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secondary prevention in patients with cardiovascular disease

Management: 1) antiplatelet therapy a) aspirin 1] 81-162 mg QD for most patients (see aspirin) 2] 325 mg QD for up to 6 months* after stent or up to 1 year after CABG 3] aspirin + dipyridamole (Aggrenox) [7] 3] add proton pump inhibitor to aspirin for elderly [24] b) clopidogrel 1] 75 mg QD 2] 75 mg QD + aspirin for up to 12 months after stent or acute coronary syndrome c) clopidogrel is superior to aspirin for secondary prevention of ischemic stroke [7,15] & superior to aspirin for prevention of myocardial infarction [28] d) clopidogrel 75 mg + aspirin 81 mg QD - NOT superior to clopidogrel alone [12] 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 [17] - annual mortality is higher with dual therapy (2.9% vs 1.4%) [17] - 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 [18] e) other P2Y12 receptor inhibitor f) P2Y12 inhibition might provide more benefit & less toxicity than aspirin [30] g) ticlopidine better than aspirin but associated with agranulocytosis & thrombotic thrombocytopenic purpura [7] 2) anticoagulation for patients with atrial fibrillation a) warfarin - INR of 2.0-3.0 is therapeutic (exception is rheumatic heart disease, INR=2.5-3.5 [7] b) thrombin inhibitor (dabigatran) [8] 1] FDA approved (2010) & included in AHA guidelines for treatment of atrial fibrillation [9] 2] no need for therapeutic monitoring (INR) c) factor Xa inhibitor 1] rivaroxaban not inferior to wafarin in preventing embolic stroke [10] 2] apixaban better than warfarin [11] - apixaban with close monitoring in patients with ESRD [7] d) warfarin plus antiplatelet agent substantially increases risk of bleeding, & risk outweighs any potential benefit except, possibly, after acute MI e) rivaroxaban plus dual antiplatelet therapy (NICE see NGC) f) zontivity (Vorapaxar) FDA-approved for high-risk patients 3) blood pressure control (antihypertensives) a) goal: < 140/90 b) start with ACE inhibitors &/or beta-blockers - maintenace with both ACE inhibitors & beta-blocker [7] c) add thiazide & other antihypertensives if needed 4) dyslipidemia - high-potency statin indicated regardless of LDL cholesterol - moderate-intensity statin therapy (atorvastatin 10 mg QD) for elderly > 75 years of age [19,21] - statins of no significant benefit in patients > 80 years of age [22] - despite this GRS11, recommends continuing statin [19] - 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 [25] considers all candidates for secondary prevention high risk - add ezetimibe or PCSK9 inhibitor as needed to achieve LDL cholesterol goals [25] - ezetimibe 10 mg 1st line for addition to high potency statin to achieve LDL cholesterol < 70 mg/dL [31] - PCSK9 inhibitor not yet cost effective [31] - 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 [27] - statin intolerance may be associated with increased risk of recurrent MI (RR=1.37) [23] 5) annual influenza vaccine 6) 30-60 minutes of moderate exercise 5 days/week - exercise as effective as drugs (statins, beta-blockers ACE inhibitors & anti-platelet agents) [14] 7) weight loss: a) initial goal: 10% (if overweight) b) BMI < 25 c) waistline < 40 inches (men); < 35 inches (women) d) 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) [32] - reduces second major cardiovascular event after myocardial infarction in obese patients without diabetes mellitus [33] 8) diet - fish consumption lowers cardiovascular risk in patients with preexisting cardiovascular disease [29] - plant-based diet: Blue Zone diet, vegan diet [19] 9) smoking cessation 10) HgbA1c < 7% in diabetics 11) cognitive behavioral therapy to alleviate stress & hostility reduces subsequent cardiovascular events [5] 12) meditation may be of some benefit [26] 13) surgery & other procedures a) patients with atrial fibrialltion should continue anticoagulation when undergoing dental procedures or dermatologic procedures [13] b) 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 [13] c) aspirin likely increases bleeding risk during orthopedic hip procedures [13] 14) paucity of strong evidence available to guide practice in older individuals [16]

Related

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

General

Prevention of Cardiovascular Disease

References

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  2. Smith SC et al, AHA/ACC Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update J Am Coll Cardiol 2006; 47:2130 PMID: 16697342
  3. Prescriber's Letter 13(5): 2006 Summary of 2006 AHA/ACC secondary prevention for patients with coronary and other atherosclerotic vascular disease Detail-Document#: 220707 (subscription needed) http://www.prescribersletter.com
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