If you have had a heart attack or episodes of angina, or diagnostic tests reveal significant deposits in your coronary arteries, you have CAD and need to take "secondary prevention" measures. People in "primary prevention," who have neither evidence of CAD nor a history of heart problems, can help stave off heart problems by heeding the advice in the section on preventing CAD. If you are in need of secondary prevention, you have a known risk that must be managed. This section explains what that involves.
The biggest single difference between preventing first-time heart problems and managing known CAD is the emphasis your physician will place on pushing down your LDL cholesterol—the "bad" cholesterol. The goal is achieving a level below 100 milligrams per deciliter (mg/dL). Even lower is better. For someone at very high risk because of diabetes, a previous heart attack, or other risk factors, the target for LDL was changed in 2004 by an advisory panel to below 70 mg/dL.
To push down LDL, most people in secondary prevention automatically are given a statin drug, which blocks production of a liver enzyme that the body uses to manufacture cholesterol. Indeed, many physicians believe in starting secondary-prevention patients at a high dose to push down their LDL quickly. (Studies also have found that a large percentage of patients who start at a low dose never get raised to a higher one, because they—or their doctor—don't follow up.)
Statins also raise HDL cholesterol to some extent. HDL cholesterol, the "good" kind, acts to remove LDL cholesterol from the body, so is thought to protect against heart disease.
A small number of people placed on a statin experience side effects, such as initial or lasting muscle or joint discomfort or weakness, and the incidence of such side effects tends to rise at higher doses. In a very small number of people, the problems are so severe that they are temporarily or even permanently incapacitated.
Generally speaking, the higher the dose, the greater the likelihood of side effects, so people need to be particularly tuned in to the signals their body might send, and report any difficulties to their physician. The dose might need to be adjusted, or switching to another statin might eliminate the problem.
Because statins interfere with the liver's production of a particular enzyme, your blood will need to be checked every three to six months to be on guard for changes in liver function.
Statins do not take the place of diet and lifestyle changes to lower your cholesterol. You may need to take a statin for the rest of your life.
Based on your full lipid profile, your doctor may want to try other drugs that optimize your LDL, HDL, and triglyceride levels.
A daily low dose of aspirin—a baby aspirin or half an adult aspirin—dramatically reduces the incidence of angina and heart attacks, and is now routinely prescribed for people in secondary prevention. The conventional explanation is that the aspirin reduces clotting, although how such a low dose has that effect has long been unclear. Researchers now suspect that its more important effect is to interfere with the inflammatory process that is part of ongoing CAD. A baby aspirin or half of an adult aspirin is recommended.
If you have had a heart attack or a stent in your coronary artery, your physician may prescribe a powerful antiplatelet agent known as clopidogrel to prevent further episodes of heart attack or to keep the stent open. In these situations, the use of both aspirin and clopidogrel may be needed, and it is best to follow the recommendations of your treating physician.
Your physician will also ask you to reduce your risks by changing the way you live, emphasizing good habits and discouraging bad ones. The National Cholesterol Education Program administered by the federal government refers to this effort as therapeutic lifestyle changes (TLC), and considers TLC the first line of defense for people in primary prevention. For you, however, TLC is but one weapon, albeit an important one, in a larger arsenal.
Among the big guns in TLC, the most powerful is to quit smoking. Even a single cigarette a day significantly raises the risk of a heart attack. But other changes are important, too:
In some cases, lifestyle changes and medications are not enough to treat your coronary artery disease, and interventional or surgical therapies may be required to prevent damage to your heart. The treatment section has more information on these therapies.
The section on preventing CAD has more information and advice concerning smoking, diet, exercise, and weight control.
Last reviewed on 3/9/2011
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