Tag: secondary prevention

  • Prevention of Acute coronary syndrome

    Prevention of Acute coronary syndrome

    Overview

    Preventing acute coronary syndromes, which are serious heart conditions like heart attacks, is incredibly important for living a long and healthy life. Whether you’ve never had a heart event or are recovering from one, understanding the steps you can take is key. This information aims to help you or someone you know to reduce the risk of these life-threatening heart issues. By actively managing risk factors and following medical advice, we can significantly improve health outcomes and reduce the burden of heart disease, which sadly remains the leading cause of death worldwide.

    There are two main types of prevention: primary prevention, which focuses on stopping a heart event from happening in the first place, and secondary prevention, which focuses on preventing future events once someone has already experienced an acute coronary syndrome. Both are crucial for maintaining heart health and improving quality of life.

    In details:

    Quick List for Prevention of Acute Coronary Syndrome

    • Lifestyle modifications
    • Blood pressure control
    • Cholesterol management (lipid-lowering therapy)
    • Diabetes management (glycemic control)
    • Antiplatelet therapy
    • Anticoagulant therapy
    • Beta-blockers
    • Renin-angiotensin system inhibitors (ACE inhibitors/ARBs)
    • Cardiac rehabilitation

    Primary Prevention of Acute Coronary Syndrome

    Primary prevention means taking steps to prevent a heart attack (myocardial infarction) or other acute coronary syndrome from ever occurring. It is about managing existing risk factors and adopting healthy habits to avoid the first event. Key risk factors for heart disease include high cholesterol (known as dyslipidemia), high blood pressure (or hypertension), diabetes mellitus (high blood sugar), obesity, and smoking. The good news is that many of these factors can be changed or controlled through careful attention to your health.

    Lifestyle changes are a powerful tool in primary prevention. Quitting smoking is one of the most impactful steps, as it’s a major risk factor globally and can halve the risk of a heart attack. Eating a healthy diet, such as a “Mediterranean-style” diet rich in fruits, vegetables, and fish, while reducing meat and saturated fats, is recommended. Regular physical activity, aiming for 20-30 minutes of exercise daily to the point of slight breathlessness, is also vital. Additionally, maintaining a healthy weight is crucial for heart health.

    Beyond lifestyle, medications play a significant role in primary prevention for those at higher risk. Statins, which are medicines that lower cholesterol levels, are recommended based on an individual’s overall risk of developing atherosclerotic cardiovascular disease (ASCVD), a condition where plaque builds up in the arteries. Despite their known benefits, studies show that a notable number of people who later suffer their first acute coronary event were actually eligible for statin therapy but hadn’t started it. For example, in one study, 85% of patients with calculable heart risk needed statins for primary prevention, but only about two-thirds received them, often not at the right dose. Common statins include atorvastatin.

    The use of aspirin for primary prevention is still debated and should be carefully considered with your doctor, weighing the potential benefits against risks like bleeding. Controlling high blood pressure with prescribed medications is another essential step. It’s important to work with your healthcare provider to ensure your blood pressure is within target ranges. For those with diabetes, effective management is critical, but achieving optimal blood sugar control (measured by glycated hemoglobin or HbA1c) can sometimes be challenging for patients who go on to experience heart events. Lastly, your doctor can calculate your cardiovascular risk score to help identify if you would benefit from preventive medications, though sometimes there isn’t enough information in medical records for a full assessment.

    Secondary Prevention of Acute Coronary Syndrome

    Secondary prevention refers to the measures taken after someone has already experienced an acute coronary syndrome, such as a heart attack, to prevent future heart attacks, strokes, or other cardiovascular complications. Patients who have had an acute coronary syndrome are at a significantly higher risk of having another event. Therefore, aggressive and sustained management is essential.

    One of the cornerstones of secondary prevention is dual antiplatelet therapy (DAPT). This involves taking two types of medicines that prevent blood clots: aspirin, which should be started immediately and continued for life (unless you can’t tolerate it, in which case a different antiplatelet like clopidogrel may be used), and a P2Y12 inhibitor. P2Y12 inhibitors, such as ticagrelor or prasugrel, are generally preferred over clopidogrel and are recommended for 12 months in most patients after an acute coronary syndrome. For patients at a very high risk of future heart events (for example, those with diabetes, kidney disease, peripheral artery disease, or disease in multiple heart arteries) and a low risk of bleeding, this dual therapy might be continued for longer than 12 months. However, this extended duration does increase the risk of bleeding. Conversely, if a patient has a high risk of bleeding, a shorter duration of DAPT (e.g., 6 months) might be recommended by their heart specialist.

