cardiovascular%20disease%20prevention
CARDIOVASCULAR DISEASE PREVENTION
Patients 18 years old and above should receive a risk factor assessment for cardiovascular disease (CVD) at every routine physician visit.
Cardiovascular disease 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 cardiovascular event.
Very high-risk group refers to patients with documented CVD, by invasive or non-invasive testing, and with presence of risk factors.
High-risk patients are those who have already experienced a cardiovascular event or have very high levels of individual risk factors.
Moderate-risk patients require monitoring of risk profile every 6-12 months.
Low-risk patients may be given conservative management, focusing on lifestyle interventions.

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.

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 (risk of 10-20%) patients require monitoring of risk profile every 6-12 months
  • Low-risk patients (risk of <10%) 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

  • Risk-benefit profile should be assessed before using Aspirin for primary prevention
    • In patients with 10-year risk of CVD risk of <20% or low-moderate CVD risk, Aspirin therapy is recommended
  • 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, 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 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

Angiotensin Converting Enzyme (ACE) Inhibitors1

  • Should be used in all patients with left ventricular ejection fraction (LVEF) ≤40%, hypertension, diabetes mellitus (DM), or chronic kidney disease, unless contraindicated
  • Optional for lower-risk patients
  • It is recommended to use a renin-angiotensin-aldosterone system (RAAS) inhibitor in treating hypertension in DM especially if with proteinuria or microalbuminuria

Angiotensin II Antagonists1

  • Indicated for patients who have heart failure, MI with left ventricular ejection fraction ≤40%
  • For use in patients intolerant of ACE inhibitors
  • May be used in combination with ACE inhibitors in select cases of systolic dysfunction heart failure

Anti-Obesity Agents2

  • Recommended for patients with BMI ≥30 kg/m2 or ≥27 kg/m2 with ≥1 obesity-associated comorbidities who are willing to follow lifestyle interventions
  • Increased physical activities during therapy is required
  • See Obesity Disease Management Chart for more details

Beta-Blockers1

  • Recommended for use in patients who have had MI, acute coronary syndrome (ACS) or LV dysfunction (ejection fraction ≥40%) with or without heart failure or previous MI, unless contraindicated
    • Use as required in all other patients to manage angina, rhythm, BP and treatment in heart failure (HF)
  • May be given for 3 years in patients with normal left ventricular function who have had MI or ACS
  • Effect: Shown to favorably alter prognosis in patients with chronic heart disease, reduce risk of sudden death, improve left ventricular function and slow atherosclerotic progression

Lipid-lowering Agents3

  • 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, Rosuvastatin) for approximately ≥50% LDL-C reduction
    • Moderate-intensity statin therapy (eg Atorvastatin, Rosuvastatin) for goals of <50% lower LDL-C levels
    • Low-intensity statin therapy (eg Fluvastatin, Lovastatin, ) for <30% reduced LDL-C levels
  • May halt progression or induce regression of coronary atherosclerosis
  • See Dyslipidemia Disease Management Chart for more details

PCSK9 Inhibitors

  • Eg Alirocumab, Evolocumab
  • Recently approved to be used as an adjunct to diet and statin therapy in symptomatic atherosclerotic cardiovascular disease 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 ACE inhibitors, Angiotensin II antagonists and Beta-blockers are available. Specific prescribing information may be found in the latest MIMS. See Hypertension, Acute Coronary Syndromes w/o Persistent ST-Segment Elevation and Myocardial Infarction w/ ST-Segment Elevation Disease Management Charts for specific dosing recommendations.
2Many anti-obesity agents are available. Specific prescribing information may be found in the latest MIMS. See Obesity Disease Management Chart for specific dosing recommendations.
3Many 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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