What is the recommended management for patients at high risk of Major Adverse Cardiovascular Events (MACE)?

From the Guidelines

Management of patients at high risk for Major Adverse Cardiovascular Events (MACE) requires a comprehensive approach focusing on aggressive risk factor modification and appropriate pharmacotherapy, with the most recent evidence from 2024 supporting the use of single antiplatelet therapy, such as aspirin or clopidogrel, and low-dose rivaroxaban combined with low-dose aspirin to reduce the risk of MACE 1.

Key Components of Management

• High-risk patients should receive a combination of lifestyle interventions and medications including moderate to high-intensity statins (such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily) and blood pressure control targeting <130/80 mmHg with appropriate antihypertensives, as recommended by the 2024 ACC/AHA guideline 1.
• ACE inhibitors or ARBs are preferred in patients with diabetes, chronic kidney disease, or heart failure, as they have been shown to reduce the risk of MACE in these populations 1.
• For diabetic patients, SGLT-2 inhibitors (empagliflozin, dapagliflozin) or GLP-1 receptor agonists should be considered as they provide cardiovascular benefits beyond glucose control, as supported by the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes 1.
• Lifestyle components such as smoking cessation, weight management targeting BMI <25, regular physical activity (150 minutes of moderate exercise weekly), and a Mediterranean or DASH diet are essential for reducing the risk of MACE, as emphasized in the 2024 ACC/AHA guideline 1.

Monitoring and Follow-up

• Regular monitoring of lipids (targeting LDL <70 mg/dL for very high-risk patients), blood pressure, and diabetes control is necessary to ensure that patients are meeting their treatment goals and to adjust therapy as needed, as recommended by the 2024 ACC/AHA guideline 1.
• This aggressive multimodal approach is justified by evidence showing that comprehensive risk factor management significantly reduces the likelihood of myocardial infarction, stroke, cardiovascular death, and revascularization procedures in high-risk individuals, as supported by the 2024 ACC/AHA guideline 1.

From the Research

Management of Patients at High Risk of MACE

The management of patients at high risk of Major Adverse Cardiovascular Events (MACE) involves a multi-targeted approach to reduce cardiovascular risk factors.

• Patients with hypertension and metabolic syndrome should be started on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) unless contraindicated, as these drugs provide cardioprotective and renoprotective benefits beyond their effect on blood pressure 2.
• Long-acting calcium channel blockers are also recommended in hypertensive patients with metabolic syndrome, as they improve insulin resistance 2.
• Intensive statin therapy has been shown to reduce MACE among patients undergoing percutaneous coronary intervention for acute coronary syndrome, with a reduction in the incidence of target vessel revascularization and non-target vessel revascularization 3.
• High-dose statin therapy is recommended for patients at high cardiovascular risk, with a goal of achieving an LDL-C level of < 70 mg/dl 4.
• The use of PCSK9 inhibitors, such as evolocumab and alirocumab, may be considered in patients with very high-risk ASCVD who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe 5.
• Loading with high-dose atorvastatin before percutaneous coronary intervention may prevent the occurrence of postoperative no-reflow, reduce HbA1c levels, and decrease the incidence of MACE in patients with ST-segment elevation myocardial infarction 6.

Recommended Therapies

• ACE inhibitors or ARBs for patients with hypertension and metabolic syndrome
• Long-acting calcium channel blockers for patients with hypertension and metabolic syndrome
• Intensive statin therapy for patients undergoing percutaneous coronary intervention for acute coronary syndrome
• High-dose statin therapy for patients at high cardiovascular risk
• PCSK9 inhibitors for patients with very high-risk ASCVD who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe
• Loading with high-dose atorvastatin before percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction

Key Considerations

• A multi-targeted approach to reduce cardiovascular risk factors is essential for managing patients at high risk of MACE.
• The choice of therapy should be individualized based on the patient's specific risk factors and medical history.
• Close monitoring of the patient's response to therapy and adjustment of the treatment plan as needed is crucial to achieving optimal outcomes 2, 3, 4, 5, 6.