Pharmacology: Drugs used for secondary prevention

Contents:

Check out our coronary artery disease crib sheet:

Secondary prevention in a nutshell:

After acute MI, NICE guidance gives the following recommendations for secondary prevention (CG172 published Nov 2013):

Cardiac rehabilitation programme including exercise, patient information, psychological and social support, advice about driving, sexual activity, lifestyle changes

Lifestyle changes: Mediterranean style diet, stop alcohol consumption or within safe limits, regular physical activity, smoking cessation, weight management

Drug therapy:

Procedures: Coronary revascularisation (percutaneously or surgically)

ACE inhibitors/ARB

Guidance: ACE i titrated up starting in hospital until target dose reached in community over 4-6 weeks, check electrolytes and BP before starting and within 1-2 weeks post starting treatment. Monitor patients with chronic heart failure and renal failure especially carefully. Start only when harm-dynamically stable in hospital.

Offer ARB if intolerant to ACEi, and not in combination.

Dual anti platelet therapy

The recommendations are for different patient groups after acute coronary syndrome. See full flowsheets below, but in summary:

Acute coronary syndrome +

  • PCI + high bleeding risk = DAPT 6 months most commonly with aspirin and ticagrelor
  • PCI + low bleeding risk = DAPT (aspirin ticagrelor) 12 months and longer if previous MI
  • Medical management alone + high bleeding risk = DAPT (aspirin clopidogrel) 1 month
  • Medical management alone + low bleeding risk = DAPT (aspirin ticagrelor) 12 months and more if previous MI
  • CABG + high bleeding risk = DAPT (aspirin clopidogrel or ticagrelor) 6 months
  • CABG + low bleeding risk = DAPT (aspirin ticagrelor or prasugrel) 12 months and more if previous MI

Group 1: Patients who undergo percutaneous coronary intervention:

This figure is from the 2017 EACTS guidelines: Algorithm for dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention. ACS = acute coronary syndrome; BMS = bare-metal stent; BRS = bioresorbable vascular scaffold; CABG = coronary artery bypass graft surgery; DCB = drug-coated balloon; DES: drug-eluting stent; PCI = percutaneous coronary intervention; Stable CAD = stable coronary artery disease.
High bleeding risk is considered as an increased risk of spontaneous bleeding during DAPT (e.g. PRECISE-DAPT score ≥25).
Colour-coding refers to the ESC Classes of Recommendations (green = Class I; yellow = IIa; orange = Class IIb).
Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated otherwise.
1: After PCI with DCB 6 months. DAPT should be considered (Class IIa B).
2: If patient presents with Stable CAD or, in case of ACS, is not eligible for a treatment with prasugrel or ticagrelor.
3: If patient is not eligible for a treatment with prasugrel or ticagrelor.
4: If patient is not eligible for a treatment with ticagrelor.

Group 2: Patients who undergo cardiac surgery

Algorithm for dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome undergoing coronary artery bypass grafting. High bleeding risk is considered as an increased risk of spontaneous bleeding during DAPT (e.g. PRECISE-DAPT score ≥25). Colour-coding refers to the ESC Classes of Recommendations (green = Class I; yellow = IIa; orange = Class IIb). Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated otherwise.
1: if patient is not eligible for a treatment with prasugrel or ticagrelor.

Group 3: Patients who are medically managed

Algorithm for dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome undergoing medical management. High bleeding risk is considered as an increased risk of spontaneous bleeding during DAPT (e.g. PRECISE-DAPT score ≥25). Colour-coding refers to the ESC Classes of Recommendations (green = Class I; yellow = IIa; orange = Class IIb). Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated otherwise.
1: if patient is not eligible for a treatment with ticagrelor

Beta blockers, calcium channel blockers, potassium channel activators and aldosterone antagonists

Start once harm-dynamically stable, titrate up in community, continue for 12 months after MI if no heart failure, but continue lifelong if heart failure or LV systolic dysfunction.

Do not offer calcium channel blockers unless beta blockers contraindicated or discontinued, in which case try diltiazem or verapamil (if no heart failure), amlodipine if heart failure.

Do not offer nicorandil after MI.

Offer spironolactone if heart failure or LV systolic dysfunction, after starting ACEi within 3-14 days of the event. Monitor renal function and serum potassium before starting.

Statins

Start atorvastatin 80mg once in the night in patients with coronary vascular disease as soon as possible post MI, continue lifelong. Take a lipid sample on admission and about 3 months after the start of treatment.

Image
Statins are HMG-CoA reductase inhibitors, preventing formation of cholesterol from Acetyl-CoA and thus increasing LDL receptor expression and lowering serum LDL. Image from Up to Date (Reprinted with permission from: Vaughan, CJ, Gotto, AM, Basson, CT. J Am Coll Cardiol 2000; 35:1. Copyright © 2000 American College of Cardiology.)

figure1
Safety and efficacy of statin therapy, Nature Reviews Cardiology

References:

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