    In certain high-risk individuals, combining an antiplatelet with a low dose of an anticoagulant (a medicine to prevent blood clots) like rivaroxaban has been shown to reduce cardiovascular events, particularly in those with stable atherosclerotic vascular disease who have had a previous heart attack. It’s important to remember that this combination also carries an increased risk of bleeding.

    Intensive lipid-lowering therapy is another critical component. This begins with prescribing high-intensity statins for all patients immediately after a heart attack, regardless of their initial cholesterol levels. If the target level of “bad cholesterol” (low-density lipoprotein cholesterol or LDL-C) is not reached (e.g., below 1.4 mmol/L) within 4-6 weeks, additional medications like ezetimibe should be added. If the LDL-C goal is still not achieved, PCSK9 inhibitors, such as evolocumab or alirocumab, may be introduced. These are powerful medicines that significantly reduce LDL-C and the risk of cardiovascular events. The aim is to lower LDL-C as much as possible with the maximum tolerated therapy.

    Additionally, neurohormonal agents are a standard part of secondary prevention. Beta-blockers are typically started within 24 hours of the event if there are no reasons not to, and usually continued for at least three years. These medicines help reduce the heart’s workload. Medications that modify the renin-angiotensin aldosterone system (RAAS), such as ACE inhibitors or angiotensin receptor blockers (ARBs), are given within 24 hours to patients with certain conditions like fluid in the lungs (pulmonary congestion) or reduced heart pumping capacity. Aldosterone antagonists are recommended for specific patients with heart failure and diabetes who are already on ACE inhibitors/ARBs and beta-blockers.

    New areas of focus in secondary prevention include targeting inflammation. Chronic inflammation is increasingly recognized as a key factor in heart disease and recurrent events. Medications like colchicine, traditionally used for gout, have shown some promise in reducing major adverse cardiovascular events after a recent heart attack, though more research is needed.

    Elevated triglycerides can also be addressed with specific treatments, such as icosapent ethyl, which has been shown to reduce cardiovascular events even when patients are already on statins. Furthermore, for patients with Type 2 diabetes, certain glucose-lowering agents have been found to reduce cardiovascular events and even mortality, independent of their effects on blood sugar.

    Finally, adherence to these long-term therapies is paramount for success. Studies show that many patients stop taking their medicines over time, with nearly 30% discontinuing one or more within 90 days of their acute coronary syndrome. Factors influencing adherence can be complex, including a patient’s understanding of their condition, their mood (e.g., depression), and how well the healthcare system supports them with early follow-up and ongoing education. Therefore, a comprehensive approach involving patient education and active engagement from healthcare providers is key to improving outcomes.

    Other similar questions

    What is acute coronary syndrome?

    It is a group of heart conditions that includes unstable angina (chest pain without heart muscle damage) and myocardial infarction (a heart attack where heart muscle damage occurs, classified as ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction)

    What causes a heart attack?

    Most commonly, it is caused by a sudden blockage in one of the heart’s arteries, usually due to a blood clot forming on a damaged or ruptured plaque (a fatty deposit) inside the artery wall.

    How are heart attacks diagnosed?

    Diagnosis typically relies on the patient’s symptoms (such as chest pain), changes seen on an electrocardiogram (ECG), and blood tests that measure markers of heart muscle injury, like troponin. Modern high-sensitivity troponin tests allow for rapid and accurate diagnosis.

    Resources

    • Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet. 2022 Apr 2;399(10332):1347-1358. doi: 10.1016/S0140-6736(21)02391-6. PMID: 35367005; PMCID: PMC8970581.
    • Smith JN, Negrelli JM, Manek MB, Hawes EM, Viera AJ. Diagnosis and management of acute coronary syndrome: an evidence-based update. J Am Board Fam Med. 2015 Mar-Apr;28(2):283-93. doi: 10.3122/jabfm.2015.02.140189. PMID: 25748771.
    • Bahit MC, Korjian S, Daaboul Y, Baron S, Bhatt DL, Kalayci A, Chi G, Nara P, Shaunik A, Gibson CM. Patient Adherence to Secondary Prevention Therapies After an Acute Coronary Syndrome: A Scoping Review. Clin Ther. 2023 Nov;45(11):1119-1126. doi: 10.1016/j.clinthera.2023.08.011. Epub 2023 Sep 9. PMID: 37690915.
    • Gallone G, Baldetti L, Pagnesi M, Latib A, Colombo A, Libby P, Giannini F. Medical Therapy for Long-Term Prevention of Atherothrombosis Following an Acute Coronary Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018 Dec 11;72(23 Pt A):2886-2903. doi: 10.1016/j.jacc.2018.09.052. PMID: 30522652.
    • Gaviria-Mendoza A, Zapata-Carmona JA, Restrepo-Bastidas AA, Betancur-Pulgarín CL, Machado-Alba JE. Prior Use of Medication for Primary Prevention in Patients with Coronary Syndrome. J Prim Care Community Health. 2020 Jan-Dec;11:2150132720946949. doi: 10.1177/2150132720946949. PMID: 32755281; PMCID: PMC7543101.
    • Silverio, A.; Cancro, F.P.; Esposito, L.; Bellino, M.; D’Elia, D.; Verdoia, M.; Vassallo, M.G.; Ciccarelli, M.; Vecchione, C.; Galasso, G.; et al. Secondary Cardiovascular Prevention after Acute Coronary Syndrome: Emerging Risk Factors and Novel Therapeutic Targets. J. Clin. Med. 2023, 12, 2161. https://doi.org/10.3390/jcm12062161
    • Fitchett DH, Leiter LA, Lin P, Pickering J, Welsh R, Stone J, Gregoire J, McFarlane P, Langer A, Gupta A, Goodman SG. Update to Evidence-Based Secondary Prevention Strategies After Acute Coronary Syndrome. CJC Open. 2020 Apr 10;2(5):402-415. doi: 10.1016/j.cjco.2020.04.002. PMID: 32995726; PMCID: PMC7499366.
    • Isted A, Williams R, Oakeshott P. Secondary prevention following myocardial infarction: a clinical update. Br J Gen Pract. 2018 Mar;68(668):151-152. doi: 10.3399/bjgp18X695261. PMID: 29472228; PMCID: PMC5819978.

