II. Prevention: Approach
- Mnemonic: Remember your ABCDEs
- Antiplatelet (e.g. Aspirin) or Anticoagulant
- Blood Pressure control
- Cholesterol management
- Diabetes management
- Exercise (or Cardiac Rehabilitation if indicated)
- Smoking Cessation
-
General
- Four health habits dramatically reduce risk
- Benefits
- Following all 4 habits reduces cardiovascular events by 40%
- Overall survival is extended 14 years in those following all 4 habits
- Even adopting 1 new health habit significantly reduces mortality
- References
III. Management: Risk factor modification
-
Heart Healthy Diet
- See DASH Diet
- See Mediterranean Diet (Heart Healthy Diet)
- See Low Fat Diet
- Avoid trans fats (hydrogenated oil products)
- Weight loss (in Overweight patients with BMI >27 to 30 kg/m2)
- See Obesity Management
- Consider GLP1 Agonist (e.g. Semaglutide, Liraglutide, Tirzepatide)
-
Hypertension Management
- Blood Pressure control (Ideally less than 130/80)
-
Tobacco Cessation
- Regardless of age, Tobacco Cessation reduces risk
- Overall mortality reduced as much as 36% in CHD
- Risk reduction more than medications (e.g. ASA)
- Critchley (2003) JAMA 290:86-97 [PubMed]
- Other substance use is associated with premature coronary events
- Stimulants (Cocaine, Methamphetamine) significantly increase risk of ACS
- Lower Cholesterol
- Diet or pharmacologic treatment
- See Statin use below
- Non-Statins have provided minimal to no significant benefit in Cardiovascular Risk Reduction
- Specific LDL and HDL targets have been replaced with high-intensity Statin if 10 year CV risk >20%
- Historic lipid targets
- LDL Cholesterol <100 mg/dl (very high risk patients should aim for <70 mg/dl)
- Each 40 mg/dl drop in LDL lowers Cardiovascular Risk by 20% over one year regardless of age
- HDL Cholesterol >40 mg/dl (50 mg/dl for women)
- Triglycerides <150 mg/dl
- LDL Cholesterol <100 mg/dl (very high risk patients should aim for <70 mg/dl)
-
Exercise
- See Exercise Prescription
- Aerobic Exercise
- Muscle Strengthening and Resistance Training
- References
-
Diabetes Mellitus Management
- Keep the Hemoglobin A1C less than 7% in Type I Diabetes and <8% in Type II Diabetes
- Consider GLP1 Agonist or SGLT2 Inhibitor
- Treat comorbid Major Depression
- See Depression Management in Cardiovascular Disease
- Increased risk of Coronary Artery Disease
- Risk of MI related death increased 2 to 3.5 fold
-
Immunizations
- Pneumococcal Vaccine
- Covid-19 Vaccine
- Influenza Vaccine
- Lowers cardiovascular event risk by 50%
- Gurfinkle (2002) Circulation 105: 2143-7 [PubMed]
- Pregnancy
- Reliable Contraception
- Preconception Counseling regarding the risks of pregnancy in Coronary Artery Disease
- Multidisciplinary care (cardiology, maternal fetal medicine) should CAD patient become pregnant
IV. Management: Disproved strategies
-
Fish Oil Supplementation
- See omega 3 Fatty Acid supplementation
- Fish oil (DHA and EPA) 1000 mg/day
- Is effective in the mild to moderate lowering of Serum Triglycerides
- However, as of 2024, not recommended to reduce cardiovascular events
- Do not appear to lower risk of cardiovascular events
- Tadic (2021) J Clin Med 10(11):2495 +PMID: 34200081 [PubMed]
- Anti-Oxidant regimen
- Negates Statin and Niacin HDL-2 beneficial effects
- No proven efficacy
- Anti-Oxidants
- Vitamin E 400 iu/day
- Increases Cardiovascular Risk, risk of Congestive Heart Failure and Hemorrhagic Stroke
- Not effective in coronary disease prevention
- Skekelle (2004) J Gen Intern Med 19:380-9 [PubMed]
- Vitamin C 500-1000 mg/day
- Beta Carotene 25000 u/day (increases Cardiovascular Risk)
- B Vitamins offer no benefit in Cardiac Risk
- Vitamin B12 Supplementation 400 mg qd
- Vitamin B6 supplementation 10 mg qd
- (2006) N Engl J Med 354:1567-77 [PubMed]
- Vitamin E 400 iu/day
-
Estrogen Replacement (Hormone Replacement Therapy)
- Stop HRT in those at risk for coronary disease
- No longer thought to be protective against CAD
- Data based on NIH Women's Health Initiative
- References
V. Medications: Platelet activation inhibitors
- See Antiplatelet Therapy for Vascular Disease
-
Aspirin
- Indications
- Aspirin is first line antiplatelet agent in Coronary Artery Disease
- Indication for primary prevention (no known Coronary Artery Disease)
