Secondary Prevention of Coronary Heart Disease

Question 1

Secondary prevention definition

Answer 1

prevention actions taken after the development of disease to halt its progress and subsequent complications

Question 2

Major goals of secondary prevention of CVD

Answer 2

o Goal #1: Prevention of plaque rupture and progression o Goal #2: Prevention of new plaque formation

Question 3

Major categories of tools used in secondary prevention of CVD

Answer 3

-medications: rely on health care system (and compliance) -lifestyle changes: rely’s mainly on patient and built environment

Question 4

Main pharmacologic secondary CVD prevention guidelines

Answer 4

-anti-platelets -beta-blockers -RAAS inhibitors

Question 5

Main pharmacologic+lifestyle secondary CVD prevention guidelines

Answer 5

-Blood pressure control -Lipid management -Diabetes management -Depression screening and treatment -Smoking cessation

Question 6

Main lifestyle secondary CVD prevention guidelines

Answer 6

-weight management -physical activity

Question 7

Other possible secondary CVD prevention guidelines

Answer 7

-cardiac rehabilitation -influenza vaccination

Question 8

Anti-platelets used in secondary CVD and rationale

Answer 8

-Anti-platelets prevent platelet adhesion to the site of a ruptured plaque, reduce platelet activation, and prevent platelet aggregation -Aspirin -Thienopyridines

Question 9

Thienopyridines MOA & examples

Answer 9

(clopidogrel, ticlodipine, prasugrel, and ticagrelor) Inhibits adenosine diphosphate (ADP) production and platelet aggregation

Question 10

Aspirin MOA

Answer 10

Reduces platelet activation by blocking cyclooxygenase and thromboxane A2 (a vasoconstrictor) production

Question 11

Class I Antiplatelet guidelines

Answer 11

• ALL CAD patients: asprin daily
• PTS w/ACS or PCI for one year following the event: Thienopyridines + aspirin
• PTS post-bypass surgery: aspirin (at least one year)
• PTS post-stroke: aspirin alone, clopidogrel alone, or combined aspirin/dipyridamole daily chronically
• PTS w/symptomatic peripheral arterial disease: aspirin alone or clopidogrel alone
• PTS w/warfarin: continue low-dose aspirin and monitor closely for bleeding

Question 12

Class I beta-blocker guidelines

Answer 12

Beta-blockers in all with LVSD (ejection fraction <40%) and heart failure symptoms or MI/ACS in the prior 3 years

Question 13

Class IIa beta-blocker guidelines

Answer 13

• Beta-blockers in all with LVSD (ejection fraction <40%) even in the absence of heart failure symptoms
• Beta-blockers in all with any history of MI/ACS

Question 14

Class I RAAS inhibition guidelines

Answer 14

• ACEIs
  
  • All with LVSD (ejection fraction <40%), DM, HTN, or chronic kidney disease
• ARBs
  
  • All with LVSD (ejection fraction <40%) and either a prior MI or heart failure symptoms and who are ACEI-intolerant
• Aldosterone inhibition
  
  • Post-MI patients with LVSD (ejection fraction <40%) on BB and ACEI/ARB w/heart failure or diabetes.
  • Avoid in those with renal dysfunction or significant hyperkalemia

Question 15

Class I BP control guidelines

Answer 15

• Age <60yo: BP <140/90
• Age ≥60yo: BP <150/90

Question 16

Class I lipid guidelines

Answer 16

• Statins in ALL CAD patients
• No need to titrate to LDL
• No indication for non-statin lipid-lowering therapies
• Not proven in HF NYHA Class III-IV or hemodialysis patients

Question 17

Class I diabetes guidelines

Answer 17

-lifestyle modifications -coordination w/PCP

Question 18

Class IIa/IIb diabetes guidelines

Answer 18

• IIa: metformin=first-line pharm therapy
• IIb: HbA1c <7% can be considered as goal

Question 19

Class IIa/IIb depression guidelines

Answer 19

• IIa: assess depression
• IIb: tx may not improve cardiac outcomes but is at least beneficial to overall mental health

Question 20

Class I smoking guidelines

Answer 20

Stop that shit.

Question 21

Class I weight control guidelines

Answer 21

• Goal BMI is 18.5-24.9
• Goal waist circumference is <35 inches for women
• Initial goals of weight loss should be 5-10% of body weight

Question 22

Class I physical activity guidelines

Answer 22

Just do it (mod-high intensity for 30-60 minutes/5-7 days/week)