Secondary Prevention of CVD

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Cardiac rehab

• Intensive programme involving lifestyle changes, exercise, stress management
• Starts pre-discharge, first follow-up within 10 days of discharge
• Can use home-based rehab using www.theheartmanual.com

See also: British Heart Foundation website

Lifestyle

• Stop smoking, exercise 20–30mins/day and increase as able, reduce alcohol to <14U/week, Mediterranean diet

Smoking

• Ask, advise, assist approach
• Management options: counselling, NRT, varenicline, bupropion

See also: National Centre for Smoking Cessation and Training website

Exercise

• Evidence-based treatment or prevention in 39 national guidelines!
• Large BMJ meta-analysis: showed exercise = drugs in secondary prevention of CV mortality for all except heart failure, where it is only slightly inferior. Exercise actually better than drugs for strokes
• Running 1 hour every week → 55% reduction in CV mortality
• Find something patients enjoy doing
• Advise 150 minutes per week of moderate-intensity, or 75 minutes per week of high-intensity exercise
• There should also be 2 days per week set aside for weight-lifting involving all major muscle groups (think hip hinge/squat/push/pull/core)

Alcohol

• Aim <14 units per week for both men and women. An interesting BMJ article showed drinking more than this can actually lead to dementia!

Screen using AUDIT-C and manage accordingly:

• <5: no problem-drinking
• 5–7: encourage cutting down
• ≥8: signpost to resources like NHS Change 4 Life, refer to support teams, consider thiamine ± Vit B co-strong

Do a full AUDIT if scoring ≥5 on the AUDIT-C

Mediterranean diet

• Similar to Eatwell guide advice
• High in veggies, starchy foods, unsaturated fats
• Low in meat and dairy

Medications — ABCDEs

ACEi/Antiplatelets, Beta blockers, Calcium channel blockers, DOACs, Eplerenone, Statins

ACEi/ARB

• Lifelong
• Max tolerated dose within 6w of D/C
• Monitor U&Es, BP

Antiplatelets

• Heart-related CV event: aspirin ± another antiplatelet 12m, then aspirin alone
• Non heart-related: clopidogrel

Usual antiplatelet choices (secondary care)

• STEMI + PCI — Aspirin + Prasugrel
• NSTEMI + PCI — Aspirin + Ticagrelor OR Prasugrel
• ACS on anticoags — Clopidogrel + anticoagulant for 12m, then stop clop

Beta-blockers

• Max tolerated dose
• Aim HR <60bpm
• Give 12m but continue lifelong if heart failure

Calcium channel blockers

• If BBs contraindicated + normal ejection fraction

DOAC

• Rivaroxaban 2.5mg OD + aspirin if stable CAD or symptomatic PAD

AND high recurrence risk and low bleeding risk

See: ATLAS and COMPASS trials

High recurrence risk

• ≥65y
• Atherosclerosis ≥2 vascular territories
• ≥2 of: diabetes, smoker, eGFR 15–59, heart failure, previous non-lacunar ischaemic stroke

Low bleeding risk

• Low bleeding risk = ORBIT score ≤2

Eplerenone

• If heart failure with reduced ejection fraction
• Start after ACEi, introduce very cautiously, regular U&Es
• Can continue spironolactone if already on it and tolerating

Statins

• Lifelong atorvastatin 80mg OD aiming for LDL <1.4mmol/L
• Can add ezetimibe if LDL not achieved with statin alone

Common Concerns

Return to work

• Depends on health, occupation, and work environment

Driving

Group 1

• No need to inform DVLA
• Can drive
• 4w after MI/CABG
• 4w after failed PCI
• 1w after successful PCI/PPM
• STOP DRIVING if angina at rest

Group 2

• Inform DVLA using VOCH1 form
• Stop driving — check DVLA website re length

Sexual activity

• Does not trigger MI
• Can safely resume in 4w

Erectile dysfunction

• Usually psychological
• Lifestyle interventions may help
• Consider PDE5i >6m if no contraindications

Air travel

• 7d after uncomplicated MI
• 4–6w after complicated MI
• 10d after CABG
• Not recommended in unstable angina

Further Reading

• Cardiac rehab on the British Heart Foundation website: https://www.bhf.org.uk/informationsupport/support/practical-support/cardiac-rehabilitation
• ATLAS trial [ATLAS — Rivaroxaban in patients with a recent ACS — NERDCAT] — low dose rivarox+aspi = better outcomes after ACS
• COMPASS trial Lancet Rivaroxaban with or without aspirin in patients with stable coronary artery disease: an international, randomised, double-blind, placebo-controlled trial — The Lancet — rivarox + asp for secondary prevention in stable CAD or PAD patients after ACS: Absolute risk reduction of major adverse CV events from 6% to 4%; NNT to prevent major CV event over 1.9y = 71, to prevent 1 death = 105. Major bleed risk increased from 2 to 3% but no significant increase in cerebral or fatal bleeding
• Very brief advice for smoking: NCSCT — National Centre for Smoking Cessation and Training
• Exercise = drugs in secondary prevention of CV mortality: https://www.bmj.com/content/347/bmj.f5577
• Drinking >14U/week = increased risk of cancer Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies | The BMJ
• and dementia (Alcohol consumption and risk of dementia: 23 year follow-up of Whitehall II cohort study | The BMJ)
• Alcoholuse_disorders_identification_test_for_consumption__AUDIT_C.pdf (publishing.service.gov.uk)) and do a full AUDIT questionnaire if they score 5 or more (Alcoholuse_disorders_identification_test__AUDIT.pdf (publishing.service.gov.uk))
• Eatwell guide: The Eatwell Guide — NHS (www.nhs.uk)
• Mediterranean diet: What is a Mediterranean diet? — NHS (www.nhs.uk)