cardiovascular%20disease%20prevention
CARDIOVASCULAR DISEASE PREVENTION
Cardiovascular disease (CVD) development is closely related to lifestyle characteristics and associated risk factors.
There is an overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a CV event.
Primary CVD prevention is aimed at the healthy population, individuals who have several CV risk factors or 1 CV risk factor at a very high level, and individuals whose risk for a CV event is high. Secondary CVD prevention is aimed at individuals with confirmed CVD.

Cardiovascular%20disease%20prevention Treatment

Principles of Therapy

Cardiovascular disease (CVD) development is closely related to lifestyle characteristics and associated risk factors. There is overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a CV event.

CVD Prevention

  • Primary prevention is aimed at the healthy population, individuals who have several CV risk factors or 1 CV risk factor at a very high level and individuals whose risk for a CV event is high
  • Secondary prevention is aimed at individuals with confirmed CVD

Selection of Patients for Clinical Intervention

  • For very high- to high-risk patients, intensive lifestyle modification and appropriate drug treatment are required
    • Monitor risk profile every 3-6 months
    • High-risk patients intolerant of statin therapy should be given non-statin agents (Ezetimibe, monoclonal antibodies, bile acid sequestrants, phytosterols)
  • Moderate-risk patients require monitoring of risk profile every 6-12 months
  • Low-risk patients may be given conservative management, focusing on lifestyle interventions

Pharmacotherapy

Antiplatelet Agents

  • Antiplatelet agents have been shown to reduce vascular mortality, nonfatal reinfarction of the myocardium, nonfatal stroke in patients with unstable angina (UA), acute myocardial infarction (MI), stroke, transient ischemic attacks (TIAs) or other evidence of CVD

Aspirin

Primary prevention

  • Low-dose Aspirin (75-100 mg/day) should not be routinely used for primary prevention of ASCVD in patients >70 years old and in adults of any age with increased risk of bleeding
    • May be considered for primary prevention of ASCVD in select patients 40-70 years old with high ASCVD risk but without bleeding risk
    • Risk-benefit profile should be assessed before using Aspirin for primary prevention especially in patients with DM
  • Recommended for use in men >45 years, primarily to protect against MI; and women >55 years, primarily to protect against stroke

Secondary prevention

  • Good evidence shows that Aspirin therapy can prevent MI, stroke and vascular death in men and women with established CVD
  • Low dose or 75 mg/day is recommended for the high-risk group or individuals with >20% risk of MI and stroke, and in diabetic patients
  • Other groups recommend Aspirin in all patients with established CVD and in patients without a history of CVD but with >10% 10-year CVD risk
    • Low-dose Aspirin given indefinitely is recommended in patients with established CVD and after a TIA or stroke, unless contraindicated

Clopidogrel

  • Recommended in combination with Aspirin in UA/NSTEMI patients wherein Ticagrelor or Prasugrel is unavailable or contraindicated
    • Initial dose of 300 mg followed by 75 mg daily for at least 1 month and ideally up to 12 months
  • Recommended in patients with TIA or non-cardioembolic ischemic stroke

Prasugrel

  • Recommended in combination with Aspirin only in P2Y12-inhibitor-naive patients (especially diabetics) in whom coronary anatomy is known and who will undergo percutaneous coronary intervention (PCI)
    • Initial dose of 60 mg to be given at the time of PCI, followed by 10 mg daily for 12 months

Ticagrelor

  • Recommended in combination with Aspirin in UA/non-ST segment elevation myocardial infarction (NSTEMI)/ST segment elevation myocardial infarction (STEMI) patients with intermediate to high risk of ischemic events regardless of choice of therapy (invasive or conservative)
    • Initial dose of 180 mg then 90 mg 12 hourly for 12 months

Vorapaxar

  • Newly approved protease activated receptor-1 (PAR-1) antagonist that inhibits platelet activation
  • Studies showed that Vorapaxar, when given with other antiplatelet agents, significantly reduced incidences of MI, stroke, and death caused by cardiovascular disease

