Am Fam Physician. 2010 Feb 1;81(3):289-296.

Article Sections

  • Abstruse
  • Physical Activity
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Direction of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Coronary avenue disease is the leading cause of mortality in the United States. In patients who take had a myocardial infarction or revascularization process, secondary prevention of coronary avenue disease by comprehensive risk factor modification reduces mortality, decreases subsequent cardiac events, and improves quality of life. Options for secondary prevention include medical therapy and surgical revascularization in the form of coronary artery featherbed grafting or percutaneous coronary intervention. Medical therapy focuses on comprehensive run a risk factor modification. Therapeutic lifestyle changes (including weight direction, concrete activity, tobacco abeyance, and dietary modification) improve cardiac take a chance factors and are universally recommended by evidence-based guidelines. Treatment of hypertension and dyslipidemia reduces morbidity and mortality. Recommendations for persons with diabetes mellitus generally encourage glucose control, but electric current prove has non shown reductions in bloodshed with intensive glucose direction. Aspirin, angiotensin-converting enzyme inhibitors, and beta blockers reduce recurrent cardiac events in patients after myocardial infarction. Surgical revascularization by coronary artery bypass grafting is recommended for those with significant left primary coronary artery stenosis, significant stenosis of the proximal left inductive descending avenue, multivessel coronary illness, or disabling angina. Percutaneous coronary intervention may be considered in select patients with objective show of ischemia demonstrated past noninvasive testing.

Coronary artery disease (CAD) is the leading cause of decease in the U.s.a., with more 1 1000000 new and recurrent cardiovascular events occurring each twelvemonth, and its prevalence and impact are expected to grow.i,2 Advances in treatment accept improved survival after the initial outcome, but persons with established CAD have a high risk of future cardiovascular events.2

SORT: Key RECOMMENDATIONS FOR Exercise

Clinical recommendation Show rating References

Exercise-based cardiac rehabilitation reduces morbidity and mortality in patients with CAD.

A

3–7

Weight management is recommended by the AHA for the secondary prevention of CAD.

C

two, iv, 11

Smoking cessation reduces bloodshed by at to the lowest degree i 3rd in patients after MI or cardiac surgery.

A

13, 14

The AHA and The Seventh Study of the Articulation National Committee on Prevention, Detection, Evaluation, and Handling of High Claret Pressure recommend treating hypertension for a claret pressure goal of < 140/90 mm Hg, or < 130/eighty mm Hg in patients with diabetes mellitus or chronic kidney disease.

B

17, 18

Beta-blocker therapy reduces recurrent MI, sudden cardiac decease, and mortality in patients afterwards MI.

A

19–22

Aspirin therapy (81 to 162 mg daily) reduces recurrent vascular events past one quaternary in patients with a previous vascular consequence.

A

2, iv, 35

Statins reduce recurrent vascular events and all-crusade mortality in patients following astute coronary syndromes.

A

37, 38, 40, 41

Percutaneous coronary interventions have not been shown to be superior to optimal medical treatment alone for death or recurrent cardiovascular events in patients with stable CAD.

B

36, 52, 53

Recent clinical studies show that persons with CAD can reduce their take a chance of subsequent cardiovascular events through effective secondary prevention, which reduces bloodshed and improves quality of life.two Family physicians play an important role in initiating and maintaining risk factor modification using show-based standards. This article reviews the risk factors for recurrent CAD, current evidence-based interventions, and comprehensive risk factor improvement strategies.

Physical Activity

  • Abstract
  • Concrete Activity
  • Weight and Dietary Management
  • Tobacco Abeyance
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Regular physical action is an important component of secondary prevention of CAD; it increases exercise capacity, treats comorbid risk factors, and improves quality of life.3,iv Exercise-based cardiac rehabilitation has been shown to reduce all-crusade and cardiac mortality compared with usual care.3–7 The goal for all patients is thirty to hr of moderate-intensity physical activity (e.k., brisk walking, biking) on most, if not all, days of the week.2–4,viii Consequent physical activity improves cardiovascular risk factors—peculiarly total cholesterol and triglyceride levels—and systolic blood pressure.5