- Falling out of favor in the primary prevention of lower risk patients without Myocardial Infarction or stroke
- Number Needed to Treat: 1 in 250 to prevent one first cardiovascular event (primary prevention)
- Aspirin is still an important mainstay of secondary prevention (known cardiovascular disease)
- Aspirin is still considered beneficial for primary prevention when 10 year CVD risk >10%
- Strongest benefit in age 40 to 60 years (esp. in Diabetes Mellitus)
- Benefits are less strong in age 60-69 years
- USPTF no longer recommends for primary prevention over age 60 years
- Davidson (2022) JAMA 327(16): 1577-84 [PubMed]
- Aspirin risk may outweigh benefit over age 75 years (consider discontinuing Aspirin in advanced age)
- Benefits may not outweigh the risks of GI Bleeding, Hemorrhagic CVA
- Number Needed to Harm: 1 in 200 to result in major bleeding
- Hemorrhage risk increases with older age, male gender, Tobacco Abuse, NSAID and Anticoagulant use
- Resources
- Aspirin Guide (web-based Shared Decision Making tool)
- References
- (2018) Presc Lett 25(11): 61
- Davidson (2022) JAMA 327(16):1577-84 [PubMed]
- Falling out of favor in the primary prevention of lower risk patients without Myocardial Infarction or stroke
- Dosing
- Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
- Aspirin 81 mg is sufficient for most patients
- Berger (2008) Am J Med 121(1): 43-9 [PubMed]
- Some postulated that enteric coating makes the 81 mg Aspirin less effective
- Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
-
Aspirin resistance confers 3x Cardiovascular Risk
- Consider lab screening in high risk patients
- Optical aggregation for Aspirin resistance
- Use Clopidogrel for Aspirin resistant patients
- Reference
- Consider lab screening in high risk patients
-
Aspirin with Proton Pump Inhibitor
- Indicated for history of bleeding Peptic Ulcer
- Less bleeding risk than Clopidogrel
- Chan (2005) N Engl J Med 352:238-44 [PubMed]
-
Aspirin use without vascular disease
- Overall NNT 254 on Aspirin for 7 years to prevent one cardiovascular event
- At the expense of 1 major bleeding episode in same group
- Berger (2011) Am Heart J 162(1): 115-24 [PubMed]
- Women without vascular disease
- Reduces stroke risk but not Myocardial Infarction risk
- Associated with higher risk of GI Bleeding
- Not recommended for women at low vascular risk
- Ridker (2005) N Engl J Med 352:1293-304 [PubMed]
- Prior Gastrointestinal Bleeding
- Overall NNT 254 on Aspirin for 7 years to prevent one cardiovascular event
- Indications
-
Platelet ADP Receptor Antagonist (e.g. Clopidogrel, Ticagrelor, Prasugrel)
- See Platelet ADP Receptor Antagonist
- Marginally more effective than Aspirin in preventing CV events
- Aside from post-coronary stenting, avoid combining with Aspirin in stable cardiovascular disease
- Dual Antiplatelet Therapy is more effective CV prevention, but raises the major bleeding risk
- Bittl (2016) Circulation 134(10): e156-78 +PMID:27026019 [PubMed]
- Indicated in known vascular disease if Aspirin contraindicated
- References
VI. Medications: Antihypertensives
- Goal Blood Pressure
- High Risk (CAD, CRF, DM): <130/80
- Other patients: <140/90 (consider as goal for most patients after JNC 8)
- Keep diastolic Blood Pressure >60 mmHg to maintain perfusion (especially in Diabetes Mellitus, age >60 years)
- First-line Antihypertensives in CAD Prevention
- Beta-Blockers
- Medications
- Metoprolol Succinate titrate up to 200 mg orally daily
- Carvedilol titrate up to 25 mg orally twice daily
- Bisoprolol tritrate up to 10 mg orally daily
- Continue for at least 1 year (previously 3 years) after MI, indefinately for CHF, Angina
- Primary benefit in Post-MI is for those with reduced ejection fraction (<50%)
- Continue for at least 1 year after Myocardial Infarction (previously recommended for 3 years)
- Post-MI with revascularization and preserved EF appears to benefit little from Beta Blockers
- Yndigegn (2024) N Engl J Med 390(15):1372-81 +PMID: 38587241 [PubMed]
- Medications
- ACE Inhibitors (or Angiotensin Receptor Blockers)
- Anticipate a small increase in Serum Creatinine on starting ACE Inhibitors (or ARBs)
- Stop or decrease ACE Inhibitor dose if Serum Creatinine rises >30% over baseline
- Thiazide Diuretics
- Chlorthalidone or Indapamide is preferred over Hydrochlorothiazide
