Acute Coronary Syndrome – long term management
| Goal: | Recommendations |
| Smoking | |
| Complete cessation No exposure to environmental/ passive tobacco smoke | – ceasing ↓ %Y mortality by half – Patients should be asked about tobacco use status at every office visit – Consider pharmacotherapy for patients smoking >10 cigarettes per day: Nicotine replacement therapy (NRT) — is the first line choice of medication — NRT patches can be used safely in smokers with less severe cardiovascular disease (eg. stable angina or a history of myocardial infarction) — but is not recommended with recent myocardial infarction, unstable angina, severe arrhythmias, refractory angina or recent cerebrovascular event Bupropion – is a treatment option for patients with stable cardiovascular disease. – safety of bupropion in patients who have had an acute coronary event has not been established bupropion + NRT can be considered for patients requiring additional assistance – consider high risk of continuing to smoke when assessing benefits and risks of pharmacotherapy |
| Blood pressure control | |
| Goal: <130/80 mm Hg | – Commence blood pressure (BP)-lowering treatment if systolic BP is >120–130 mmHg unless contraindicated by symptomatic hypotension – Investigate as appropriate: exclude secondary hypertension – Referral to specialist for SBP ≥180, or DBP ≥110 mmHg, or if secondary hypertension suspected or difficult to manage hypertension – All patients should be counselled regarding the need for lifestyle modification: weight control increased physical activity alcohol moderation sodium reduction emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products Urinary protein – In those without diabetes with hypertension: if proteinuria detected on urinalysis, determine 24 hour urinary protein excretion or protein/creatinine ratio on a spot urine sample (consider when ≥1+ on dipstick) – In people with diabetes with hypertension, knowledge of urinary albumin excretion determines the intensity of antihypertensive therapy. The best screening test (if available) is the urinary albumin/ creatinine ratio on a ‘spot’ urine. In patients with values at least in the microalbuminuric range, a 24 hour urine collection should be obtained for accurate quantification |
| Lipid management | |
| Establish/maintain healthy eating including saturated + trans fatty acid intake no more than 8% of total energy intake LDL-C < 1.8 mmol/L Tot-C <4.0 mmol/L HDL-C >1.0 mmol/L TG <2.0 mmol/L | Statin Therapy for Patients with CHD Recommendation: Statin therapy is recommended for all patients with Coronary Heart Disease (CHD) except in exceptional circumstances. Timing: Should be commenced during hospital admission. Dietary Therapy Recommendations Reduced Intake: Saturated fats: <7% of total calories Trans fatty acids: <1% of total calories Cholesterol: <200 mg/day Diet Composition: Plant-based foods: Vegetables Fruits Legumes (dried peas, dried beans, and lentils) Grain-based foods:Preferably wholegrain bread Pasta Noodles Rice Animal-based foods:Moderate amounts of lean meats Poultry Fish Reduced-fat dairy products Fats:Moderate amounts of polyunsaturated or monounsaturated fats Additional Support: Consider referral to a dietitian for personalized dietary advice and support. |
| Physical activity | |
| At least 30 minutes, 7 days per week (minimum 5 days per week) | Assessment: Evaluate patient’s physical activity habits. Consider severity of disease and comorbidities. Conditions Requiring Clinical Assessment and Supervision: – Unstable angina – Uncontrolled hypertension – Severe aortic stenosis – Uncontrolled diabetes – Complicated AMI (within 3 months) – Untreated heart failure or cardiomyopathy – Symptoms such as chest discomfort or shortness of breath on low exertion – Resting heart rate >100 bpm – Physical Activity Recommendations Discussion: Discuss patient’s physical activity needs, capabilities, and barriers. Encourage the patient to be active. Guidelines: Written Guidelines: Provide written guidelines for everyday physical activity tasks, including light-moderate walking. Initial Activity: Begin at low intensity and gradually increase over several weeks, particularly in the post-acute event period.Start with one or two activities for a short time at low intensity. Gradually increase time spent, intensity, and variety of activities over several weeks. Notes: Vigorous physical activity is generally not encouraged for people with CHD. Cardiac Rehabilitation: Referral to a cardiac rehabilitation program where appropriate and available, especially useful in the post-acute event period. Aerobic Activity: Encourage 30 to 60 minutes of moderate-intensity aerobic activity (e.g., brisk walking) at least 5 days and preferably 7 days per week. Daily Lifestyle Activities: Supplement aerobic activity with an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). Goals: Begin at low intensity and gradually increase. Achieve and maintain 30 to 60 minutes of moderate-intensity aerobic activity most days of the week. Encourage a sustainable increase in daily physical activity. |
