secondary prevention in patients with cardiovascular disease

Management

• antiplatelet therapy
  • aspirin
    • 81-162 mg QD for most patients (see aspirin)
    • 325 mg QD for up to 6 months* after stent or up to 1 year after CABG
    • aspirin + dipyridamole (Aggrenox)
    • add proton pump inhibitor to aspirin for elderly
  • clopidogrel
    • 75 mg QD
    • 75 mg QD + aspirin for up to 12 months after stent or acute coronary syndrome
  • clopidogrel is superior to aspirin for secondary prevention of ischemic stroke & superior to aspirin for prevention of myocardial infarction
  • clopidogrel 75 mg + aspirin 81 mg QD
    • NOT superior to clopidogrel alone for prevention of stroke (see MATCH study)
      • increased risk of serious bleeding, including intracranial hemorrhage
    • aspirin plus clopidogrel is not more effective than a aspirin alone for preventing subsequent stroke in patients with lacunar stroke while on aspirin
      • annual mortality is higher with dual therapy (2.9% vs 1.4%)
      • increased risk of GI bleed
      • no increase in intracranial hemorrhage (contrast with MATCH study)
    • aspirin plus clopidogrel superior to aspirin alone for preventing stroke after transient ischemic attack or ischemic stroke
  • other P2Y12 receptor inhibitor
  • P2Y12 inhibition might provide more benefit & less toxicity than aspirin
  • ticlopidine better than aspirin but associated with agranulocytosis & thrombotic thrombocytopenic purpura
• anticoagulation for patients with atrial fibrillation
  • warfarin - INR of 2.0-3.0 is therapeutic (exception is rheumatic heart disease, INR=2.5-3.5
  • thrombin inhibitor (dabigatran)
    • FDA approved (2010) & included in AHA guidelines for treatment of atrial fibrillation
    • no need for therapeutic monitoring (INR)
  • factor Xa inhibitor
    • rivaroxaban not inferior to wafarin in preventing embolic stroke
    • apixaban better than warfarin
      • apixaban with close monitoring in patients with ESRD
  • warfarin plus antiplatelet agent substantially increases risk of bleeding, & risk outweighs any potential benefit except, possibly, after acute MI
  • rivaroxaban plus dual antiplatelet therapy (NICE see NGC)
  • zontivity (Vorapaxar) FDA-approved for high-risk patients
• blood pressure control (antihypertensives)
  • goal: < 140/90
  • start with ACE inhibitors &/or beta-blockers
    • maintenace with both ACE inhibitors & beta-blocker
  • add thiazide & other antihypertensives if needed
• dyslipidemia
  • high-potency statin indicated regardless of LDL cholesterol
  • moderate-intensity statin therapy (atorvastatin 10 mg QD) for elderly > 75 years of age
  • statins of no significant benefit in patients > 80 years of age
    • despite this GRS11, recommends continuing statin
  • management based on risk
  • previously LDL goal: < 100 mg/dL & < 70 mg/dL in high-risk patients
    • if triglycerides > 200 mg/dL, goal non HDL cholesterol: < 130 mg/dL, < 100 mg/dL in high-risk patients
  • ref considers all candidates for secondary prevention high risk
  • add ezetimibe or PCSK9 inhibitor as needed to achieve LDL cholesterol goals
  • ezetimibe 10 mg 1st line for addition to high potency statin to achieve LDL cholesterol < 70 mg/dL
    • PCSK9 inhibitor not yet cost effective
  • simvastatin 40 mg + ezetimibe 10 mg lowers risk of cardiovascular events after acute coronary event (relative to simvastatin 40 mg alone) even in patients > 75 years of age
  • statin intolerance may be associated with increased risk of recurrent MI (RR=1.37)
• annual influenza vaccine
• 30-60 minutes of moderate exercise 5 days/week
  • exercise as effective as drugs (statins, beta-blockers ACE inhibitors & anti-platelet agents)
• weight loss:
  • initial goal: 10% (if overweight)
  • BMI < 25
  • waistline < 40 inches (men); < 35 inches (women)
  • semaglutide for weight reduction
    • reduces cardiovascular events in obese patient with cardiovascular disease but without diabetes mellitus (6.5% vs 8.0% over 40 months)
    • reduces second major cardiovascular event after myocardial infarction in obese patients without diabetes mellitus
• diet
  • fish consumption lowers cardiovascular risk in patients with preexisting cardiovascular disease
  • plant-based diet: Blue Zone diet, vegan diet
• smoking cessation
• HgbA1c < 7% in diabetics
• cognitive behavioral therapy to alleviate stress & hostility reduces subsequent cardiovascular events
• meditation may be of some benefit
• surgery & other procedures
  • patients with atrial fibrialltion should continue anticoagulation when undergoing dental procedures or dermatologic procedures
  • stroke patients should probably continue aspirin during
    • dental procedures
    • dermatologic procedures
    • invasive ocular anesthesia
    • cataract surgery
    • transrectal ultrasound-guided prostate biopsy
    • spinal or epidural procedures
    • carpal tunnel surgery
  • aspirin likely increases bleeding risk during orthopedic hip procedures
• paucity of strong evidence available to guide practice in older individuals

Additional terms

• cardiovascular disease (CVD)
• coronary artery disease; coronary atherosclerosis (CAD)
• ischemic stroke
• peripheral vascular disease (PVD)
• primary prevention of cardiovascular disease
• sexual activity & cardiovascular disease