Prevention of cardiovascular disease events in those with established disease or at high risk
- Charles H Hennekens, MD, DrPH
Charles H Hennekens, MD, DrPH
- First Sir Richard Doll Professor & Senior Academic Advisor to the Dean, Charles E. Schmidt College of Medicine, Florida Atlantic University
- Clinical Professor, Nova Southeastern University
- Voluntary Professor, University of Miami Miller School of Medicine
- Jose Lopez-Sendon, MD, PhD
Jose Lopez-Sendon, MD, PhD
- Chief, Cardiology Department
- Hospital Universitario La Paz
- Instituto de Investigación La PAZ
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
Patients with established cardiovascular disease (CVD) have a high risk of subsequent cardiovascular events, including myocardial infarction (MI), stroke, and death. Therapeutic lifestyle changes (TLCs) such as increased physical activity, dietary modification/weight loss, and smoking cessation are of proven benefit and are likely to improve outcomes beginning within a matter of months. Adjunctive drug therapies of proven benefit are principally aspirin and statins and in patients with MI or heart failure, they include beta blockers and angiotensin converting enzyme inhibitors or angiotensin receptor blockers. TLCs and adjunctive drug therapies of proven benefit are likely to have additive benefits in the secondary as well as primary prevention of CVD.
Other individuals without established CVD are also at high risk of cardiovascular events and include individuals with multiple traditional risk factors for CVD or patients with chronic kidney disease.
Interventions to prevent CVD events in those with established disease or at high risk will be summarized here. More detailed discussions of each risk factor are presented elsewhere. (See "Overview of primary prevention of coronary heart disease and stroke".)
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
All patients with established cardiovascular disease (CVD) including coronary heart disease, cerebrovascular disease, and peripheral artery disease should receive interventions to prevent a subsequent CVD event [1-3]. These are termed secondary preventive interventions. All healthcare providers should attempt to lower the risk of a subsequent event in all patients with CVD using therapeutic lifestyle changes as well as adjunctive drug therapies of proven benefit.
PATIENTS AT HIGH RISK
We define patients at high risk as those with a prior CVD event as well as those whose 10-year risk is >10 percent. These latter subjects are likely to include most patients with diabetes, and those with chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) <45 mL/min/per 1.73 m2 as well as many with metabolic syndrome, the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia, which is also called the insulin resistance syndrome. In all subjects without a prior CVD event, preventive interventions are labelled as primary. (See "Estimation of cardiovascular risk in an individual patient without known cardiovascular disease" and "The metabolic syndrome (insulin resistance syndrome or syndrome X)", section on 'Prevalence and risk factors'.)
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- ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
- PATIENTS AT HIGH RISK
- Diabetes mellitus
- Chronic kidney disease
- Older adults
- MULTIPLE RISK FACTOR INTERVENTION
- Initial therapy in stable patients
- LDL-C goal
- After an acute coronary syndrome
- Patients for whom statin monotherapy is insufficient
- Possible role of CRP
- HDL-cholesterol and triglycerides
- Residual risk
- LIFESTYLE MODIFICATION
- Cardiac rehabilitation programs
- Text messaging
- Smoking cessation
- Weight reduction
- Physical activity
- OTHER ADJUNCTIVE THERAPIES
- Antithrombotic therapy
- - Antiplatelet therapy
- - Anticoagulant therapy
- Beta blockers
- ACE inhibitors or ARBs
- Aldosterone blockade
- Influenza vaccination
- Fish oil and marine omega-3 fatty acids
- Therapies without well established benefit
- PATIENT EDUCATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS