Secondary Prevention of Coronary Heart Disease

Secondary prevention in individuals who have proven to suffer from Coronary Heart Disease is an effort to prevent coronary heart disease was not repeated again. Secondary prevention is particularly important because :

»Individuals who have ever been, or has been proven to suffer from coronary heart disease tend to have more heart disease, are more likely than those who had never hurt the heart.

»The process underlying atherosclerosis of coronary heart disease, can occur in other organs of blood vessels in the brain who lead to cerebrovascular disease (stroke), the aorta or carotid arteries, peripheral arteries. Therefore, secondary prevention for coronary heart disease may also be the primary prevention of atherosclerotic disease to other types. »Secondary Prevention has not been fully received attention (under utilized) of medical practitioners, particularly in countries with low per capital income and middle-

Risk factors and changes expected

Smoke

Stop completely and not exposed to environmental smoke. Blood pressure control

The goal is the blood pressure <140/90mm Hg; <130/80 in renal impairment or heart failure or <130/80 mm Hg in diabetes. diet

This diet is by eating healthy foods.

Giving aspirin

The purpose of giving low dose aspirin in patients with high cardiovascular risk (in particular patients with a 10-year risk of cardiovascular events ≥ 10%)

Guidelines for Primary Prevention of Cardiovascular Disease and Stroke

There is no better motto than "Prevention is better than cure". Motto applies to anyone, especially in people who have high risk factors. Prevention priorities is mainly done to :

1. Patients with heart disease, peripheral arterial disease and   cerebrovascular    atherosclerosis. 
2.  Patients without symptoms but considered high risk because of :

• Many risk factors and the amount of risks in the 10 years ≥ 5% (more than 60 years of age) to have a fatal cardiovascular disease.

• The increase of one component of risk factors: cholesterol ≥ 8 mmol / l (320 mg / dl), low density lipoprotein (LDL) cholesterol ≥ 6 mmol / l (240 mg / dl), BP ≥ 180/110 mm Hg.

     3. Close relatives of

• Patients with atherosclerotic cardiovascular disease earlier

• Patients with high risk but without symptoms.

     4.  People who regularly perform a clinical examination.

There are a lot of evidence that Coronary Heart Disease can be prevented and to Coronary Heart Disease research is still continuing. From the results of long-term prospective study showed that people with low risk factors have a smaller risk for coronary heart disease and stroke. 

 ACC / AHA recommends directions for prevention of cardiovascular disease which is determined from the existing risk factors. Business ventures by way of non-pharmacology interventions and pharmacology as well as various clinical trials showed a beneficial thing. 

Guidelines Primary Prevention of Disease and Stroke Cardiovascular based on risk factors

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Risk Factors	Recommendation
Search for Risk Factors The objective is: Adults should know the extent and importance of risk factors checked routinely.	Risk factor screening should begin at age 20 years. Family history of coronary heart disease should be routinely monitored. Smoking, diet, alcohol, physical activity should be evaluated regularly. Blood pressure, body mass index, waist circumference should be checked lapse of 2 years. Cholesterol checks and blood sugar levels must still be monitored as well.
Estimation of risk factors in general The objective is: All adults over the age of 40 should know their risk factors for coronary heart disease which suffered to reduce a big risk factor	Every 5 years or more if there are changes in risk factors, particularly those with ≥ 40 years of age or a person with more than 2 risk factors, should be able to determine the risk factors based on a count of 10-year risk factor. Risk factors are seen smoking, blood pressure, cholesterol checks, blood sugar levels, age, gender and diabetes. Patients with diabetes or a 10-year risk> 20% is considered similar to patients with coronary heart disease

Revascularization vs Medical Treatment of Coronary Heart Disease Patient

Coronary heart disease patients experiencing sudden cardiac arrest complications, mortality rate is very high (> 90%). Now, with advances in technology can be done a primary percutaneous coronary intervention (primary PCI). Primary PCI is a technique to remove thrombus and widen the narrowed coronary arteries with balloon catheters and stent be done.

This action can eliminate the blockage with immediately, so that blood flow can be normal again, so the heart muscle damage can be avoided. Nowadays primary PCI is the best treatment of acute cardiac infarction, because it can stop an attack of acute heart infarction and reduce mortality to below 2%.

Choice of action in patients with coronary heart disease, is it enough just with medication and how when compared with revascularization? In most patients with stable coronary heart disease can be given medical treatment as an alternative to the PCI and the complications that occurred less than PCI or surgery in the follow-up for 1 year at MASS study.

 From the ACIP study (The Asymptomatic Cardiac Ischaemia Pilot) obtained in patients with high risk of having a better outcome with revascularization.

From various studies (ACME, RITA-2 trial) stated that PCI ( Percutneous Coronary Intervention ) better in improving patient quality of life than medical drugs. In the AVERT study, 341 patients with coronary heart disease with medical treatment of atorvastatin 80 mg per day. From these results it was found that in patients with stable coronary heart disease and low risk, medical treatment including aggressive fat-lowering drugs may be as effective as PCI( Percutneous Coronary Intervention )  in terms of reduction in ischemic events. Angina symptoms is better controlled by the PCI ( Percutneous Coronary Intervention ).