Exercise-based cardiac rehabilitation programs may be initiated soon after an acute coronary syndrome or revascularization procedure.ii,3 Infirmary-based cardiac rehabilitation has not been shown to be superior to domicile-based cardiac rehabilitation for low-risk patients.9 Before patients begin a rigorous exercise program, physicians should appraise their cardiovascular status by taking a physical activeness history or performing an exercise test.four Details of assessment tools and practice prescriptions were reviewed in a previous article in American Family Dr. (AFP; https://www.aafp.org/afp/2008/0415/p1129.html).ten

Weight and Dietary Management

  • Abstract
  • Physical Activity
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Direction of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Obesity is associated with increased CAD mortality and adversely affects cardiac function and comorbid CAD risk factors.11  Obesity is classified using the trunk mass alphabetize (BMI; Tabular array 1).11 Weight loss is indicated for patients who are classified as overweight or obese according to their BMI. The American Heart Clan (AHA) recommends measuring BMI at each office visit, and so providing objective feedback and consistent counseling on weight loss strategies.2,four,8,11 Long-term weight maintenance is best achieved through a balance of physical activity and moderation of caloric intake; improvements in cardiac risk factors are unremarkably observed with even small weight loss (i.east., 10 percent of baseline weight).8,11 Bereft bear witness exists to determine whether weight reduction decreases cardiovascular mortality in persons who are obese.eleven The testify for current dietary recommendations for primary and secondary prevention of CAD is summarized in a previous article in AFP (https://world wide web.aafp.org/afp/2009/0401/p571.html).12

Table ane.

Weight Classification by Body Mass Alphabetize

Classification Trunk mass alphabetize (kg per grandtwo)

Underweight

< 18.v

Normal

18.5 to 24.9

Overweight

25.0 to 29.9

Obese

≥ 30.0

Tobacco Cessation

  • Abstract
  • Physical Activity
  • Weight and Dietary Management
  • Tobacco Abeyance
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Avenue Bypass Grafting
  • References

Tobacco abeyance has been shown to reduce all-cause bloodshed in patients with established CAD.13,14 In a recent Cochrane review, investigators concluded that persons who quit smoking after a myocardial infarction (MI) or cardiac surgery reduce their take a chance of decease by at least one tertiary, and that discontinuing smoking is at to the lowest degree as beneficial as modifying other hazard factors.thirteen,14

Physicians are encouraged to ask about tobacco use at each function visit, and to extend a clear recommendation to quit to every patient who smokes. If a patient is willing to endeavor to quit, physicians tin assist with cessation through counseling and pharmacotherapy, which are nigh effective when combined.15,16 Providing behavior therapy, telephone back up, and self-assist materials for at to the lowest degree one calendar month can help patients with CAD to quit smoking.15,16

Hypertension

  • Abstract
  • Physical Activity
  • Weight and Dietary Direction
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Direction of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Avenue Bypass Grafting
  • References

The Seventh Written report of the Articulation National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure level (JNC 7) and the AHA recommend treating hypertension (i.due east., blood pressure greater than 140/90 mm Hg, or greater than 130/80 mm Hg for persons with diabetes mellitus or chronic kidney disease) for the secondary prevention of CAD.17,18 Lifestyle modifications involve weight management, regular physical action, prudent alcohol consumption, and a low-sodium diet. The JNC 7 and the AHA recommend initial treatment of hypertension after an MI with beta blockers or angiotensin-converting enzyme (ACE) inhibitors, with additional medications added in a stepwise fashion to accomplish goal blood pressure.17,18

Beta Blockers

  • Abstract
  • Physical Activity
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Flu Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Multiple clinical trials have shown that beta-blocker therapy can reduce recurrent MI, sudden cardiac death, and mortality in patients after MI, even in those who are normotensive.19–22 Consequently, the AHA has recommended that a beta-blocker regimen exist initiated and maintained indefinitely for the secondary prevention of CAD in all patients after having an MI, unless contra-indicated.2,23  Common contraindications and precautions for beta-blocker therapy are listed in Table 2.22 In that location is no clear consensus equally to which beta blocker is the safest or nigh effective.22

Tabular array 2.