Anticoagulants

Warfarin

  • May be used in post-MI patients for stroke prevention when clinically indicated (such as atrial fibrillation or left ventricle (LV) thrombus, dilated LV with poor systolic function)
  • May be considered for paroxysmal or chronic atrial fibrillation or atrial flutter
  • Warfarin with either Aspirin or Clopidogrel increases risk of bleeding and should be monitored closely by checking prothrombin time (PT)/INR
  • Monitor international normalized ratio (INR) when using Warfarin

Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)

  • Also called novel oral anticoagulants, new oral anticoagulants or direct oral anticoagulants
  • Direct-acting inhibitors of either thrombin (Dabigatran) or factor Xa (Apixaban, Edoxaban, Rivaroxaban)
  • May be used in the prevention and treatment of VTE and in the prevention of stroke and systemic embolism in patients with ACS and non-valvular atrial fibrillation
  • See Ischemic Stroke, Venous Thromboembolism - Management and Venous Thromboembolism - Prevention disease management charts for specific dosing recommendations

Antihypertensive Agents

  • Initiation of drug therapy is recommended for patients with a BP of ≥130/80 mmHg and ≥10% estimated 10-year ASCVD risk, and those with a BP of ≥140/90 mmHg and <10% estimated 10-year ASCVD risk
  • Include ACE inhibitors or angiotensin receptor blockers (ARBs) with calcium channel blockers, thiazide diuretics or beta-blockers, either alone or in combination
  • If BP is uncontrolled despite treatment with 3 antihypertensive medications at maximally tolerated doses, consider adding an aldosterone antagonist, an alpha blocker, a centrally acting agent or a vasodilator
  • Many antihypertensive agents are available. Specific prescribing information may be found in the latest MIMS. See Hypertension disease management chart for specific dosing recommendations

Lipid-lowering Agents1

  • Includes statins, fibrates, bile acid binding resins, Niacin, anti-sense apolipoprotein B oligonucleotide (Mipomersen), microsomal transfer protein inhibitor (Lomitapide), PCSK9 inhibitors and selective cholesterol absorption inhibitors (Ezetimibe); statins are 1st drugs of choice
  • Have been shown not only to reduce hyperlipidemia but also to reduce CV events and mortality
  • Use of statin therapy may benefit patients who undergo coronary artery bypass grafting (CABG), preoperatively and postoperatively
  • Statin therapy recommendations per target LDL-C reductions as follows:
    • High-intensity statin therapy [eg Atorvastatin (80 mg), Rosuvastatin (20 mg)] for approximately ≥50% LDL-C reduction
      • May be given to patients with ≥20% 10-year ASCVD risk
    • Moderate-intensity statin therapy [eg Atorvastatin (10 mg), Rosuvastatin (10 mg), Simvastatin (20-40 mg), Pravastatin (40 mg), Lovastatin (40 mg), Fluvastatin (40 mg 12 hrly), Pitavastatin (1-4 mg)] for goals of <50% lower LDL-C levels
      • May be given to patients with 7.5-19.9% 10-year ASCVD risk
    • Low-intensity statin therapy [eg Simvastatin (10 mg), Pravastatin (10-20 mg), Lovastatin (20 mg), Fluvastatin (20-40 mg)] for <30% reduced LDL-C levels
  • May halt progression or induce regression of coronary atherosclerosis
  • See Dyslipidemia disease management chart for further information

PCSK9 Inhibitors

  • Eg Alirocumab, Evolocumab
  • Recently approved to be used as an adjunct to diet and statin therapy in symptomatic ASCVD patients needing additional treatment to lower LDL-C levels
  • As human monoclonal PCSK9 antibody, it binds to PCSK9 which then increases LDL receptor density
  • May be given in combination with other LDL-lowering therapies

1Many lipid-lowering agents are available. Specific prescribing information may be found in the latest MIMS. See Dyslipidemia disease management chart for specific dosing recommendations.

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