Patients with established coronary heart disease (CHD) have a high risk of subsequent cardiovascular events, including myocardial infarction (MI), stroke, and death from cardiovascular disease (CVD). Therapeutic lifestyle changes in the form of increased physical activity, dietary modification/weight loss, and smoking cessation are of proven benefit and may improve outcomes in as quickly as six months. Drug therapies of proven benefit include aspirin, statins, and, in patients with MI or heart failure, beta blockers and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). These therapies work, in part, by ameliorating the risk attributable to the major modifiable risk factors of hypertension, dyslipidemia, diabetes, and smoking.
Secondary prevention interventions 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".)
Patients who should receive secondary preventive interventions — All patients with clinical atherosclerotic CVD should receive secondary preventive interventions [1,2]. In addition, intensive risk factor modification is recommended for patients with high risk due to the presence of multiple risk factors that confer a 10-year risk of CVD ≥7.5 percent, most patients with diabetes, or those with chronic kidney disease (CKD) with estimated glomerular filtration rate <45mL/min/ per 1.73 m2.
Atherosclerotic cardiovascular disease — Patients with established CHD, such as those with prior MI, have increased risks of MI as well as noncoronary atherosclerotic vascular disease events, such as stroke [3,4]. Increased risk also exists for patients with noncoronary atherosclerotic arterial disease, which includes carotid artery and peripheral artery disease.
Multiple risk factors — Patients without prior CVD but with multiple risk factors that confer a 10-year risk of CHD ≥7.5 percent are considered to be at high risk. These patients include many of those with the metabolic syndrome, the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia, which is also called the insulin resistance syndrome or syndrome X. (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'.)