It could be argued that the invasive action performed on patients with high risk or who are not well controlled with medical drugs, whereas pharmacotherapy alone in patients with high risk or who are not well controlled with medical drugs, whereas pharmacotherapy alone in patients with stable coronary heart disease with low risk

The actions of PCI ( Percutneous Coronary Intervention )

In the beginning, the act of percutaneous trans Iuminal angioplasty is only performed on one blood vessels only, now it has grown more rapidly both because of the experience, equipment, especially stents and supporting drugs. In patients with stable coronary heart disease with suitable coronary anatomy. PCI ( Percutneous Coronary Intervention ) can be performed on one or more blood vessels (multi-vessel) with a good (successful PCI). The risk of death by this action ranged from 0.3 to 1%. The action of PCI ( Percutneous Coronary Intervention ) in patients with stable heart disease compared with the coroner medical drugs, does not increase survival and this is different as compared with CABG ( Coronary Artery Bypass Surgery).

 Elective stent implantation and drug-eluting stents (DES)

Stenting can reduce restenosis and repeat PCI ( Percutneous Coronary Intervention ) compared with balloon angioplasty actions. There is now available  stents coated drug (drug-eluting stent = DES) as serolimus, paclitaxel and others. Compared with bare-metal stents, the use of DES may reduce restonesis. Ravel studies showed restenosis can be reduced to 0%.

 Direct stenting (without stent implantation with balloon predilatasi first) is a feasible action in patients with coronary artery stenosis that is certain single lesions, without angulation or severe turtoasitas. Direct action stenting can reduce the time action / ischemic time, reduce radiation, the use of contrast, reducing costs.

Myocardial Revascularization

There are two ways that have proven good revascularization in stable coronary heart disease due to atherosclerotic coronary revascularization action ie surgery, Coronary Bypass Surgery (Coronary Artery Bypass Surgery = CABG) and Percutaneous Intervention (PCI = Percutneous Coronary Intervention).

Lately both methods has progressed rapidly in the introduction of the action, off pump with minimally invasive surgery and drug eluting stents (DES).Revascularization goal is to improve survival or prevent infarction or eliminate symptoms. Where the action is selected, depending on the risk and patient complaints. 

Indications for Revascularization

Generally, patients who have indications for coronary arteriography and actions performed catheterization that showed a narrowing of the coronary arteries is a potential candidate for myocardial revascularization action.

In addition, the act of revascularization performed on the patient, if :

a. Treatment failed to control the patient's complaints.

b. Non-invasive test results indicate a risk of infarction.

c. Encountered at high risk for the incidence and mortality.

d. Patients prefer the intervention compared with usual treatment and fully understand the risks of the treatment given to them. 

Actions CABG Surgery

Surgery is better if done in comparison with the treatment, on the circumstances : 

a. Significant stenosis (≥ 50%) in the area left to play. (LM).

b. Significant stenosis (≥ 70%) in the region proximal to the 3 major coronary arteries.

c. Significant stenosis in two main areas, including coronary artery stenosis, a high enough level in the proximal region of the left anterior descending coronary artery.

Pharmacological Treatment in Patients with Coronary Heart Disease

 Low-dose aspirin.

From various studies have shown that aspirin is still the main drug for the prevention of thrombosis. Meta-analysis showed that a dose of 75-150 mg have similar effectiveness when compared with larger doses. Recommended for all patients were given aspirin except when contraindicated found. In addition aspirin is also recommended given the long term, but keep in mind the side effects of gastrointestinal irritation, bleeding and allergies. Cardioaspirin provide a more minimal side effects compared with other aspirin.

   Clopidogrel dan Ticlopidine Thienopyridine

an ADP antagonist and inhibits platelet aggregation. Clopidogrel is more indicated in patients with aspirin resistance or intelorensi against. AHA / ACC guidelines include a combination of aspirin and clopidogrel should be given to patients with stent implantation, more than 1 month for bare metal stent, 3 months for sirolimus eluting stents, and over 6 months for paclitaxel-eluting stents.

  Cholesterol-lowering drugs

Treatment with statins are used to reduce the risks to both primary prevention and secondary prevention. Various studies have shown that statins can reduce complications by 39% (Heart Protection Study), Ascott-LLA atorvastatin for primary prevention of coronary heart disease in post-hypertension. Than as a cholesterol-lowering statins also have other mechanisms (pleiotropic effect) that can act as an anti-inflammatory, anti-thrombotic and others. Giving atorvastasin 40 mg for one week can reduce the myocardial damage caused by the action. The target reduction in LDL cholesterol is <100 mg / dl and in patients at high risk. Patients with coronary heart disease is recommended lowering LDL cholesterol <70 mg / dl.

  ACE-Inhibitor/ARB

The role of ACE-I as a cardio protection for secondary prevention in patients with coronary heart disease has been demonstrated from various studies ai, HOPE study, EUROPE study and others. If intolerance to ACE-I can be replaced with ARB.

  Nitrate

Nitrate is generally recommended, because nitrate has venodilator effect, so that myocardial preload and left ventricular end volume decreases and thus the amount of myocardial oxygen consumption also decreases. Nitrates also dilate blood vessels to be normal and atherosclerotic experience. Raising the collateral blood flow and inhibits platelet aggregation. When an attack of angina does not respond to short-term nitrate, then be aware of the existence of myocardial infarction. Side effects of this drug are headache and flushing.