  • Treatment and Management of Acute Coronary Syndrome

    Treatment and Management of Acute Coronary Syndrome

    Understanding the treatment and management of Acute Coronary Syndrome (ACS) is vital because it explains the steps taken to address these serious heart conditions and prevent future problems. The goal is to restore blood flow to the heart muscle quickly, minimize damage, and improve long-term health.

    Overview

    The treatment and management of Acute Coronary Syndrome focus on prompt restoration of blood flow, typically through procedures like coronary revascularization (opening blocked arteries), alongside a combination of medications to prevent blood clots and support heart function. Long-term management, known as secondary prevention, is equally crucial, involving ongoing medication and significant lifestyle changes to reduce the risk of future heart events.

    The approach to managing Acute Coronary Syndrome is personalized, taking into account the specific type of Acute Coronary Syndrome, the patient’s individual risk factors, and other health conditions.

    In Details

    First, here’s a quick list of the main treatment and management strategies for Acute Coronary Syndrome:

    • Immediate Assessment and Risk Stratification
    • Coronary Revascularization (e.g., Percutaneous Coronary Intervention (PCI), Fibrinolysis)
    • Antiplatelet Therapy (e.g., Aspirin, P2Y12 inhibitors like Clopidogrel, Prasugrel, Ticagrelor)
    • Anticoagulation Therapy
    • Adjuvant Medications (e.g., Beta-blockers)
    • Lipid-Lowering Therapy (e.g., Statins)
    • Secondary Prevention (Lifestyle modifications)
    • Management in Special Populations (e.g., Women, Elderly, Patients with COVID-19, those in Low- and Middle-Income Countries)

    Initial management of Acute Coronary Syndrome

    The diagnosis and initial management of Acute Coronary Syndrome begin with a thorough clinical assessment, including a patient’s symptoms, an electrocardiogram (ECG) (a test that records the electrical activity of the heart), and cardiac troponin levels (blood tests that detect proteins released when heart muscle is damaged). These steps help determine the type of ACS and the urgency of treatment. For instance, ST-segment elevation myocardial infarction (STEMI), a severe type of heart attack, is identified by specific ECG changes and requires immediate attention. Prompt evaluation is crucial to prevent potentially fatal outcomes and relieve ongoing lack of oxygen to the heart.

    Coronary Revascularization

    A key treatment strategy for Acute Coronary Syndrome is coronary revascularization, which aims to reopen blocked or severely narrowed coronary arteries. For patients experiencing a ST-segment elevation myocardial infarction, immediate reperfusion therapy (restoring blood flow) is the top priority, ideally within 12 hours of symptom onset. The preferred method is Percutaneous Coronary Intervention (PCI), often called angioplasty and stenting, which involves inserting a balloon and usually a stent (a small mesh tube) to open the artery. The goal is to perform PCI within 60-90 minutes of the first medical contact. If timely PCI is not available (e.g., if a patient is far from a PCI-capable hospital), fibrinolysis (clot-busting medication) is given within 30 minutes of hospital arrival to dissolve the blood clot. For non-ST-segment elevation acute coronary syndrome patients, the timing of an invasive procedure like angiography (an X-ray of the heart’s arteries) and possible PCI depends on their risk.