Contraindications and Precautions for Beta-Blocker Therapy

Contraindications

Asthma that requires the apply of bronchodilators and/or steroids

Cardiogenic shock

Heart rate < l to threescore beats per infinitesimal

Second- or tertiary-caste atrioventricular cake

Severe middle failure that requires the utilize of intravenous diuretics or inotropes

Systolic blood force per unit area < 90 to 100 mm Hg

Precautions

Chronic obstructive pulmonary disease

Diabetes mellitus (although some experts practice not consider this a precaution)

Start-caste atrioventricular block

Middle failure*

Peripheral vascular illness

ACE Inhibitors

  • Abstract
  • Concrete Action
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Direction
  • Flu Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Two large randomized trials accept demonstrated the benefits of ACE inhibitors in the secondary prevention of CAD. The Heart Outcomes Prevention Evaluation (HOPE) study showed that 10 mg per day of ramipril (Altace) reduced cardiovascular death and MI in those who were at high gamble of or had established vascular disease without middle failure.24 The European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Avenue Disease (EUROPA) revealed a 20 percent reduction in cardiovascular mortality and MI in patients with stable CAD without middle failure who were treated with perindopril (Aceon).25 Investigators who performed a combined analysis of several studies ended that at that place is potent evidence for consistent cardiovascular protection with ACE-inhibitor therapy by improving survival and reducing the risk of major cardiovascular events in patients with vascular disease.26

Direction of Patients with Diabetes

  • Abstract
  • Concrete Activity
  • Weight and Dietary Management
  • Tobacco Abeyance
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Direction
  • Influenza Vaccination
  • Low
  • PCI and Coronary Artery Bypass Grafting
  • References

The mortality rate of CAD is college in patients with diabetes than in those without diabetes.27 Controversy exists regarding appropriate glucose control for diabetes management. Several guidelines recommend handling to reduce A1C levels to less than 7 percent; still, recent randomized clinical trials have not demonstrated reductions in cardiovascular events or mortality with intensive glucose control.ii,27–thirty Studies have shown inconsistent improvement with intensive glucose control in microvascular complications, including nephropathy, only increased adverse furnishings were observed, including weight gain, fluid retention, and symptomatic hypoglycemia.28–31 The largest recent trial investigating cardiovascular outcomes with intensive glucose control was discontinued early because of a 22 pct increased chance of all-cause mortality in the group treated toward an A1C goal of six percent compared with less-intensive glucose control.28 In summary, recent randomized clinical trials take not shown significant reductions in cardiovascular events or bloodshed with intensive glucose control.28–31

Secondary prevention of CAD in patients with diabetes likewise includes treatment of comorbid hypertension, dyslipidemia, and hypercoagulability.32 Handling of diabetes with statins reduces vascular morbidity and bloodshed regardless of cholesterol values, and a 2008 meta-analysis33 reported a proportional reduction in major vascular events, with a reduction in low-density lipoprotein (LDL) cholesterol levels in those with diabetes.27,32–34 A multifactorial approach to diabetic care that includes glucose command; blood force per unit area management with reninangiotensin arrangement blockers; aspirin therapy; and lipid management with statins has been shown to reduce vascular complications and cardiovascular mortality.32

Antiplatelet Agents

  • Abstract
  • Physical Action
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Artery Featherbed Grafting
  • References

Antiplatelet agents are recommended in all patients for the secondary prevention of CAD. In a big meta-analysis, antiplatelet therapy reduced recurrent vascular events by one 4th in patients with a previous vascular outcome.35 Aspirin treatment (81 to 162 mg per day) should brainstorm immediately after diagnosis of CAD and continue indefinitely unless contraindicated.2,4,35 Clopidogrel (Plavix) is an effective alternative in patients who cannot take aspirin, and the AHA recommends using clopidogrel in combination with aspirin for up to 12 months after an acute cardiac upshot or percutaneous coronary intervention (PCI) with stent placement.35,36

