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Get with the Guidelines: Risk Reduction in Patients with Coronary Artery and Vascular Disease

The American Heart Association released an updated set of guidelines in November 2011 targeting patients known to have blocked arteries of the heart (CAD), legs or carotids. The goal is to reduce the risk for progression of disease, improve survival and reduce recurrent events or the need for surgical procedures. The evidence behind these guidelines is compelling and is considered a standard of care by the major cardiology societies and applicable governmental agencies.

These guidelines should serve as a framework for patient care and must be tailored to an individual’s needs and circumstances. The following is a summary of recommendations based on the guidelines and other accepted data:

Smoking: No one should smoke, especially people with blocked arteries. Smoking damages the lining of arteries and initiates the process of atherosclerosis (blockage).

Blood Pressure: The goal is less than 140/90. Therapy includes two classes of drugs, alone or in combination: B-blockers (such as metoprolol or carvedilol) and/or ACE inhibitors (such as enalapril or ramipril). Occasionally other medications are needed. Treatment includes weight control, exercise, alcohol moderation, sodium reduction and increased consumption of fruits and vegetables.

Lipid Management: The goal is to achieve an LDL (bad) cholesterol value of less than 100 mg/dl; some studies suggest an LDL of less than 70 mg/dl. Theoretically, the formation of plaque in arteries begins at 70 mg/dl. If the LDL can be brought down below 70 mg/dl, blockages can be partially reversed. Statin drug therapy is usually necessary with lifestyle modification such as exercise, weight reduction and dietary changes. Dietary recommendations include less than 7 percent of total daily calories from saturated fats, less than 1 percent from trans fats and less than 200 mg per day of cholesterol. Triglycerides and HDL (good) cholesterol values should be managed as well.

Physical Activity: Patients should engage in moderate-intensity aerobic activity such as brisk walking for 30 to 60 minutes per day, for at least five days, and preferably seven days, a week.

Weight Management: Maintain a body mass index of 18.5 to 24.9 kg/m2. Measurement at the top of the hip bone should be less than 35 inches for women and less than 40 inches for men. Dietary changes and exercise can help achieve this goal.

Drugs

• Aspirin: Aspirin reduces platelet clumping and impairs blood-clot formation. Recommended dosage for coronary artery patients is 75-162 mg. Patients who are allergic or intolerant to aspirin can use clopidogrel (Plavix). For patients with a heart stent or recent hospitalization related to heart attack, clopidogrel (Plavix) or plasugrel (Effient) for 12 months with aspirin is indicated. Patients undergoing bypass should take 100 to 325 mg per day. Patients with symptomatic peripheral artery disease should take 75 to 325 mg of aspirin per day or 75 mg per day of clopidogrel. Patients with carotid artery disease with a stroke or transient ischemic attack (TIA) are advised to take 75 to 325 mg of aspirin alone or 75 mg per day of clopidogrel alone or an aspirin/dipyridamole combo of 25 to 200 mg twice daily.
• ACE inhibitors: Patients with weak heart muscles (ejection fraction of less than 40 percent) and those with hypertension, diabetes or chronic kidney disease should use ACE inhibitors unless contra-indicated. In heart patients they can improve heart pump performance and dilate heart arteries.
• B-blockers: In patients with a weak heart muscle or prior heart attack they can decrease the risk for sudden death and reduce episodes of congestive heart failure and angina.

Influenza Vaccine: Advisable for patients with heart disease.

Cardiac Rehabilitation: Recommended for patients after bypass, heart stents and heart attacks.

Lawrence E Vallario, M.D. is board certified in cardiovascular diseases, nuclear cardiology, cardiac CT angiography and internal medicine. He is a partner of the Cardiovascular Center P.A. with offices in Lake Mary and Deltona. He lives in Lake Mary with his wife and five daughters.