    Those at very high risk (e.g., unstable blood pressure, ongoing chest pain, life-threatening irregular heartbeats) need emergent angiography within 2 hours. In stable ST-segment elevation myocardial infarction patients with blockages in multiple arteries, opening all significant blockages (complete revascularization) may improve outcomes, but in those with cardiogenic shock (when the heart cannot pump enough blood to meet the body’s needs), only the main blocked artery should be treated immediately.

    Antiplatelet therapy

    Antiplatelet therapy is a cornerstone of Acute Coronary Syndrome management, working to prevent blood clots by stopping platelets (tiny blood cells that help blood clot) from sticking together. Aspirin should be started as soon as possible after an Acute Coronary Syndrome event and continued indefinitely. In addition to aspirin, a P2Y12 inhibitor is typically added. Common P2Y12 inhibitors include clopidogrel, prasugrel, and ticagrelor. These are usually given for at least 12 months in most patients, as this dual antiplatelet therapy (DAPT) has been shown to reduce future heart problems. While prasugrel and ticagrelor are generally preferred over clopidogrel due to their stronger effects, they also carry a higher risk of bleeding. The choice of agent and duration of dual antiplatelet therapy are carefully considered based on a patient’s individual risk of both clotting and bleeding. Recent studies are also exploring if aspirin can be stopped earlier in some high-bleeding-risk patients after a few months of dual antiplatelet therapy, without increasing the risk of clotting.

    Anticoagulation therapy

    Anticoagulation therapy, which uses medications to thin the blood and prevent new clots from forming or existing clots from growing, is also critical in the initial management of Acute Coronary Syndrome. Parenteral (injected) anticoagulants, such as unfractionated heparin, low-molecular-weight heparin, fondaparinux, or bivalirudin, are used alongside antiplatelet agents during the acute phase. For patients who also have conditions requiring long-term blood thinners, such as atrial fibrillation (an irregular heart rhythm), the combination of dual antiplatelet therapy and an oral anticoagulant requires careful balance due to an increased risk of bleeding. New oral anticoagulants have been studied in this setting, but while some reduce cardiovascular events, they generally increase bleeding risk and are not yet broadly approved for ACS prevention in Europe or the US.

    Adjuvant medications

    Beyond these immediate interventions, adjuvant medications play a crucial role in long-term management and secondary prevention. Beta-blockers are usually started within 24 hours of Acute Coronary Syndrome if there are no contraindications, as they help reduce the heart’s workload and oxygen demand. They are typically continued long-term, though the exact duration is debated. Renin-angiotensin system inhibitors (ACE inhibitors or ARBs) are recommended for patients with specific conditions like heart failure or reduced pumping function of the heart (ejection fraction below 40%), as they can reduce mortality. Aldosterone antagonists are also beneficial for certain heart failure patients with reduced ejection fraction and diabetes.

    Lipid-lowering therapy

    Lipid-lowering therapy is fundamental for preventing future heart events. All patients with Acute Coronary Syndrome should start or continue high-intensity statin therapy to aggressively lower LDL-cholesterol (LDL-C), often called “bad cholesterol”. If the LDL-C target (e.g., less than 1.4 mmol/L) is not reached with statins alone, additional medications like ezetimibe and then PCSK9 inhibitors may be added. These therapies are critical even if initial cholesterol levels seem acceptable, as reducing LDL-C significantly impacts cardiovascular risk. While inflammation is known to contribute to Acute Coronary Syndrome, anti-inflammatory therapies like colchicine have shown mixed results in trials and are not currently broadly recommended by major guidelines.

    Secondary prevention

    Finally, secondary prevention for Acute Coronary Syndrome patients is crucial and involves both medication and lifestyle modifications. This includes dietary changes, regular exercise, quitting smoking, and participating in cardiac rehabilitation programmes. These measures, combined with adherence to long-term medications, are vital for reducing the risk of recurrent events and improving overall quality of life.

    It’s important to recognize that the management of Acute Coronary Syndrome can be complicated by factors such as COVID-19, which can directly injure the heart, increase clot risk, and disrupt healthcare systems. Additionally, sex- and race-based disparities exist, with women and certain racial groups sometimes experiencing delays in diagnosis, less frequent revascularization, and lower rates of receiving guideline-recommended medications. Older patients and those in low- and middle-income countries also face unique challenges and disparities in Acute Coronary Syndrome care.

    Other Similar Questions

    Resources

    • Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet. 2022 Apr 2;399(10332):1347-1358. doi: 10.1016/S0140-6736(21)02391-6. PMID: 35367005; PMCID: PMC8970581.
    • Smith JN, Negrelli JM, Manek MB, Hawes EM, Viera AJ. Diagnosis and management of acute coronary syndrome: an evidence-based update. J Am Board Fam Med. 2015 Mar-Apr;28(2):283-93. doi: 10.3122/jabfm.2015.02.140189. PMID: 25748771.