Lipid Direction

  • Abstruse
  • Physical Activeness
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Flu Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Recent clinical trials have demonstrated that reducing cholesterol levels decreases the risk of recurrent coronary events, and show-based cholesterol-lowering guidelines have been established past the National Cholesterol Education Programme Adult Treatment Panel 3 (ATP Iii).37–39 The AHA and ATP III recommend that all patients with CAD initiate lipid management through therapeutic lifestyle changes.2,4,38 For the secondary prevention of CAD, ATP Iii recommends LDL levels of less than 100 mg per dL (two.59 mmol per L), with an optional goal of less than seventy mg per dL (1.81 mmol per L); if the LDL level is greater than 130 mg per dL (three.37 mmol per Fifty), cholesterol-lowering medications are indicated in addition to lifestyle changes.38

Statins should be the initial medication choice; however, boosted agents may be considered if the LDL goal is not reached through statin therapy alone.2,37,38 Contempo studies have shown intensive statin therapy reduces all-cause mortality in patients after acute coronary syndromes compared with standard therapy; consequently, some have encouraged statin use in all patients who have CAD.forty,41 For every sustained 2 mg per dL reduction in LDL cholesterol, statin therapy has been shown to reduce major coronary events, coronary revascularization, and stroke by 1 percent.41 The AHA suggests that physicians consider advising patients to increase dietary intake of omega-3 fatty acids to improve cholesterol levels,42 but a Cochrane review found bereft prove to recommend for or against supplementation.43

Influenza Vaccination

  • Abstract
  • Concrete Activity
  • Weight and Dietary Direction
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Direction of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Low
  • PCI and Coronary Artery Bypass Grafting
  • References

Flu vaccination has been shown to reduce the adventure of hospitalizations for heart disease and all-cause mortality in older persons, and almanac influenza vaccination is recommended by the AHA for patients with CAD.44–46 However, a recent Cochrane review concluded that the data were insufficient to evaluate the effect of vaccination in the secondary prevention of CAD.47

Low

  • Abstruse
  • Physical Activity
  • Weight and Dietary Management
  • Tobacco Cessation
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Depression
  • PCI and Coronary Artery Bypass Grafting
  • References

Observational studies have shown that depression is about iii times more common in patients after having an MI than in the general population, and fifteen to 20 percentage of hospitalized patients with astute MI run across criteria for major low.48 Studies have shown that depression is associated with a higher take a chance of recurrent cardiac events one to ii years after an MI.48,49 Results of a retrospective review showed that patients with CAD who were depressed and treated with a selective serotonin reuptake inhibitor (SSRI) were 42 percent less likely to experience recurrent MI or death compared with patients who had depression only did non accept an antidepressant.48,49 All the same, a subsequent randomized trial in patients who had an MI found that treatment with an SSRI and cognitive behavior therapy (CBT) did non reduce mortality,50 and the authors of a recent systematic review concluded that treatment of low with medication or CBT in patients with cardiovascular affliction is associated with modest improvement in depressive symptoms, merely no improvement in cardiac outcomes.51 The AHA recommends screening for depression during secondary prevention of CAD and, if diagnosed, beginning appropriate treatment.two,4,48,50

PCI and Coronary Artery Featherbed Grafting

  • Abstract
  • Physical Activeness
  • Weight and Dietary Direction
  • Tobacco Abeyance
  • Hypertension
  • Beta Blockers
  • ACE Inhibitors
  • Management of Patients with Diabetes
  • Antiplatelet Agents
  • Lipid Management
  • Influenza Vaccination
  • Low
  • PCI and Coronary Avenue Bypass Grafting
  • References

Interventional treatment options for the secondary prevention of CAD include surgical revascularization by coronary artery bypass grafting (CABG) or PCI. No standardized assessment tool exists, only several factors influence determination making, including the extent of CAD, the severity of ischemia on noninvasive testing, and the presence of left ventricular dysfunction.2 The AHA recommends that persons with CAD undergo adventure stratification by exercise stress testing with left ventricular functional cess or radionuclide myocardial perfusion imaging to place who would do good from surgical intervention.23

The office of PCI in the secondary prevention of CAD is limited. Clinical trials involving patients with stable CAD have not shown that PCI prevents further events.36,52,53 1 recent trial showed no difference between optimal medical therapy with PCI versus optimal medical therapy alone for death or recurrent cardiovascular events52; still, PCI remains indicated for treatment of angina in select patients considering there may be transient comeback in physical limitations, angina frequency, and quality of life.36,52,53 Current guidelines support obtaining objective evidence of ischemia before elective PCI.36,52–54

