Cardiac Risk Management

Aka: Cardiac Risk Management, CAD Risk Management, Cardiovascular Risk Reduction, Cardiac Risk Reduction, Coronary Risk Management, Coronary Heart Disease Prevention, Prevention of Coronary Events, Anticoagulation in Coronary Artery Disease Prevention

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II. Prevention: Approach

  1. Mnemonic: Remember your ABCDEs
    1. Antiplatelet (e.g. Aspirin) or Anticoagulant
    2. Blood Pressure control
    3. Cholesterol management
    4. Diabetes management
    5. Exercise (or Cardiac Rehabilitation if indicated)
    6. Smoking Cessation
  2. General
    1. Four health habits dramatically reduce risk
      1. Tobacco avoidance
      2. BMI <25 kg/m2 (but even <30 kg/m2 reduces risk)
      3. Eating 5 or more fruits and vegetables daily
      4. Aerobic Exercise >150 minutes per week
    2. Benefits
      1. Following all 4 habits reduces cardiovascular events by 40%
      2. Overall survival is extended 14 years in those following all 4 habits
      3. Even adopting 1 new health habit significantly reduces mortality
    3. References
      1. Akesson (2007) Arch Intern Med 167: 2122-27 [PubMed]
      2. King (2007) Am J Med 120:598-603 [PubMed]

III. Management: Risk factor modification

  1. Heart Healthy Diet
    1. See DASH Diet
    2. See Mediterranean Diet (Heart Healthy Diet)
    3. See Low Fat Diet
    4. Avoid trans fats (hydrogenated oil products)
  2. Weight loss (in Overweight patients with BMI >27 to 30 kg/m2)
    1. See Obesity Management
    2. Consider GLP1 Agonist (e.g. Semaglutide, Liraglutide, Tirzepatide)
  3. Hypertension Management
    1. Blood Pressure control (Ideally less than 130/80)
  4. Tobacco Cessation
    1. Regardless of age, Tobacco Cessation reduces risk
      1. Hermanson (1988) N Engl J Med 319:1365-9 [PubMed]
    2. Overall mortality reduced as much as 36% in CHD
      1. Risk reduction more than medications (e.g. ASA)
      2. Critchley (2003) JAMA 290:86-97 [PubMed]
    3. Other substance use is associated with premature coronary events
      1. Stimulants (Cocaine, Methamphetamine) significantly increase risk of ACS
  5. Lower Cholesterol
    1. Diet or pharmacologic treatment
    2. See Statin use below
      1. Non-Statins have provided minimal to no significant benefit in Cardiovascular Risk Reduction
    3. Specific LDL and HDL targets have been replaced with high-intensity Statin if 10 year CV risk >20%
    4. Historic lipid targets
      1. LDL Cholesterol <100 mg/dl (very high risk patients should aim for <70 mg/dl)
        1. Each 40 mg/dl drop in LDL lowers Cardiovascular Risk by 20% over one year regardless of age
      2. HDL Cholesterol >40 mg/dl (50 mg/dl for women)
      3. Triglycerides <150 mg/dl
  6. Exercise
    1. See Exercise Prescription
    2. Aerobic Exercise
      1. Moderate intensity aerobic Exercise >150 min/week (ideally >300) OR
        1. Examples: Body pump, swim, bike, garden, walk>3 mph
      2. Vigorous intensity aerobic Exercise >75 min/week (ideally >150)
        1. Examples: Bike >10 mph, jog, hike uphill with pack
    3. Muscle Strengthening and Resistance Training
      1. Exercise all major Muscle groups at least twice weekly
    4. References
      1. Anderson (2016) Cochrane Database Syst Rev (1): CD001800 [PubMed]
      2. Wannamethee (2000) Circulation 102:1358-63 [PubMed]
  7. Diabetes Mellitus Management
    1. Keep the Hemoglobin A1C less than 7% in Type I Diabetes and <8% in Type II Diabetes
    2. Consider GLP1 Agonist or SGLT2 Inhibitor
  8. Treat comorbid Major Depression
    1. See Depression Management in Cardiovascular Disease
    2. Increased risk of Coronary Artery Disease
    3. Risk of MI related death increased 2 to 3.5 fold
  9. Immunizations
    1. Pneumococcal Vaccine
    2. Covid-19 Vaccine
    3. Influenza Vaccine
      1. Lowers cardiovascular event risk by 50%
      2. Gurfinkle (2002) Circulation 105: 2143-7 [PubMed]
  10. Pregnancy
    1. Reliable Contraception
    2. Preconception Counseling regarding the risks of pregnancy in Coronary Artery Disease
    3. Multidisciplinary care (cardiology, maternal fetal medicine) should CAD patient become pregnant

