What is the management of atherosclerosis?

Management of Atherosclerosis

The comprehensive management of atherosclerosis requires aggressive risk factor modification, appropriate pharmacotherapy, and lifestyle interventions to reduce morbidity and mortality from cardiovascular events. 1

Risk Assessment and Stratification

• Assess total cardiovascular disease (CVD) risk to determine treatment priorities, considering that an individual's risk should be judged in the context of the overall CVD risk of the population 1
• Patients with established atherosclerotic vascular disease (coronary heart disease, stroke, or peripheral arterial disease) are at high risk of recurrent cardiovascular events and require intensive intervention 1
• The prevention approach is the same regardless of which arterial territory is symptomatic, as atherosclerosis is a systemic disease 1

Pharmacological Management

Lipid Management

• Primary goal: Start dietary therapy in all patients (limit saturated fat to 7% and cholesterol to 200 mg/day) and assess fasting lipid profile 1
• For LDL ≥130 mg/dL: Intensify LDL-lowering therapy with statins or resins and add lifestyle therapies 1
• For LDL 100-129 mg/dL: Consider intensifying LDL-lowering therapy and adding fibrates or niacin if HDL is low or triglycerides are high 1
• For triglycerides 200-499 mg/dL: Consider fibrate or niacin after LDL-lowering therapy 1
• For triglycerides ≥500 mg/dL: Consider fibrate or niacin before LDL-lowering therapy 1
• Consider omega-3 fatty acids as adjunct therapy for high triglycerides 1

Antiplatelet/Anticoagulant Therapy

• Start and continue aspirin 75-325 mg/day indefinitely if not contraindicated 1, 2
• Consider clopidogrel 75 mg/day if aspirin is contraindicated 1, 2
• For post-MI patients who cannot take aspirin or clopidogrel, consider warfarin with INR 2.0-3.0 1, 2

Blood Pressure Control

• Initiate lifestyle modifications (weight control, physical activity, moderate sodium restriction, emphasis on fruits and vegetables) for all patients with BP ≥130/80 mmHg 1
• Add BP medication if blood pressure exceeds 140/90 mmHg or 130/85 mmHg for those with heart failure or renal insufficiency (130/80 mmHg for diabetes) 1

Other Pharmacotherapy

• ACE inhibitors: Recommended for all post-MI patients indefinitely; start early in stable high-risk patients and consider for all patients with coronary or vascular disease 1, 2
• Beta-blockers: Start in all post-MI and acute ischemic syndrome patients and continue indefinitely; use as needed for angina, rhythm, or blood pressure control 1, 2

Lifestyle Interventions

Smoking Cessation

• Strongly encourage patients and families to stop smoking and avoid secondhand smoke 1
• Provide complete cessation counseling, pharmacological therapy (nicotine replacement, bupropion), and formal smoking cessation programs 1

Physical Activity

• Assess risk with exercise testing to guide prescription 1
• Encourage 30-60 minutes of aerobic activity daily or at least 3-4 times weekly (walking, jogging, cycling) 1
• Supplement with increased daily lifestyle activities (walking breaks at work, gardening, household work) 1
• Recommend medically supervised programs for moderate to high-risk patients 1

Weight Management

• Calculate BMI and measure waist circumference; monitor response to therapy 1
• Target BMI range: 18.5-24.9 kg/m² 1
• For BMI ≥25 kg/m², aim for waist circumference <40 inches in men and <35 inches in women 1

Diabetes Management

• Implement appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c 1
• Address other risk factors (physical activity, weight management, blood pressure, cholesterol) 1

Special Considerations

• Patients with cerebrovascular disease due to thrombosis often have concurrent coronary heart disease and should be managed accordingly 1
• Contemporary medical therapy has become so effective that carotid revascularization may not be necessary for many patients who would traditionally undergo surgery or stenting 3
• The combination of dietary modification, physical exercise, aspirin, statins, and antihypertensive therapy can provide a cumulative relative stroke risk reduction of up to 80% 3

Common Pitfalls and Caveats

• Surveys show that lifestyle and risk factor management, including prophylactic medical therapies, often falls short of evidence-based guidelines 1
• Avoid excessive grapefruit juice consumption (>1.2 liters daily) when taking statins as it may increase the risk of myopathy and rhabdomyolysis 4
• Statins should be discontinued during pregnancy as they may cause fetal harm 4
• Nitrates have not been shown to improve long-term prognosis after MI 2
• Calcium channel blockers have weaker evidence for benefit compared to beta-blockers 2