NCEP
guidelines
Established coronary heart disease
PLUS
Multiple major risk factors (especially diabetes)
OR
Severe and poorly controlled risk factors (especially continued smoking)
OR
Multple risk factors of the metabolic syndrome (especially triglycerides ≥200 plus non-HDL-C
≥130 plus HDL-C <40)
OR
Acute coronary syndrome
Stroke
• Stroke — The Stroke Council of the American
Heart Association and the American Stroke
Association recommended in 2004 that statins
should be started during hospitalization for all
patients with transient ischemic attack or first
stroke of atherosclerotic origin who are not
already being treated, regardless of serum
total cholesterol or LDL-cholesterol levels.
CONTROL OF HYPERTENSION
Modification
Recommendation
Approximate systolic BP
reduction, range*
Weight reduction
Maintain normal body weight
(BMI, 18.5 to 24.9 kg/m2)
5 to 20 mmHg per 10-kg weight
loss
Adopt DASH eating plan
Consume a diet rich in fruits,
vegetables, and low-fat dairy
products with a reduced content
of saturated and total fat
8 to 14 mmHg
Dietary sodium reduction
Reduce dietary sodium intake to
no more than 100 meq/day (2.4
g sodium or 6 g sodium chloride)
2 to 8 mmHg
Physical activity
Engage in regular aerobic
physical activity such as brisk
walking (at least 30 minutes per
day, most days of the week)
4 to 9 mmHg
Moderation of alcohol
consumption
Limit consumption to no more
than 2 drinks per day in most
men and no more than 1 drink
per day in women and lighterweight persons
2 to 4 mmHg
Smoking cessation
• Smoking cessation — Smoking cessation
produces benefits on CVD beginning within a
matter of months and reaching the
nonsmoker in three to five years.
• In a meta-analysis of 12,603 smokers who had
prior MI, CABG, angioplasty, or known CHD ,
the relative risk of mortality for quitters
compared with those who continued to smoke
was 0.64 (95% CI 0.58-0.71).
Weight reduction
• Hypertension — It has been suggested that control of
obesity would eliminate 48 percent of hypertension in
whites and 28 percent in blacks.
• Type 2 diabetes — Obesity is a major risk factor for
insulin resistance and type 2 diabetes in both men and
women.
• Dyslipidemia — Obesity is associated with adverse
effects on several lipids including increases in total
cholesterol, LDL-cholesterol, very low density
lipoprotein (VLDL)-cholesterol, and triglycerides, and a
reduction in HDL-cholesterol.
Physical activity
• Exercise should be performed for a minimum of
30 minutes per day, preferably daily but at least
five days per week.
• The ESC guidelines suggest a target heart rate of
60 to 75 percent of the average maximum heart
rate .
• Exercise should be supplemented by an increase
in daily lifestyle activities (eg, walking breaks at
work, gardening, and household work).
After acute coronary syndromes
• Smoking cessation was associated with a 43 percent
decreased risk of MI compared to persistent smoking
(odds ratio 0.57, 95% CI 0.36-0.89).
• Diet and exercise adherence was associated with a 48
percent decreased risk of MI compared with
nonadherence (odds ratio 0.52, 95% CI 0.4-0.69).
• Patients with persistent smoking who did not adhere to
diet and exercise had a 3.8 fold (95% CI 2.5-5.9)
increased risk of MI/stroke/death compared with never
smokers who modified their diet and exercises.
Anticoagulant therapy
• triple oral antithrombotic therapy (TOAT) is
indicated:
• Left ventricular (LV) thrombus or aneurysm.
• Left ventricular ejection fraction (LVEF) below 30
percent with or without heart failure.
• Chronic atrial fibrillation.
• Prosthetic heart valves.
• Prevention or treatment of venous
thromboembolism, such as deep vein thrombosis
and pulmonary embolism.
Aldosterone blockade
• Aldosterone blockade — We agree with the
2011 AHA/ACCF guideline on secondary
preventions, which recommends aldosterone
blockade for post-myocardial infarction patients
without significant renal dysfunction or
hyperkalemia who are receiving therapeutic
doses of an ACE inhibitor and a beta blocker and
who have a left ventricular ejection fraction ≤40
percent, and who have either diabetes or heart
failure .
Drug therapies with unproven
benefits
• Antioxidant vitamins — Antioxidant vitamins, which are
nonprescription and sold over the counter have promising
basic research and supportive observational data, but the
randomized evidence has not demonstrated clinical
benefits on CVD in secondary or primary prevention.
• Homocysteine and folic acid — Although in observational
studies, subjects with elevated levels of homocysteine have
an increased risk of CHD, and the fact that vitamin
supplementation with folic acid lowers homocysteine
levels, data from multiple randomized trials designed to
test the hypothesis show no significant benefits of folic acid
supplementation on the risks of CVD.
• Postmenopausal hormone therapy
ATP III LDL-cholesterol goals and cutpoints for therapeutic
lifestyle changes and drug therapy in different risk categories
Risk category
LDL-cholesterol goal
LDL-cholesterol level
at which to initiate
therapeutic lifestyle
changes
LDL-cholesterol level
at which to consider
drug therapy
Coronary heart disease
(CHD) or CHD risk
equivalent (10-year risk
>20 percent)*
<100 mg/dL (2.58
mmol/L)
≥100 mg/dL (2.58
mmol/L)
≥130 mg/dL (3.36
mmol/L); drug optional
at 100 to 129 mg/dL
(2.58 to 3.33 mmol/L)•
2 or more risk factors
(10-year risk ≤20
percent)Δ
≤130 mg/dL (3.36
mmol/L)
≥130 mg/dL (3.36
mmol/L)
10-year risk 10 to 20
percent: >130 mg/dL
(3.36 mmol/L) 10-year
risk <10 percent: ≥160
mg/dL (4.13 mmol/L)
0 to 1 risk factor◊
≤160 mg/dL (4.13
mmol/L)
≥160 mg/dL (4.13
mmol/L)
≥190 mg/dL (4.91
mmol/L); LDLcholesterol lowering drug
optional at 160 to 189
mg/dL (4.13 to 4.88
mmol/L)