Guidelines on prevention of coronary heart disease (CHD) in clinical practice have been issued by Joint Task Forces of European and other Societies1–3and the latest update was released in 2003 by the Third Joint Task Force.3
The objectives of these guidelines are the pre- vention of disability and early death from cardio- vascular disease (CVD) through lifestyle changes, management of risk factors and when needed the prophylactic use of certain drugs.
The guidelines represent a state of the art regarding what is known on effective and safe preventive strategies applicable in clinical practice.
Resources available for preventive cardiology are generally limited; therefore one should use them as efficiently as possible and this requires priority setting. Patients with established CVD are the top priority; they should receive all the atten- tion one can give for the prevention of recurrent events.
Next in priority are asymptomatic subjects at high risk for developing CVD in the coming years. To identify them an estimate of total coronary or cardiovascular risk should be used. The first and Second Joint Task Forces in Europe have recommended the use of the risk estimation model based on results from the Framingham study4; in the guidelines from the Third Joint Task Force a new model based on the results from the SCORE project5 is recommended.
One of the reasons why the risk estimation model was changed is that the SCORE model predicts cardiovascular events, not merely
coronary events, and the latest update of the guidelines is now focused on CVD, and not just CHD.
The reason for moving from prevention of CHD to prevention of CVD is that the etiology of myocardial infarction, ischemic stroke, and peripheral arterial disease (PAD) is similar and, indeed, recent intervention trials have shown that several forms of therapy prevent not only coronary events and revascularizations but also ischemic stroke and PAD. Hence, decisions about whether to initiate specific preventive action should be guided by an estimation of the risk of suffering any such vascular event not just a coro- nary event.
However, in the management of coronary patients there is no need for total CV risk esti- mation. The fact that they have already suffered a CV event places them in the highest risk category and therefore secondary prevention should contain all aspects of effective and safe strategies.
The goals that one should try to achieve are summarized in Table 4-1: they relate to lifestyle, to risk factor management, and to the prophylactic use of certain drugs.
The greatest challenge and failure in rehabilita- tion and secondary prevention relate to lifestyle changes. Therefore the guidelines pay great atten- tion to behavioral change models and to the consideration of psychosocial factors as possible barriers for lifestyle changes.
Strategies to make behavioral counseling more effective have been developed and tested and have been described in detail.3 In Table 4-2 10
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Prevention Guidelines: Management of the Coronary Patient
Guy de Backer
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4. Prevention Guidelines: Management of the Coronary Patient 27
strategies identified in the Report of the US Preventive Services Task Force6 are given. The physician/caregiver–patient interaction is a pow- erful tool to enhance patients’ ability to cope with stress and illness and their adherence to recom- mended lifestyle change.
Multimodal behavioral interventions integrate educational efforts with practical training ses- sions, combining learning with practical imple- mentation and skills training. All this fits very well within the framework of a comprehensive multi- disciplinary rehabilitation program for patients with CHD.
Regarding smoking of tobacco, results from EUROASPIRE7,8have shown that 1 in 4 to 1 in 5 of our patients continue to smoke after an acute event. They should be encouraged by health pro- fessionals to permanently stop smoking all forms of tobacco. The momentum for smoking cessation is particularly strong at the time of an acute event, an invasive treatment, or vascular surgery.
However, relapse occurs frequently. Therefore this problem should be identified at all possible occasions.
If necessary, the patient’s capacity to change should be identified in order to adapt the neces- sary action accordingly. The value of the simple advice of a doctor or other health professional should not be underestimated. But, if needed, there are nowadays different techniques that can help in assisting patients during the difficult period of withdrawal. And there is a need for follow-up visits; relapses are frequent and should be dealt with as soon as possible.
On making healthy food choices the guidelines remain very general because it was realized that
adaptations are necessary according to local culture. But obesity seems to have become a global problem and therefore energy balances through diet and physical activity strategies are needed everywhere.
Other general recommendations are not new but should be re-emphasized:
– Foods should be varied.
– The consumption of certain foods should be encouraged: fruits and vegetables, whole grain cereals and bread, low fat dairy products, fish and lean meat.
– Oily fish and omega-3 fatty acids have particu- lar protective properties, especially in patients with established CHD.
– Total fat should account for no more than 30%
of energy intake and the intake of saturated fats should not exceed a third of total fat intake;
the intake of cholesterol should be less than 300 mg/day.
– In an isocaloric diet, saturated fat can be replaced partly by complex carbohydrates, and partly by monounsaturated and polyunsatu- rated fats from vegetables and marine animals.
Patients with arterial hypertension, with severe dyslipidemias, and/or with diabetes should receive specialist dietary advice.