- Beta-Blockers
- Other agents: Calcium Channel Blockers
- May be higher mortality in general CAD
- Especially avoid short acting agents (e.g. Nifedipine)
- Less effective CAD prevention than other agents
- Indications
- Black patients (CCBs are more effective than ACE/ARB agents)
- Rest and Variant Angina
- Silent ischemia
- Microvascular Angina (syndrome X)
- Use in combination with nitrates
- Preparations
- Dihydropyridine Calcium Channel Blocker
- Consider for Hypertension, Angina (may be added to Beta Blocker)
- Amlodipine
- Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil)
- Avoid unless Beta Blocker not tolerated
- Dihydropyridine Calcium Channel Blocker
- May be higher mortality in general CAD
VII. Medications: AntiHyperlipidemic therapy with Statin
- Effective in preventing future cardiovascular events
- Benefit even in patients over age 80 years
- Goal LDL Cholesterol
- Low-intensity and high-intensity protocols have replaced historic LDL targets
- Adjunctive measures added to Statins (high risk patients)
- Ezetimibe
- PCSK9 Inhibitor (e.g. Alirocumab, for very high risk patients)
- Older LDL target
- Most patients: 100 mg/dl
- High risk patients: <70 mg/dl (Intensive lipid lowering)
- Statins independently lower CAD risk with Plaque stabilization and are first-line tools in preventive cardiology
-
Statins in high cardiovascular disease risk (10 year risk >20%)
- Number Needed to Treat (NNT) 25 on Statin for 10 years to prevent one significant cardiovascular event
- Baigent (2005) Lancet 366(9493): 1267-78 [PubMed]
-
Statins in low to moderate cardiovascular disease risk (10 year risk with Framingham Score of 6%)
- Number Needed to Treat (NNT) 80 on Statin for 10 years to prevent one significant cardiovascular event
- Tonelli (2011) CMAJ 183(16): E1189-1202 [PubMed]
VIII. Medications: Reduce Homocysteine (e.g. Folic Acid)
- Supplementation only benefits venous events, but does not affect arterial Cardiovascular Risk
-
Folic Acid supplementation 1000 mg daily
- Not beneficial post-stenting
- References
IX. Medications: Other
- See Post Myocardial Infarction Medications
-
Antianginals
- See Angina
- Beta Blockers
- Calcium Channel Blockers (if normal ejection fraction)
- Long Acting Nitroglycerin (e.g. Isosorbide Mononitrate)
- Ranolazine (Ranexa, refractory cases)
- Supplements that show initial benefit
- Coenzyme Q10 60 mg orally twice daily (more helpful in reduction in Statin-Induced Myalgias)
- Implantable Cardioverter Defibrillators
- Used post-MI for high risk of ventricular Arrhythmia
- Did not reduce mortality (n=674) over >30 months
- Hohnloser (2004) N Engl J Med 351:2481-8 [PubMed]
-
Colchicine (Lodoco)
- Refractory, recurrent cardiovascular events despite maximal Cardiovascular Risk Reduction AND eGFR >60 ml/min
- Lowers cardiovascular event rate (NNT 36)
- Dose 0.5 mg orally daily
X. Medications: Avoid NSAIDs (other than Aspirin)
-
NSAIDs are associated with increased risk of cardiovascular events
- Even short-term NSAID use 5 years after coronary event increases CAD event risk
- Associated with 19 more events in 1000 patients with CAD
- Antman (2007) Circulation 115(12):1634-42 [PubMed]
- Moore (2007) BMC Musculoskelet Disord 8:73 [PubMed]
- Schjerning Olsen (2011) Circulation 123(20):2226-35 [PubMed]
- Wehrmacker (2006) Compr Ther 32(4):236-9 [PubMed]
- Even short-term NSAID use 5 years after coronary event increases CAD event risk
- Step-wise approach to Analgesics (in order of least to most Cardiovascular Risk)
- Acetaminophen (lowest Cardiovascular Risk)
- Aspirin (cardioprotective)
- Tramadol (but has other risks)
- Opioid Analgesics (e.g. Vicodin)
- Salsalate
- Naproxen (Naprosyn)
- Cox-2 selective NSAIDs such as Celecoxib or Diclofenac (most Cardiovascular Risk)
- References
- Prescriber's Letter (2008) 15(2): 8
XI. Resources
- ASCVD Risk Estimator (may overestimate risk)
- Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator
- https://www.mdcalc.com/calc/10491/predicting-risk-cardiovascular-disease-events-prevent
- https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
- Expanded Test Sensitivity to include younger patients with cardiovascular, renal or metabolic risk factors
- May replace ASCVD Risk Estimator (less over-estimation of Cardiac Risk)