Prevention, Secondary

What is secondary prevention?

Identifying and treating people with established disease and those at very high risk of developing cardiovascular disease.
Treating and rehabilitating patients who've had a heart attack or stroke to prevent another cardiovascular or cerebrovascular event.

AHA Recommendation

Although risk interventions significantly improve clinical outcomes, they are applied inconsistently across medical care settings and patient groups. The American Heart Association urges that every effort be made to promote more comprehensive application of risk reduction in all eligible patients.

What can secondary prevention achieve?

Comprehensive risk factor interventions

extend overall survival.
improve quality of life.
decrease need for interventional procedures such as angioplasty and bypass grafting.
reduce the incidence of subsequent heart attack (myocardial infarction).

Heart or stroke patients can do this to help lower their risk of recurring disease:

Before your next visit, tell your doctor you'd like an assessment of your fasting lipid profile. You'll receive simple instructions before the test. If you need to lower your blood cholesterol, find out whether drug therapy or a low-saturated-fat diet or simpler treatment is warranted.
During your visit, ask your doctor to suggest physical activity that you can do for 30–60 minutes, preferably daily, or at least five days per week.
Ask what your ideal weight is, and if you exceed it, ask your doctor to prescribe a diet and exercise program.
Have your blood pressure checked regularly. If you have high blood pressure, you may be put on medication. You'll also be told about weight control, physical activity, drinking alcohol and sodium (salt) intake.
Ask your doctor if you should take aspirin daily or another medication.
If you smoke, ask about counseling, nicotine replacement methods and formal programs to help you quit.
Always see your doctor regularly, follow instructions and ask questions.

NOTE: If you are taking any of the medications discussed below, it is important that you don't stop taking them without consulting your doctor.

Smoking

Goal: Complete cessation.

Intervention recommendations

Ask about tobacco use status at every visit.
Advise patient and family members to quit.
Assess the tobacco user’s willingness to quit.
Assist by counseling and developing a plan for quitting.
Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion).
Urge avoidance of exposure to environmental tobacco smoke at work and home.

Blood pressure control

Goal:

Less than 140/90 mm Hg.
Less than 130/80 mm Hg in people with diabetes or chronic kidney disease.

Intervention recommendations

For all patients, initiate or maintain lifestyle modification (weight control, increased physical activity, alcohol moderation, sodium reduction, and emphasis on increased consumption of fresh fruits, vegetables and low-fat dairy products).
For patients with blood pressure 140/90 mm Hg or greater (or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes): As tolerated, add blood pressure medication, initially treating with beta blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure.

Lipid management

Primary goal: LDL cholesterol (LDL-C) less than 100 mg/dL. Further reduction of LDL-C to less than 70 mg/dL is reasonable.

Intervention recommendations

For all patients:

Start dietary therapy. Reduce intake of saturated fat (to less than 7 percent of calories) trans-fatty acids, and cholesterol (to less than 200 mg dietary cholesterol per day).
Adding plant stanol/sterols (2 grams/day) and viscous fiber (more than 10 grams/day) will further lower LDL-C.
Promote daily physical activity and weight management.
Encourage increased intake of omega-3 fatty acids in the form of fish or in capsule form (1 gram/day) for risk reduction. For treating elevated triglycerides, higher doses are usually necessary for risk reduction.

For lipid management:

Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. If patients are hospitalized, initiate lipid-lowering medication before discharge as follows:
If baseline LDL-C is 100 mg/dL or greater, initiate LDL-lowering therapy (typically with a statin).
If on-treatment LDL-C is 100 mg/dL or greater, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination [statin + ezetimibe, bile acid sequestrant, or niacin*]).
If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C less than 70 mg/dL.
If triglycerides are 200 to 499 mg/dL, non-HDL-C^# should be less than 130 mg/dL, and further reduction of non-HDL-C to less than 100 mg/dL is reasonable.