IV. Management: Disproved strategies

  1. Fish Oil Supplementation
    1. See omega 3 Fatty Acid supplementation
    2. Fish oil (DHA and EPA) 1000 mg/day
    3. Is effective in the mild to moderate lowering of Serum Triglycerides
    4. However, as of 2024, not recommended to reduce cardiovascular events
      1. Do not appear to lower risk of cardiovascular events
      2. Tadic (2021) J Clin Med 10(11):2495 +PMID: 34200081 [PubMed]
  2. Anti-Oxidant regimen
    1. Negates Statin and Niacin HDL-2 beneficial effects
    2. No proven efficacy
    3. Anti-Oxidants
      1. Vitamin E 400 iu/day
        1. Increases Cardiovascular Risk, risk of Congestive Heart Failure and Hemorrhagic Stroke
        2. Not effective in coronary disease prevention
        3. Skekelle (2004) J Gen Intern Med 19:380-9 [PubMed]
      2. Vitamin C 500-1000 mg/day
      3. Beta Carotene 25000 u/day (increases Cardiovascular Risk)
      4. B Vitamins offer no benefit in Cardiac Risk
        1. Vitamin B12 Supplementation 400 mg qd
        2. Vitamin B6 supplementation 10 mg qd
        3. (2006) N Engl J Med 354:1567-77 [PubMed]
  3. Estrogen Replacement (Hormone Replacement Therapy)
    1. Stop HRT in those at risk for coronary disease
    2. No longer thought to be protective against CAD
    3. Data based on NIH Women's Health Initiative
    4. References
      1. (2002) JAMA 288:321-333 [PubMed]
      2. Waters (2002) 288:2432-40 [PubMed]

V. Medications: Platelet activation inhibitors

  1. See Antiplatelet Therapy for Vascular Disease
  2. Aspirin
    1. Indications
      1. Aspirin is first line antiplatelet agent in Coronary Artery Disease
    2. Indication for primary prevention (no known Coronary Artery Disease)
      1. Falling out of favor in the primary prevention of lower risk patients without Myocardial Infarction or stroke
        1. Number Needed to Treat: 1 in 250 to prevent one first cardiovascular event (primary prevention)
        2. Aspirin is still an important mainstay of secondary prevention (known cardiovascular disease)
        3. Aspirin is still considered beneficial for primary prevention when 10 year CVD risk >10%
          1. Strongest benefit in age 40 to 60 years (esp. in Diabetes Mellitus)
          2. Benefits are less strong in age 60-69 years
            1. USPTF no longer recommends for primary prevention over age 60 years
            2. Davidson (2022) JAMA 327(16): 1577-84 [PubMed]
          3. Aspirin risk may outweigh benefit over age 75 years (consider discontinuing Aspirin in advanced age)
      2. Benefits may not outweigh the risks of GI Bleeding, Hemorrhagic CVA
        1. Number Needed to Harm: 1 in 200 to result in major bleeding
        2. Hemorrhage risk increases with older age, male gender, Tobacco Abuse, NSAID and Anticoagulant use
      3. Resources
        1. Aspirin Guide (web-based Shared Decision Making tool)
          1. http://www.aspiringuide.com/
      4. References
        1. (2018) Presc Lett 25(11): 61
        2. Davidson (2022) JAMA 327(16):1577-84 [PubMed]
    3. Dosing
      1. Doses of 75-162 mg are as effective (and less GI Bleeding) as 325 mg daily
        1. Aspirin 81 mg is sufficient for most patients
        2. Berger (2008) Am J Med 121(1): 43-9 [PubMed]
      2. Some postulated that enteric coating makes the 81 mg Aspirin less effective
        1. Some recommended 162 mg daily if enteric coated Aspirin used
        2. However, 81 mg Aspirin daily appears to be effective despite enteric coating and remains standard
    4. Aspirin resistance confers 3x Cardiovascular Risk
      1. Consider lab screening in high risk patients
        1. Optical aggregation for Aspirin resistance
      2. Use Clopidogrel for Aspirin resistant patients
      3. Reference
        1. Gum (2003) J Am Coll Cardiol 41:961-5 [PubMed]
    5. Aspirin with Proton Pump Inhibitor
      1. Indicated for history of bleeding Peptic Ulcer
      2. Less bleeding risk than Clopidogrel
      3. Chan (2005) N Engl J Med 352:238-44 [PubMed]
    6. Aspirin use without vascular disease
      1. Overall NNT 254 on Aspirin for 7 years to prevent one cardiovascular event
        1. At the expense of 1 major bleeding episode in same group
        2. Berger (2011) Am Heart J 162(1): 115-24 [PubMed]
      2. Women without vascular disease
        1. Reduces stroke risk but not Myocardial Infarction risk
        2. Associated with higher risk of GI Bleeding
        3. Not recommended for women at low vascular risk
        4. Ridker (2005) N Engl J Med 352:1293-304 [PubMed]
      3. Prior Gastrointestinal Bleeding
        1. Avoid Aspirin (and other antiplatelet agents) for primary prevention after prior GI Bleed
        2. Limit Aspirin after GI Bleed to secondary prevention (known cardiovascular disease)
  3. Platelet ADP Receptor Antagonist (e.g. Clopidogrel, Ticagrelor, Prasugrel)
    1. See Platelet ADP Receptor Antagonist
    2. Marginally more effective than Aspirin in preventing CV events
      1. (1996) Lancet 348(9038): 1329-39 [PubMed]
    3. Aside from post-coronary stenting, avoid combining with Aspirin in stable cardiovascular disease
      1. Dual Antiplatelet Therapy is more effective CV prevention, but raises the major bleeding risk
      2. Bittl (2016) Circulation 134(10): e156-78 +PMID:27026019 [PubMed]
    4. Indicated in known vascular disease if Aspirin contraindicated
    5. References
      1. Cannon (2002) Am J Cardiol 90:160-2 [PubMed]

