Cardiovascular Preventive Care (Secondary Prevention)

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).

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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

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