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Medications used for secondary prevention that are contraindicated in pregnancy include: - ACE inhibitors
- ARBs
- Statins
- β-blockers (not contraindicated, but caution is advised because they can depress vital signs in neonate and cause uterine vasoconstriction)
- Aspirin (potential risk of birth defect and bleeding risk in the 1st trimester safe in 2nd-3rd trimester).
- Warfarin (embryopathy, especially between 6 and 12 wk; CNS malformations during any time of gestation).
Additional Treatment
General Measures
Aggressive modification of risk factors in high-risk patients produces risk reductions of up to 50%.
Issues for Referral
Patients with complex lipid disorders or refractory to treatment should be referred to a specialist.
Ongoing Care
Follow-Up Recommendations
Implement systems that ensure the reliable identification of patients who can benefit from secondary prevention interventions.
Patient Monitoring
Home monitoring of the following variables: Weight, waist size, BP, glucose, number of steps per day (pedometer), calories, total fat, carbohydrate, protein consumption.
Diet
- Total caloric intake to achieve maintenance of achievable ideal weight with patient input
- Low saturated fat, no trans-fatty acids, low-sodium, high-fiber nutrition, rich in whole grains, vegetables, whole fruit (Mediterranean)
- Adequate intake of omega-3 fatty acids in fish or 1 g/d omega-3 fatty acids in capsule form appears to reduce the incidence of CV disease and especially sudden death.
Patient Education
Goals for Secondary Prevention (AHA/ACC guidelines):
- Complete smoking cessation
- Physical activity:
- A symptom-limited exercise test in selected patients before starting an exercise program.
- Exercise: >30 min/d, >3-4 times per week, predominantly aerobic type
- Weekly energy expenditure with aerobic exercise between 1000 and 2000 kcal
- Weight management:
- Body mass index (BMI 18.5-24.9 kg/m2
- Waist <40 inches (102 cm) in men and <35 inches (89 cm) in women
- HTN:
- <130/80 mm Hg: Diabetics, heart failure or renal insufficiency.
- <140/90 mm Hg: All others.
- Hyperlipidemia:
- LDL-C: <100 mg/dL; (optional <70 mg/dL for "very high risk")
- HDL-C: >40 mg/dL (optional >60)
- Triglycerides: <150 mg/dL (optional <100)
- Non-HDL: <130 mgl/dL (optional <100)
- DM:
- Fasting blood glucose <126 mg/dL and HbA1c <7%
Prognosis
- Relative risk in patients with a history of MI: Recurrent MI or CV death, 5.7; stroke or TIA, 3-4; sudden cardiac death, 4-6
- Relative risk in patients with a history of stroke: Recurrent stroke 9; MI, angina, or CV death, 2-3
- Relative risk in patients with a history of PAD: Fatal MI or other CV death, 4; stroke or TIA, 2
- Male patients with symptomatic PAD have mortality rates of 62% after 10 yr, compared with 16.9% in general population. The mortality rates for women are 33.3% and 11.6%, respectively.
Complications
- Coronary
- Peripheral vascular
- Cerebrovascular
Additional Reading
1
Grundy SM, Cleeman JI, Merz CN. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227. [View Abstract] 2
Smith SCJr, Allen J, Blair SN. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung and Blood Institute. J Am Coll Card. 2006;47:2130. [View Abstract]
- Internet sites:
- www.americanheart.org
- www.acc.org and www.cardiosource.com
- www.nhlbi.nih.gov
Codes
ICD9
- 414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft
- 429.2 Cardiovascular disease, unspecified
SNOMED
- 49601007 disorder of cardiovascular system (disorder)
- 53741008 coronary arteriosclerosis (disorder)
- 440358008 primary prevention of cardiovascular disease (regime/therapy)