VI. Medications: Antihypertensives

  1. Goal Blood Pressure
    1. High Risk (CAD, CRF, DM): <130/80
    2. Other patients: <140/90 (consider as goal for most patients after JNC 8)
    3. Keep diastolic Blood Pressure >60 mmHg to maintain perfusion (especially in Diabetes Mellitus, age >60 years)
  2. First-line Antihypertensives in CAD Prevention
    1. Beta-Blockers
      1. Medications
        1. Metoprolol Succinate titrate up to 200 mg orally daily
        2. Carvedilol titrate up to 25 mg orally twice daily
        3. Bisoprolol tritrate up to 10 mg orally daily
      2. Continue for at least 1 year (previously 3 years) after MI, indefinately for CHF, Angina
      3. Primary benefit in Post-MI is for those with reduced ejection fraction (<50%)
        1. Continue for at least 1 year after Myocardial Infarction (previously recommended for 3 years)
        2. Post-MI with revascularization and preserved EF appears to benefit little from Beta Blockers
        3. Yndigegn (2024) N Engl J Med 390(15):1372-81 +PMID: 38587241 [PubMed]
    2. ACE Inhibitors (or Angiotensin Receptor Blockers)
      1. Anticipate a small increase in Serum Creatinine on starting ACE Inhibitors (or ARBs)
      2. Stop or decrease ACE Inhibitor dose if Serum Creatinine rises >30% over baseline
    3. Thiazide Diuretics
      1. Chlorthalidone or Indapamide is preferred over Hydrochlorothiazide
  3. Other agents: Calcium Channel Blockers
    1. May be higher mortality in general CAD
      1. Especially avoid short acting agents (e.g. Nifedipine)
    2. Less effective CAD prevention than other agents
      1. Black (2003) JAMA 289:2073-82 [PubMed]
    3. Indications
      1. Black patients (CCBs are more effective than ACE/ARB agents)
      2. Rest and Variant Angina
      3. Silent ischemia
      4. Microvascular Angina (syndrome X)
        1. Use in combination with nitrates
    4. Preparations
      1. Dihydropyridine Calcium Channel Blocker
        1. Consider for Hypertension, Angina (may be added to Beta Blocker)
        2. Amlodipine
      2. Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil)
        1. Avoid unless Beta Blocker not tolerated

VII. Medications: AntiHyperlipidemic therapy with Statin

  1. Effective in preventing future cardiovascular events
  2. Benefit even in patients over age 80 years
  3. Goal LDL Cholesterol
    1. Low-intensity and high-intensity protocols have replaced historic LDL targets
      1. High intensity Statin protocols (goal LDL reduction >50%, for high risk patients)
      2. Moderate intensity Statin protocols (goal LDL reduction 30-50%, if intolerant to high intensity)
      3. Low Intensity Statin protocols (goal LDL reduction <30%)
    2. Adjunctive measures added to Statins (high risk patients)
      1. Ezetimibe
      2. PCSK9 Inhibitor (e.g. Alirocumab, for very high risk patients)
    3. Older LDL target
      1. Most patients: 100 mg/dl
      2. High risk patients: <70 mg/dl (Intensive lipid lowering)
        1. NNT 20-40 to prevent one Myocardial Infarction or death
        2. LaRosa (2005) N Engl J Med 352:1425-35 [PubMed]
        3. Josan (2008) CMAJ 178(5): 576-84 [PubMed]
        4. Pedersen (2005) JAMA 294:2437-45 [PubMed]
  4. Statins independently lower CAD risk with Plaque stabilization and are first-line tools in preventive cardiology
    1. Collins (2004) Lancet 363:757-67 [PubMed]
    2. Maycock (2002) J Am Coll Cardiol 40:1777-85 [PubMed]
  5. Statins in high cardiovascular disease risk (10 year risk >20%)
    1. Number Needed to Treat (NNT) 25 on Statin for 10 years to prevent one significant cardiovascular event
    2. Baigent (2005) Lancet 366(9493): 1267-78 [PubMed]
  6. Statins in low to moderate cardiovascular disease risk (10 year risk with Framingham Score of 6%)
    1. Number Needed to Treat (NNT) 80 on Statin for 10 years to prevent one significant cardiovascular event
    2. Tonelli (2011) CMAJ 183(16): E1189-1202 [PubMed]

