What are the management strategies for Cardiovascular Disease (CVD)?

Management Strategies for Cardiovascular Disease (CVD)

The management of cardiovascular disease requires a comprehensive approach including lifestyle modifications, pharmacological therapy, and risk stratification to reduce morbidity and mortality. 1

Risk Assessment and Stratification

• Initial risk stratification should be based on basic clinical assessment including age, ECG, anginal threshold, diabetes, chronic kidney disease, and left ventricular ejection fraction 1
• High-risk individuals can be identified using various test results including:
  • Exercise ECG with Duke Treadmill Score < -10
  • Stress imaging showing significant ischemia (≥10% of LV myocardium)
  • CCTA showing significant coronary stenosis 1
• For asymptomatic individuals, the SCORE risk assessment system should be used to predict fatal CVD events over a ten-year period 1
• Patients with established coronary heart disease, peripheral artery disease, and cerebrovascular atherosclerotic disease should be prioritized for aggressive CVD prevention 1

Lifestyle Modifications

• Multidisciplinary behavioral approaches to achieve healthy lifestyles are recommended for all patients 1
• Physical activity recommendations:
  • Aerobic physical activity of 150-300 minutes per week of moderate intensity or 75-150 minutes per week of vigorous intensity 1
  • Reduction in sedentary time 1
• Dietary recommendations:
  • Varied diet with energy intake adjusted to maintain ideal body weight
  • Increased consumption of fruits, vegetables, whole grain cereals, low-fat dairy products, fish, and lean meat
  • Total fat intake should not exceed 30% of energy intake 1
• Smoking cessation is essential for all patients 1
• Weight management to achieve normal body mass index 2

Pharmacological Management

Antianginal Therapy

• Selection of antianginal drugs should be tailored to patient characteristics, comorbidities, and underlying pathophysiology 1
• First-line therapy:
  • Short-acting nitrates for immediate relief of angina 1
  • Beta-blockers and/or calcium channel blockers for heart rate control and symptom management 1
• Avoid ivabradine in patients with CCS, LVEF >40%, and no clinical heart failure 1
• Nitrates are contraindicated in patients with hypertrophic cardiomyopathy or when co-administered with phosphodiesterase inhibitors 1

Antithrombotic Therapy

• For patients with prior MI or remote PCI:
  • Aspirin 75-100 mg daily lifelong after initial DAPT period 1
  • Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy 1
• After CABG, aspirin 75-100 mg daily is recommended lifelong 1
• For patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75-100 mg daily is recommended lifelong 1

Lipid-Lowering Therapy

• Statins are recommended for patients with established CVD 3
• Atorvastatin is indicated to reduce the risk of:
  • Myocardial infarction, stroke, revascularization procedures, and angina in adults with multiple risk factors for CHD
  • Non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for heart failure, and angina in adults with clinically evident CHD 3
• Target LDL-cholesterol levels should be <2.5 mmol/l (100 mg/dl) in high-risk patients 1, 4
• Monitor for adverse effects including myopathy, rhabdomyolysis, and hepatic dysfunction 3

Special Considerations

Diabetes Management

• For patients with diabetes, comprehensive management should include:
  • Lifestyle modifications (diet, exercise, weight loss)
  • Glycemic control with target HbA1c <7% overall (less aggressive in older/frail adults) 1
  • First-line therapy with metformin or SGLT2 inhibitors in patients with CKD or heart failure with reduced ejection fraction 1

Chronic Kidney Disease

• CKD patients require special attention due to increased cardiovascular risk 2
• Interventions should focus on:
  • Optimal blood pressure control
  • Reduction of proteinuria
  • Treatment of dyslipidemia
  • Management of mineral metabolism abnormalities 2

Implementation Strategies

• Multidisciplinary team approach with well-defined programs and rational targets for each risk factor 2
• Home-based cardiac rehabilitation and mobile health interventions should be considered to increase long-term adherence to healthy behaviors 1
• Cell phone text messaging can improve medication adherence and healthy behaviors 1
• Task-shifting from physicians to trained non-physician health workers can improve delivery of CVD care, particularly in resource-limited settings 1

Monitoring and Follow-up

• Regular assessment of cardiovascular risk factors and treatment adherence 1
• Monitoring for medication side effects, particularly with statins (liver enzymes, muscle symptoms) 3
• Periodic reassessment of overall cardiovascular risk to guide treatment intensity 1

Common Pitfalls and Caveats

• Underestimation of cardiovascular risk in certain populations, including women and younger individuals 5, 6
• Poor medication adherence leading to suboptimal outcomes - address through patient education and simplified regimens 1
• Failure to address all modifiable risk factors simultaneously - comprehensive approach is essential 1, 5
• Inadequate attention to lifestyle modifications alongside pharmacological interventions 1
• Overlooking the importance of early intervention in high-risk asymptomatic individuals 5, 6