| Weight management | |
| Body mass index: 18.5 to 24.9 kg/m2 Waist circf: women <89 cm men <102 cm | structured exercise, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2 The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated |
| Type 2 diabetes mellitus management | |
| A target HbA1c of ≤7% may be considered | Less stringent HbA1c goals may be considered for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbidities, or those in whom the goal is difficult to attain despite intensive therapeutic interventions. |
| Medications | |
| Aspirin | (100–150 mg/day) should be continued indefinitely unless it is not tolerated or an indication for anticoagulation becomes apparent OR Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin. |
| Duel Therapy: Aspirin + P2Y12 receptor blockers (clopidogrel, ticlopidine, ticagrelor, prasugrel) | |
| is indicated in patients after ACS or PCI with stent placement. should be prescribed for up to 12 months in patients with ACS, regardless of whether coronary revascularisation was performed Consider continuation of dual-antiplatelet therapy beyond 12 months if ischaemic risks outweigh the bleeding risk of P2Y12 inhibitor therapy; conversely consider discontinuation if bleeding risk outweighs ischaemic risks. Bare-metal stent or Drug-eluting stent during PCI for ACS Clopidogrel 75 mg daily OR Prasugrel 10 mg daily OR Ticagrelor 90 mg twice daily OR should be given for at least 12 months Coronary Artery Bypass Grafting: Aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure Extracranial carotid/vertebral atherosclerosis who have had ischemic stroke or TIA: Aspirin alone (75–325 mg daily) OR Clopidogrel alone (75 mg daily) OR Aspirin plus ER Dipyridamole (25 mg and 200 mg twice daily, respectively) symptomatic atherosclerotic peripheral artery disease of the lower extremity: Aspirin (75–325 mg daily) or Clopidogrel (75 mg daily) | |
| Renin-angiotensin-aldosterone system blockers | |
| ACE inhibitors | ACE inhibitors should be started and continued indefinitely in all patients with – left ventricular ejection fraction ≤40% – hypertension – diabetes – chronic kidney disease |
| ARBs | The use of ARBs is recommended in patients who have heart failure, had a myocardial infarction with left ventricular ejection fraction ≤40%who are ACE-inhibitor intolerant |
| Aldosterone blockade | |
| Spironolactone: Typically 25 mg once daily, can be increased to 50 mg if tolerated and necessary. alternative: Eplerenone | Use of aldosterone blockade in post–myocardial infarction patients without significant renal dysfunction or hyperkalemia is recommended in patients – who are already receiving therapeutic doses of an ACE inhibitor and β-blocker – who have a left ventricular ejection fraction ≤40% – who have either diabetes or heart failure |
| β-Blockers | |
Recommendation for β-Blockers: | Indicated for:All patients with left ventricular systolic dysfunction (LVEF ≤ 40%) with heart failure or prior myocardial infarction, unless contraindicated. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce mortality. Duration: β-Blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function who have had myocardial infarction or acute coronary syndrome (ACS). Consideration for Chronic Therapy: β-Blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. |
| Influenza vaccination | Patients with cardiovascular disease should have an annual influenza vaccination |
| Depression | it is reasonable to screen for depression if patients have access to case management, in collaboration with their primary care physician and a mental health specialist. |
| Outpatient cardiovascular rehabilitation program | |
| combination of supervised exercise – gradually increase their physical activity levels and improve their cardiovascular fitness – tailored to the individual’s needs and may include aerobic activities, strength training, and flexibility exercises education – heart-healthy lifestyle choices -nutritionstress management – smoking cessation Counseling – cope with the emotional and psychological aspects of their heart conditionsupport servicesregular monitoring of vital signs, such as blood pressure and heart rate, during exercise sessions -Progress is tracked and individualized goals are set to ensure steady improvement – The program often involves collaboration among a team of healthcare professionals, including cardiologists, nurses, exercise physiologists, dietitians, and psychologists. | |