What are the recommendations for secondary prevention of coronary artery disease (CAD)?

Secondary Prevention of Coronary Artery Disease

Comprehensive secondary prevention of coronary artery disease requires a multifaceted approach including antiplatelet therapy, lipid management, blood pressure control, lifestyle modifications, and management of comorbidities. The following evidence-based recommendations are organized by intervention category:

Antiplatelet Therapy

For Established CAD (>1 year post-ACS or with prior revascularization)

• Long-term single antiplatelet therapy with aspirin 75-100 mg daily or clopidogrel 75 mg daily is recommended 1
• Single antiplatelet therapy is preferred over dual antiplatelet therapy for long-term management 1

For First Year After ACS

• Without PCI: Dual antiplatelet therapy with ticagrelor 90 mg twice daily plus low-dose aspirin, or clopidogrel 75 mg daily plus low-dose aspirin (ticagrelor preferred) 1
• With PCI and stent placement: Dual antiplatelet therapy for 12 months with one of the following plus aspirin 1:
  • Ticagrelor 90 mg twice daily (preferred)
  • Clopidogrel 75 mg daily
  • Prasugrel 10 mg daily (avoid in patients >75 years, <60 kg, or with prior stroke/TIA)

Duration of Therapy After PCI

• Bare-metal stents: Minimum 1 month of dual therapy 1
• Drug-eluting stents: Minimum 3-6 months of dual therapy 1
• All stents: Consider continuing dual therapy for 12 months 1

Lipid Management

Goals

• LDL-C should be <100 mg/dL 1
• Further reduction of LDL-C to <70 mg/dL is reasonable 1
• For triglycerides ≥200 mg/dL, non-HDL-C should be <130 mg/dL 1

Recommendations

• Start dietary therapy: Reduce saturated fats to <7% of calories, reduce trans fats, limit cholesterol to <200 mg/day 1
• Add plant stanols/sterols (2g/day) and viscous fiber (10g/day) to further lower LDL-C 1
• Initiate statin therapy for all patients with CAD 1, 2
• High-intensity statin therapy (e.g., atorvastatin 80 mg) is preferred over moderate-intensity therapy as it significantly reduces major cardiovascular events by 22% compared to lower doses 2
• For patients with triglycerides 200-499 mg/dL, consider adding niacin or fibrate after LDL-C lowering therapy 1

Blood Pressure Control

Goals

• <140/90 mmHg for most patients 1
• <130/80 mmHg for patients with diabetes or chronic kidney disease 1

Recommendations

• Lifestyle modifications: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits, vegetables, and low-fat dairy products 1
• Pharmacotherapy: Beta-blockers and/or ACE inhibitors as initial therapy, with addition of other agents as needed 1

ACE Inhibitors/ARBs

• ACE inhibitors should be started and continued indefinitely in all patients with LVEF <40%, hypertension, diabetes, or chronic kidney disease 1
• Consider ACE inhibitors for all other CAD patients 1
• ARBs are recommended for patients intolerant to ACE inhibitors 1

Beta-Blockers

• Start and continue indefinitely in all patients who have had MI, ACS, or left ventricular dysfunction 1
• Consider for all other patients with coronary or vascular disease 1

Physical Activity

• 30-60 minutes of moderate-intensity aerobic activity (e.g., brisk walking) on most, preferably all, days of the week 1
• Supplement with increased daily lifestyle activities (walking breaks at work, gardening, household work) 1
• Resistance training 2 days per week is reasonable 1
• Medically supervised programs for high-risk patients 1

Weight Management

Goals

• BMI: 18.5-24.9 kg/m² 1
• Waist circumference: <35 inches (89 cm) for women, <40 inches (102 cm) for men 1

Recommendations

• Initial weight loss goal of 5-10% from baseline 1
• Achieve through balanced physical activity, caloric intake, and behavioral programs 1

Diabetes Management

• Coordinate care with primary care physician or endocrinologist 1
• Lifestyle modifications including physical activity, weight management, blood pressure control, and lipid management 1
• Metformin is an effective first-line pharmacotherapy if not contraindicated 1
• Target HbA1c of 7% may be considered, with individualization based on hypoglycemia risk 1

Smoking Cessation

• Ask about tobacco use at every visit 1
• Advise every tobacco user to quit 1
• Assist with counseling, quitting plan, and pharmacotherapy (nicotine replacement, bupropion) 1
• Urge avoidance of environmental tobacco smoke 1

Influenza Vaccination

• Annual influenza vaccination is recommended for all patients with cardiovascular disease 1

Common Pitfalls and Caveats

1. Antiplatelet therapy: Avoid prasugrel in patients >75 years, <60 kg, or with history of stroke/TIA due to increased bleeding risk 1

2. Statin therapy: Don't undertreat with low-intensity statins; high-intensity statins provide greater cardiovascular risk reduction 2

3. Dual antiplatelet therapy: Don't continue indefinitely in stable CAD patients due to bleeding risk; transition to single antiplatelet therapy after appropriate duration 1

4. Diabetes management: Avoid overly aggressive glucose control in elderly patients or those with comorbidities; individualize HbA1c targets 1

5. Warfarin plus antiplatelet therapy: When used in combination, increased bleeding risk requires close monitoring 1

By implementing these evidence-based recommendations, clinicians can significantly reduce morbidity and mortality in patients with established coronary artery disease.