|
|
(60 intermediate revisions by 5 users not shown) |
Line 3: |
Line 3: |
| {{CMG}} | | {{CMG}} |
|
| |
|
| ==Overview== | | == Overview == |
| Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery
| |
| disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%.
| |
| There are 10 aspects of secondary prevention: Smoking cessation; blood pressure control; lipid-lowering; increasing physical activity; weight loss; diabetes control; antiplatelet agents/anticoagulants; RAS blockers; beta-blockers and influenza vaccine.
| |
|
| |
|
| ==Target Population==
| |
| Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery | | Patients who should be treated with secondary prevention are those with established atherosclerosis including peripheral artery |
| disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%. | | disease; carotid artery disease; atherosclerotic aortic disease; diabetes and those with a Framingham Risk Score of > 20%. |
| | There are 12 aspects of secondary prevention: Smoking cessation; blood pressure control; lipid-lowering; increasing physical activity; weight loss; diabetes control; antiplatelet agents/anticoagulants; RAS blockers; beta-blockers; depression management; cardiac rehabilitation and influenza vaccine. Please note that secondary prevention guidelines, especially, those involving medication, may differ between [[Unstable Angina|UA/NSTEMI]]; [[STEMI]]; and [[Chronic Stable Angina]]. Please refer to appropriate page for more specific guidelines. |
|
| |
|
| ==Smoking Cessation== | | ==[[Coronary heart disease secondary prevention target population | Target Population]]== |
| ===AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update=== | | ==[[Coronary heart disease secondary prevention patient education | Patient Education]]== |
| {{cquote|
| | ==[[Coronary heart disease secondary prevention smoking cessation | Smoking Cessation]]== |
| | ==[[Coronary heart disease secondary prevention blood pressure control | Blood Pressure Control]]== |
| | ==[[Coronary heart disease secondary prevention lipid management | Lipid Management]]== |
| | ==[[Coronary heart disease secondary prevention physical activity recommendations | Physical Activity Recommendations]]== |
| | ==[[Coronary heart disease secondary prevention weight management | Weight Management]]== |
| | ==[[Coronary heart disease secondary prevention influenza vaccination | Influenza Vaccination]]== |
| | ==[[Coronary heart disease secondary prevention depression | Depression]]== |
| | ==[[Coronary heart disease secondary prevention beta-blockers | Beta Blockers]]== |
| | ==[[Coronary heart disease secondary prevention diabetes mellitus management | Diabete Mellitus Management]]== |
| | ==[[Coronary heart disease secondary prevention antiplatelet agents/anticoagulants | Antiplatelet Agents/Anticoagulants]]== |
|
| |
|
| '''Goal:''' Complete Cessation. No Exposure to environmental tobacco smoke.
| | ==[[Coronary heart disease secondary prevention renin-angiotensin-aldosterone system blockers |Renin-angiotensin-aldosterone system blockers]]== |
| | ==[[Coronary heart disease secondary prevention cardiac rehabilitation | Cardiac Rehabilitation]]== |
|
| |
|
| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]==== | | ==References== |
| | | {{reflist|2}} |
| '''1.''' Ask about tobacco use status at every visit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''2.''' Advise every tobacco user to quit. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''3.''' Assess the tobacco user's willingness to quit. [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''4.''' Assist counseling and developing a plan for quitting. [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''5.''' Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion). [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''6.''' Urge avoidance of exposure to environmental tobacco smoke at work and home. [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| | |
| }}
| |
| | |
| ==Blood Pressure Control==
| |
| *If blood pressure is > 120/80 mm Hg:
| |
| Initiate or maintain lifestyle modification (weight control, EtOH moderation, sodium reduction, increased physical activity, increased fruits, vegetables, low-fat dairy)
| |
| *If blood pressure > 140/90 mm Hg: As tolerated, add blood pressure medication (betablockers and/or ACE inhibitors initially).
| |
| | |
| ===AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update===
| |
| {{cquote| | |
| | |
| '''Goal:''' <140/90 mm Hg or <130/80 mm Hg if patient has diabetes or chronic kidney disease.
| |
| | |
| '''For all Patients:'''
| |
| | |
| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
| |
| | |
| '''1.''' Initiate or maintain lifestyle modification—weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| | |
| '''For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes):'''
| |
| | |
| ====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
| |
| | |
| '''1.''' As tolerated, add blood pressure medication, treating initially with β-blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure. [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
| |
| | |
| }} | |
|
| |
|
| ==Lipid Management==
| | [[Category:Cardiology]] |
| === AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease : 2006 Update ===
| | [[Category:Disease]] |
|
| |
|
| {{cquote| | | {{WH}} |
| | | {{WS}} |
| '''Goal:''' LDL-C <100 mg/dL; If triglycerides are ≥200 mg/dL, non-HDL-C should be <130 mg/dL.
| |
| | |
| '''For all patients:'''
| |
| | |
| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] ====
| |
| | |
| '''1.''' Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/d). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''2.''' Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further lower LDL-C.
| |
| | |
| '''3.''' Promote daily physical activity and weight management. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] ====
| |
| | |
| '''1.''' Encourage increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| |
| | |
| '''For lipid management:'''
| |
| | |
| '''1.''' Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiate lipid-lowering medication as recommended below before discharge according to the following schedule:
| |
| | |
| ==== [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] ====
| |
| | |
| '''a.''' LDL-C should be <100 mg/dL. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
| |
| | |
| '''b.''' If baseline LDL-C is ≥100 mg/dL, initiate LDL-lowering drug therapy. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
| |
| | |
| '''c.''' If on-treatment LDL-C is ≥100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
| |
| | |
| }} | |
| | |
| ==Physical Activity Recommendations==
| |
| *Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week.
| |
| *Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, heart failure)
| |
| | |
| ==Weight Management==
| |
| *Goal: BMI 18.5 to 24.9 kg/m2
| |
| *Waist Circumference:
| |
| :*Men: < 40 inches
| |
| :*Women: < 35 inches
| |
| | |
| *If waist circumference >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 5-10 percent from baseline.
| |
| | |
| ==ACE Inhibition==
| |
| *Use in all patients with LVEF < 40%, and those with diabetes or chronic kidney disease indefinitely, unless contraindicated
| |
| *Consider for all other patients
| |
| | |
| ==Angiotensin Receptor Blockade==
| |
| *Use in patients who are intolerant of ACE inhibitors with heart failure or post MI with LVEF less than or equal to 40%.
| |
| *Consider in other patients who are ACE inhibitor intolerant.
| |
| | |
| ==Diabetes Mellitus==
| |
| *Lifestyle and pharmacotherapy to achieve HbA1C <7% may be considered.
| |
| *Less stringent goal for may be considered (severe hypoglycemia, limited life expectancy, extensive comorbidities)
| |
| | |
| | |
| ===Anti-platelet therapy===
| |
| A [[meta-analysis]] of [[randomized controlled trials]] by the international [[Cochrane Collaboration]] found "that the use of clopidogrel plus aspirin is associated with a reduction in the risk of cardiovascular events compared with aspirin alone in patients with acute non-ST coronary syndrome. In patients at high risk of cardiovascular disease but not presenting acutely, there is only weak evidence of benefit and hazards of treatment almost match any benefit obtained.".<ref name="pmid17636787">{{cite journal |author=Keller T, Squizzato A, Middeldorp S |title=Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD005158 |year=2007 |pmid=17636787 |doi=10.1002/14651858.CD005158.pub2}}</ref>
| |
| | |
| ==References==
| |
| {{Reflist|2}} | |