VIII. Medications: Reduce Homocysteine (e.g. Folic Acid)

  1. Supplementation only benefits venous events, but does not affect arterial Cardiovascular Risk
  2. Folic Acid supplementation 1000 mg daily
    1. Not beneficial post-stenting
      1. Lange (2004) N Engl J Med 350:2673-81 [PubMed]
  3. References
    1. Schnyder (2002) JAMA 288:973-9 [PubMed]
    2. Rimm (1998) JAMA 279:359-64 [PubMed]

IX. Medications: Other

  1. See Post Myocardial Infarction Medications
  2. Antianginals
    1. See Angina
    2. Beta Blockers
    3. Calcium Channel Blockers (if normal ejection fraction)
    4. Long Acting Nitroglycerin (e.g. Isosorbide Mononitrate)
    5. Ranolazine (Ranexa, refractory cases)
  3. Supplements that show initial benefit
    1. Coenzyme Q10 60 mg orally twice daily (more helpful in reduction in Statin-Induced Myalgias)
      1. Singh (2003) Mol Cell Biochem 246:75-82 [PubMed]
  4. Implantable Cardioverter Defibrillators
    1. Used post-MI for high risk of ventricular Arrhythmia
    2. Did not reduce mortality (n=674) over >30 months
    3. Hohnloser (2004) N Engl J Med 351:2481-8 [PubMed]
  5. Colchicine (Lodoco)
    1. Refractory, recurrent cardiovascular events despite maximal Cardiovascular Risk Reduction AND eGFR >60 ml/min
    2. Lowers cardiovascular event rate (NNT 36)
    3. Dose 0.5 mg orally daily

X. Medications: Avoid NSAIDs (other than Aspirin)

  1. NSAIDs are associated with increased risk of cardiovascular events
    1. Even short-term NSAID use 5 years after coronary event increases CAD event risk
      1. Associated with 19 more events in 1000 patients with CAD
    2. Antman (2007) Circulation 115(12):1634-42 [PubMed]
    3. Moore (2007) BMC Musculoskelet Disord 8:73 [PubMed]
    4. Schjerning Olsen (2011) Circulation 123(20):2226-35 [PubMed]
    5. Wehrmacker (2006) Compr Ther 32(4):236-9 [PubMed]
  2. Step-wise approach to Analgesics (in order of least to most Cardiovascular Risk)
    1. Acetaminophen (lowest Cardiovascular Risk)
    2. Aspirin (cardioprotective)
    3. Tramadol (but has other risks)
    4. Opioid Analgesics (e.g. Vicodin)
    5. Salsalate
    6. Naproxen (Naprosyn)
    7. Cox-2 selective NSAIDs such as Celecoxib or Diclofenac (most Cardiovascular Risk)
  3. References
    1. Prescriber's Letter (2008) 15(2): 8

XI. Resources

  1. ASCVD Risk Estimator (may overestimate risk)
    1. https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
  2. Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator
    1. https://www.mdcalc.com/calc/10491/predicting-risk-cardiovascular-disease-events-prevent
    2. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator
    3. Expanded Test Sensitivity to include younger patients with cardiovascular, renal or metabolic risk factors
    4. May replace ASCVD Risk Estimator (less over-estimation of Cardiac Risk)

XII. References

  1. Ferketich (2000) Arch Intern Med 160:1261-8 [PubMed]
  2. Frasure-Smith (1993) JAMA 270:1819-25 [PubMed]
  3. (2001) Lancet 357:89-95 [PubMed]
  4. Pflieger (2011) Am Fam Physician 83(7): 819-26 [PubMed]
  5. Virani (2023) Circulation 148(9):e9-e119 +PMID: 37471501 [PubMed]

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