Therapeutic options to reduce non-HDL-C are:

More intense LDL-C–lowering therapy, or
Niacin* (after LDL-C–lowering therapy), or
Fibrate therapy^# (after LDL-C–lowering therapy)
If triglycerides are 500 mg/dL or greater, therapeutic options to prevent pancreatitis are fibrate or niacin* before LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C to less than 130 mg/dL if possible. Patients with very high triglycerides should not consume alcohol.

*Dietary supplement niacin must not be used as a substitute for prescription niacin. It should not be used for cholesterol lowering because of potentially very serious side effects.
^#Non-HDL cholesterol is total cholesterol minus HDL cholesterol.

Physical activity

Goal: 30 minutes, 7 days per week (minimum goal, 5 days per week)

Intervention recommendations

For all patients, assess risk with a physical activity history and/or exercise test, to guide prescription.
For all patients, encourage minimum of 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).
Encourage resistance training two days per week.
Advise medically supervised programs for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure).

Weight management

Goal: Body mass index (BMI) 18.5–24.9 kg/m². Waist circumference less than 40 inches in men and less than 35 inches in women.

Intervention recommendations

Calculate BMI and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through appropriate balance of physical activity, caloric intake and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m².
If waist circumference (measured horizontally at the iliac crest) is 35 inches or greater in women and 40 inches or greater in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated.
The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline.
With success, further weight loss can be attempted if indicated through further assessment.

*A BMI of 18.5 to 24.9 is considered as normal body weight. People with a BMI of 25–29.9 are considered overweight, while people with a BMI of 30 or greater are considered obese.

Diabetes management

Goal: HbA1c less than 7 percent. (HbA1c is a test to measure the average amount of sugar in your blood over the past two to three months.)

Intervention recommendations

Initiate lifestyle and pharmacotherapy to achieve near normal HbA1c.
Begin vigorous modification of risk factors (e.g., physical activity, weight management, blood pressure control and cholesterol management as recommended above).
Coordinate diabetes care with patient’s primary care physician or endocrinologist.

Antiplatelet agents/anticoagulants

Intervention recommendations

Start aspirin at 75 to 162 mg/d and continue indefinitely in all patients unless contraindicated.
For patients undergoing coronary artery bypass grafting, aspirin should be started within 48 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg/d appear to be efficacious. Doses higher than 162 mg/d can be continued for up to one year.
Start and continue clopidogrel at 75 mg/d in combination with aspirin for up to 12 months in patients after acute coronary syndrome or percutaneous coronary intervention with stent placement (one month or more for bare metal stent, three months or more for sirolimus-eluting stent, and six months or more for paclitaxel-eluting stent).
Patients who have undergone percutaneous coronary intervention with stent placement should initially receive higher-dose aspirin at 325 mg/d for one month for bare metal stent, three months for sirolimus-eluting stent, and six months for paclitaxel-eluting stent.
Manage warfarin to international normalized ratio 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in post–myocardial infarction patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus).
Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely.

Renin-angiotensin-aldosterone system blockers

Intervention recommendations

Angiotensin-converting enzyme (ACE) inhibitors:

Start and continue indefinitely in all patients with left ventricular ejection fraction of 40 percent or less and in those with hypertension, diabetes or chronic kidney disease, unless contraindicated.
Consider for all other patients.
Among lower-risk patients with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed, use of ACE inhibitors may be considered optional.

Angiotensin receptor blockers:

Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial infarction with left ventricular ejection fraction of 40 percent or less.
Consider in other patients who are ACE-inhibitor intolerant.
Consider use in combination with ACE inhibitors in systolic-dysfunction heart failure.

Aldosterone blockade:

Use in post-myocardial infarction patients who do not have significant kidney dysfunction or elevated serum potassium, who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have a left ventricular ejection fraction of 40 percent or less, and have either diabetes or heart failure.

Beta blockers

Intervention recommendations

Start and continue indefinitely in all patients who have had myocardial infarction, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated.
Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated.

Influenza vaccination

Patients with cardiovascular disease should have an influenza vaccination.

Related AHA Scientific Statements:
Prevention