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Secondary Prevention of Ischemic Heart Disease and Stroke in Adults

[2014 update]

Introduction to this self-study CME activity

Purpose

Cardiovascular disease is the leading cause of death in the United States.   Ischemic heart disease accounts for 113 deaths per 100,000 population and cerebrovascular disease accounts for 39 deaths per 100,00, most of which are ischemic stroke.  Patients with ischemic heart disease (IHD), ischemic stroke, or transient ischemic attack (TIA) are at appreciably higher risk for subsequent cardiac and cerebrovascular events and mortality.  Several treatments and lifestyle changes for patients with IHD, ischemic stroke, or TIA have demonstrated large absolute risk reductions.  However, a number of studies have shown that effective secondary prevention does not occur for many patients and that only some aspects of secondary prevention are performed for many other patients. 

This guideline provides clinicians with an understanding and ability to implement a more comprehensive approach for secondary prevention of ischemic heart disease and stroke.  It summarizes secondary prevention recommendations grouped by:

 Lifestyle with Medication

  • Blood pressure control
  • Tobacco treatment
  • Lipid management
  • Diabetes management
  • Depression screening

 Medication

  • Antiplatelet agents & anticoagulants
  • b blockers in IHD      
  • Renin-angiotensin-aldosterone system blockers in IHD
  • Pain control (NSAID caution)
  • Immunization

 Lifestyle

  • Physical activity
  • Weight management
  • Nutrition
  • Supplements

Surgery

  • Carotid endarterectomy or stenting for symptomatic lesions
  • The key aspects of each prevention recommendation are summarized, operational information provided, and references provided to more detailed sources of information.  The summary and elaboration will help health care professionals provide high quality care by assuring that secondary prevention is comprehensive and that highest risk conditions are priorities for management.

 New aspects of care addressed in this update include:

Statin:

  • If ≤ 75 years old, prescribe high-intensity statin
  • If > 75 years old. consider moderate-intensity statin.

Stroke:

  • Now includes information on secondary prevention for ischemic stroke and transient ischemic attacks, including tips on management of patients with atrial fibrillation and carotid stenosis.  
  • For non cardioembolic stroke, use antiplatelet (aspirin, copidogril, or aspirin+diperdamole).  Aspirin + copidogril combination is not recommended.

New anticoagulants:

  • For patients with atrial fibrillation, warfarin is no longer the only oral anticoagulant available.
  • For stroke due to non-valvular atrial fibrillation, anticoagulants are preferred over anti-platelets.
  • Dabigtran, rivaroxaban, or apixaban are available options.

New antiplatelet agents.  Ticagrelol can be used for ACS post-stent in place of clopidogrel as well as prasugrel in appropriate patients.

Antiplatelet choice:

  • Recent ACS treated without angioplasty, in addition to aspirin add copidogril for up to 1 year.
  • Post PCI, use dual antiplatelet (aspirin plus P2Y12 inhibitor) in consultation with cardiologist for up to 1 year depending on stent type and stent indication, whether ACS vs CAD For patients with stroke or stable IHD (no event in the last 12 months), can stop anti-platelet if patient is started on warfarin

Symptomatic carotid stenosis >70%:  Surgery or stent plus medical management is recommended.

Audience

This self-study activity is appropriate for primary care clinicians and other health care providers who provide care for patients with IHD, stroke, and TIA.

Authors

Team Leaders

  • Ghazwan Toma, MD, MPH
    Family Medicine

Team Members

  • Eric E. Adelman, MD
    Neurology
  • R Van Harrison, PhD
    Medical Education
  • Robert V. Hogikyan, MD, MPH
    Geriatric Medicine
  • Thomas P. O’Connor, MD
    General Medicine
  • Michael P. Thomas, MD
    Cardiovascular Medicine

Author Disclosures

None of the authors have personal financial relationships with companies whose products are addressed in this CME activity.

Other Acknowledgements

UMHS Guidelines Oversight Team:

  • Grant M Greenberg, MD, MA, MHSA
  • R. Van Harrison, PhD

Literature Search Services:

  • Taubman Medical Library

Production of Internet format and website maintenance:

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA/PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was prepared for release in May 2014.  Credit may be awarded for a maximum of three years from its release date, specifically from May 2014 through April 2017.  Continuation of credit from that date depends on a thorough review of the content currency and accuracy.