Primary prevention
The most important preventive actions involve combined dietary and lifestyle modifications (stopping smoking; increasing physical activity; losing weight; increasing consumption of fish, fruits, vegetables, fiber, and nuts; reducing salt intake).[14][62] The American Heart Association (AHA) recommends using the ‘'5A model’' (assess, advise, agree, assist, arrange) as a framework for counseling patients in behavioral change to reduce cardiovascular disease (CVD) risk.[63]
Smoking is a leading preventable cause of disease, disability and death; even low levels of smoking increase risk of atherosclerotic cardiovascular disease (ASCVD).[8][14][17] Support programs, medications, and alternative therapies are available. In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended.[14][17] Secondhand smoke exposure should be avoided.[14]
Routine and/or opportunistic assessment of cardiovascular risk factors with calculation of 10-year risk of ASCVD should be used to guide decisions on treatment with preventive therapies (e.g., statins).[14][64] [ Pooled Cohort Equations CV Risk Calculator Opens in new window ]
The US Preventive Services Task Force recommends starting a statin for primary prevention in adults ages 40-75 years without ASCVD but who have one or more cardiovascular risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk of 10% or greater.[65] Those with 10-year risk between 7.5% and 10.0% may selectively be offered a statin.[65] For patients 76 years or older there is insufficient evidence to recommend for or against starting a statin for primary prevention.[65]
Aspirin is no longer routinely recommended for primary prevention but may be considered in selected patients for whom the absolute cardiovascular benefit outweighs the absolute risk of increased bleeding.[66]
Secondary prevention
Systolic blood pressure should be maintained at <140 mmHg and diastolic blood pressure at <80 mmHg, LDL-cholesterol <70 mg/dL, and HbA1c <7% (or according to individualized target).[171] Smoking cessation should be actively encouraged.[17][153][154] In overweight/obese patients weight loss is associated with an improvement in the constituent elements of the metabolic syndrome, as well as a reduction in the pathologic aspects implicated in coronary artery disease (CAD); endothelial dysfunction and inflammation.[28] Patients should be advised to achieve/maintain a healthy weight.[3] Nonadherence to statin therapy and failure to achieve lipid targets is associated with an increased cardiovascular mortality following acute MI.[220] Patients should be counseled on the importance of medication adherence.
Cardiorespiratory fitness is a strong predictor of outcome following an acute MI.[3] Patients should be encouraged to partake in regular aerobic and resistance exercise in addition to the exercise program of cardiac rehabilitation; in patients with CAD, there is a direct correlation between the volume of moderate to vigorous physical activity and reduction in cardiovascular risk and mortality.[35][36]
The American College of Cardiology/American Heart Association guidelines recommend that, where available, cardiac rehabilitation/secondary prevention programs are provided for patients with STEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is warranted.[152][153][154]
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[Evidence A] Systematic review evidence has shown exercise-based cardiac rehabilitation helps to improve outcomes in people with coronary heart disease.[155]
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