All patients with CVD should be encouraged and supported to increase their physical activity safely to the level associated with the lowest risk of suffering new events. For patients with estab- lished disease advice must be based on a compre- hensive clinical judgment including the results of an exercise test. Detailed recommendations for TABLE4-1. Goals for CVD prevention in patients with established
cardiovascular disease
Lifestyle: No smoking
Make healthy food choices Be physically active Risk factors:
Blood pressure <140/90mmHg in most
<130/80mmHg in some
Total cholesterol <4.5mmol/L (175mg/dL)
LDL cholesterol <2.5mmol/L (100mg/dL)
Good glycemic control in all persons with diabetes Prophylactic drug therapy in particular groups
TABLE4-2. How to achieve intensive lifestyle change in patients with coronary heart disease?
Strategies to make behavioral counseling more effective include:
• Develop a therapeutic alliance with the patient
• Counsel all patients
• Gain commitments from the patient to achieve lifestyle change
• Ensure the patient understands the relationship between lifestyle and disease
• Help the patient overcome barriers to lifestyle change
• Involve the patient in identifying the risk factor(s) to change
• Design a lifestyle modification plan
• Use strategies to reinforce the patient’s own capacity to change
• Monitor progress of lifestyle change through follow-up contacts
• Involve other healthcare staff wherever possible
28 G. de Backer
CVD patients have been given by other expert committees9,10 or are available elsewhere in this book.
Regarding the management of the classical risk factors, the guidelines for patients with estab- lished CVD can be summarized as follows: regard- ing blood pressure the goal is in general to maintain the blood pressure below 140/90 mmHg;
however, in patients with type 2 diabetes, we should aim at lower levels below 130/80 mmHg.
But patients with CVD and a systolic blood pressure of 130–140 mmHg and/or a diastolic pressure 85–89 mmHg may also qualify for further blood pressure reduction depending on the overall risk profile, the presence of target organ damage, and the effects of non-pharmacological interventions.
In terms of blood lipid levels, goals are set for total and low-density lipoprotein (LDL) cholesterol; for patients with CVD these goals are <175mg/dL or <4.5mmol/L for total choles- terol and <100mg/dL or <2.5mmol/L for LDL cholesterol. The first clinical trials which docu- mented the clinical benefits of lipid-lowering therapy with statins were restricted to patients
<70 years old and total cholesterol levels
>5mmol/L (190mg%). Now published trials indicate that such treatment can also be effective in the elderly and in patients with lower cholesterol levels.
In patients with established CVD, polyphar- macy can become a major problem and good clin- ical management is required to resolve it. In some patients goals cannot be reached even on maximal therapy but they will still benefit from treatment to the extent to which cholesterol has been lowered.
Recommended treatment targets for patients with type 1 diabetes and type 2 diabetes have been defined by the International Diabetes Federation Europe.11,12 Treatment targets should, however, always be individualized particularly, in patients with other competing diseases such as CVD, with severe late diabetic complications, and in the elderly patients. As mentioned above, the treat- ment goals for blood pressure and for lipids are generally more ambitious in patients with diabetes.
Secondary prevention includes besides lifestyle changes, risk factor management also the use of
prophylactic drugs other than those needed to control blood pressure, lipids, and diabetes.
In the guidelines four different categories are considered:
– Aspirin or other platelet-modifying drugs in virtually all patients with CVD. The most recent meta-analysis of antiplatelet trials provides convincing evidence of a significant reduction in all cause mortality, vascular mortality, non- fatal reinfarction and nonfatal stroke in patients with unstable angina, acute myocardial infarc- tion, stroke, transient ischemic attacks, or other clinical evidence of vascular disease.13 The available evidence supports daily doses of aspirin in the range of 75–150 mg for the long- term prevention of vascular events. Although there is no clinical trial evidence of treatment beyond a few years, it would be both prudent and safe to continue aspirin therapy for life.
– Beta-blockers in patients following a myocar- dial infarction or with left ventricular (LV) dys- function due to CHD are associated with a reduction in total mortality and cardiovascular death as well as non fatal reinfarction. Beta- blockers should be considered in all patients with CHD, providing there are no contraindica- tions, for the following reasons: to relieve symp- toms of myocardial ischemia, to lower blood pressure to <140/90mmHg, as prophylaxis fol- lowing myocardial infarction, and in the treat- ment of heart failure;
– ACE inhibitors in patients with symptoms or signs of LV dysfunction due to CHD and/or arterial hypertension. More recently ACE inhi- bition has been shown to reduce the risk of car- diovascular morbidity and mortality in patients with stable CHD without apparent heart failure.14
– Anticoagulants in those patients with CVD who are at increased risk of thromboembolic events.
References
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