Chapter 5 Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular DiseaseWeight management
Goal: BMI: 18.5 to 24.9 kg/m^2
Waist circumference: men less than 40 inches
(102 cm), women less than 35 inches (89 cm).
1 It is useful to assess BMI and/or waist circumfer-
ence on each visit and consistently encourage weight
maintenance/reduction through an 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/
m^2. I (B)
2 The initial goal of weight-loss therapy should be
to reduce body weight by approximately 10% from
baseline. With success, further weight loss can be
attempted if indicated through further assessment.
I (B)
3 If waist circumference (measured horizontally at
the iliac crest) is 35 inches (89 cm) or greater in
women and 40 inches (102 cm) or greater in men,
it is useful to initiate lifestyle changes and consider
treatment strategies for metabolic syndrome as indi-
cated. I (B)
Diabetes management
Goal: HbA1c less than 7%
1 It is recommended to initiate lifestyle and phar-
macotherapy to achieve near-normal HbA1c.
I (B)
2 Beginning vigorous modifi cation of other risk
factors (e.g., physical activity, weight management,
blood pressure control, and cholesterol manage-
ment as recommended above) is benefi cial.
I (B)
3 Coordination of diabetic care with the patient’s
primary care physician or endocrinologist is benefi -
cial. I (C)
Antiplatelet agents/anticoagulants: aspirin
1 For all post-PCI stented patients without allergy
or increased risk of bleeding, aspirin 162 mg to
325 mg daily should be given for at least 1 month
after BMS implantation, 3 months after sirolimus-
eluting stent implantation, and 6 months after pacli-
taxel eluting stent implantation, after which
long-term aspirin use should be continued indefi -
nitely at a dose of 75 mg to 162 mg daily. I (B)
2 In patients for whom the physician is concerned
about risk of bleeding, lower-dose 75 mg to 162 mg
of aspirin is reasonable during the initial period after
stent implantation. IIa (C)Antiplatelet agents/anticoagulants: clopidogrel
1 For all post-PCI patients who receive a DES, clop-
idogrel 75 mg daily should be given for at least
12 months if patients are not at high risk of bleeding.
For post-PCI patients receiving a BMS, clopidogrel
should be given for a minimum of 1 month and
ideally up to 12 months (unless the patient is at
increased risk of bleeding; then it should be given
for a minimum of 2 weeks). I (B)
2 For all post-PCI non-stented STEMI patients,
treatment with clopidogrel should continue for at
least 14 days. I (B)
3 Long-term maintenance therapy (e.g., 1 year)
with clopidogrel (75 mg per day orally) is reasonable
in STEMI and non-STEMI patients who undergo
PCI without reperfusion therapy. IIa (C)Antiplatelet agents/anticoagulants: warfarin
1 Managing warfarin to an INR equal to 2.0 to 3.0
for paroxysmal or chronic atrial fi brillation or fl utter
is recommended, and in post-MI patients when
clinically indicated (e.g., atrial fi brillation, left ven-
tricular thrombus). I (A)
2 Use of warfarin in conjunction with aspirin and/
or clopidogrel is associated with an increased risk of
bleeding and should be monitored closely. I (B)
3 In patients requiring warfarin, clopidogrel, and
aspirin therapy after PCI, an INR of 2.0 to 2.5 is
recommended with low dose aspirin (75 mg to
81 mg) and a 75 mg dose of clopidogrel. (1 C)Renin–angiotensin–aldosterone system
blockers: ACE inhibitors
1 ACE inhibitors should be started and continued
indefi nitely in all patients with LVEF less than or
equal to 40% and for those with hypertension, dia-
betes, or chronic kidney disease, unless contraindi-
cated. I (A)
2 ACE inhibitors should be started and continued
indefi nitely in patients who are not at lower risk,
defi ned as those with normal LVEF in whom cardio-
vascular risk factors are well controlled and revascu-
larization has been performed), unless
contraindicated. I (B)
3 Among lower risk patients (i.e., those with normal
LVEF in whom cardiovascular risk factors are