CABG has been shown to reduce bloodshed in patients who have established CAD with appropriate findings on noninvasive testing (Table 3).23 For those without indications for CABG, medical therapy should exist optimized to minimize disease progression.ii,23 Despite advisable medical management, affliction progression remains a possibility, and surgical revascularization tin can exist reconsidered based on symptoms and clinical assessment.23 Figure 1 provides an algorithm of evaluation and treatment considerations for the secondary prevention of CAD.two,23

Table iii.

Indications for CABG in Patients with Stable CAD

CABG is recommended for patients with:

Disabling angina despite maximal medical therapy, given adequate surgical risk (if angina is atypical, obtain objective prove of ischemia)

Pregnant proximal LAD stenosis (≥ 70 percent diameter)

Substantial left main coronary artery stenosis

1- or 2-vessel CAD without proximal LAD stenosis, simply with a large expanse of feasible myocardium and high-risk criteria on noninvasive testing

two-vessel CAD with significant proximal LAD stenosis and either ejection fraction < 50 per centum or ischemia on noninvasive testing

3-vessel CAD (especially if left ventricular ejection fraction < 50 percent)

CABG may be considered for patients with:

Proximal LAD stenosis with 1-vessel CAD

ane- or ii-vessel CAD without significant proximal LAD stenosis, but with moderate area of feasible myocardium and demonstrable ischemia on noninvasive testing

CABG is non recommended for patients with:

Deadline coronary artery stenosis (< 60 percentage diameter) in locations other than the left main coronary artery, and no demonstrable ischemia on noninvasive testing

Insignificant coronary artery stenosis (< fifty percentage diameter)

1- or ii-vessel CAD without significant proximal LAD stenosis, mild symptoms unlikely caused by ischemia, or inadequate trial of medical therapy and a pocket-size surface area of feasible myocardium or no demonstrable ischemia on noninvasive testing

Secondary Prevention of Coronary Artery Disease

Figure 1.

Algorithm for the secondary prevention of coronary artery affliction.

Information from references 2 and 23.

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The Authors

show all author info

SCOTT Fifty. HALL, Physician, is a clinical assistant professor and sports medicine specialist in the Department of Family and Community Medicine at the University of Nevada Schoolhouse of Medicine in Reno. Dr. Hall is as well in private practice where he directs SpecialtyHealth in Reno....

TODD LORENC, Md, is the sports medicine boyfriend of the Section of Family and Community Medicine at the University of Nevada School of Medicine.

Address correspondence to Scott L. Hall, Md, Academy of Nevada School of Medicine, Thousand/S 316 Brigham Building, Reno, NV 89557 (e-mail: shallmd@specialtyhealth.com). Reprints are not available from the authors.

Writer disclosure: Null to disclose.

REFERENCES

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xv. Fiore Thou, Jaen CR, Baker TB, et al. A clinical practise guideline for treating tobacco use and dependence: 2008 update. A U.Southward. Public Health Service report. Am J Prev Med. 2008;35(2):158–176.

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31. Intensive blood-glucose command with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with blazon 2 diabetes (UKPDS 33). United kingdom of great britain and northern ireland Prospective Diabetes Study (UKPDS) Group [published correction appears in Lancet. 1999;354(9178):602]. Lancet. 1998;352(9131):837–853.

32. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. North Engl J Med. 2008;358(6):580–591.

33. Kearney PM, Blackwell L, Collins R, et al., for the Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy of cholesterol-lowering therapy in 18,686 people with diabetes in xiv randomised trials of statins: a meta-analysis. Lancet. 2008;371(9607):117–125.

34. Collins R, Armitage J, Parish S, Sleigh P, Peto R, for the Heart Protection Report Collaborative Group. MRC/BHF Eye Protection Report of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003;361(9374):2005–2016.

35. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high chance patients [published correction appears in BMJ. 2002;324(7330):141]. BMJ. 2002;324(7329):71–86.

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