Prevenção secundária de infarto

Overview:
recommendations for secondary prevention of coronary artery disease (CAD) are synthesized from recommendations of American College of Cardiology Foundation/American Heart Association (ACCF/AHA), European Society of Cardiology (ESC), and National Institute for Health and Care Excellence (NICE); generally in agreement and details are provided where inconsistent.

comprehensive cardiovascular rehabilitation program (including exercise, education, and facilitation of risk reduction strategies)

dietary recommendations include:
limiting intake of saturated fats (< 7%-10%) and trans-fatty acids (< 1%)
increased consumption of fresh fruits and vegetables
limiting alcohol consumption to < 2-3 drinks/day in men or < 1-2 drinks/day in women
sodium restriction  (< 5 g/day)
increased dietary fiber intake  (30-35 g/day)

physical activity
aerobic physical activity uniformly recommended with recommended durations ranging from 20 minutes to 60 minutes/day and recommended frequency ranging from ≥ 3 times/week to 7 days/week
gradual increase in physical activity (light-intensity exercise or supplementing daily lifestyle activities) recommended for sedentary patients
consider resistance training ≥ 2 days/week
sexual activity is reasonable for patients at low risk of cardiovascular complications  and who can exercise without ischemic manifestations

weight management - achieve and maintain
body mass index (BMI) 18.5-24.9 kg/m2
waist circumference < 40 inches (102 cm) for men, < 35 inches (89 cm) for women

lipid management
statin therapy recommended for patients with clinical atherosclerotic cardiovascular disease
statins reduce mortality, myocardial infarction, and stroke in adults with CAD , although reduction of mortality and stroke in women is based on limited data
ACCF/AHA recommends high-intensity statin therapy (such as atorvastatin 80 mg/day or rosuvastatin 20-40 mg/day), unless contraindicated or increased risk for statin-associated adverse effects, in patients < 75 years old with clinical atherosclerotic cardiovascular disease
NICE recommends starting with atorvastatin 80 mg/day, or lower dose if potential drug interactions or high risk of adverse effects
treatment targets no longer recommended by ACCF/AHA; ESC recommends low-density lipoprotein (LDL) cholesterol < 1.8 mmol/L (< 70 mg/dL); NICE recommends > 40% reduction in non-high-density lipoprotein (non-HDL) cholesterol
fibric acid derivatives may reduce coronary mortality and myocardial infarction in some patients with CAD
gemfibrozil reduces risk for myocardial infarction and possibly stroke and coronary mortality in patients with CAD and low HDL cholesterol
bezafibrate does not appear to reduce clinical outcomes for all CAD patients but may be effective for CAD patients with metabolic syndrome or triglycerides ≥ 200 mg/dL (2.3 mmol/L)

diabetes management may include consideration of target HbA1c < 7%

smoking
at every visit, advise every tobacco user to quit
avoid environmental exposure
assist with smoking cessation support (counseling, pharmacotherapy, and/or smoking cessation services)

antiplatelet therapy
aspirin 75-162 mg/day recommended for all patients with CAD unless contraindicated
clopidogrel 75 mg once daily recommended as alternative for patients intolerant of or allergic to aspirin
dual antiplatelet therapy (P2Y12 inhibitor plus aspirin) recommended after acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) with stent placement
P2Y12 inhibitor options include clopidogrel 75 mg once daily, prasugrel 10 mg once daily, and ticagrelor 90 mg twice daily
recommended duration of P2Y12 inhibitor after stent placement
≥ 12 months following ACS and following drug-eluting stents for non-ACS indication
≥ 1 month and ideally for up to 12 months following bare-metal stent for non-ACS indication

renin-angiotensin-aldosterone system inhibitors
angiotensin-converting enzyme (ACE) inhibitors recommended indefinitely, unless contraindicated, for all patients with atherosclerotic cardiovascular disease and any of left ventricular ejection fraction ≤ 40%, hypertension, diabetes, chronic kidney disease
reasonable to use ACE inhibitors in all other patients with atherosclerotic cardiovascular disease
ACE inhibitors lower rates of mortality, myocardial infarction, and hospital admission for heart failure in patients with CAD WITH and WITHOUT left ventricular dysfunction or heart failure
angiotensin II receptor blockers (ARBs) recommended for patients intolerant of ACE inhibitors
aldosterone blockade recommended for post myocardial infarction patients with all of heart failure and/or diabetes, already receiving therapeutic doses of ACE inhibitor plus beta blocker, left ventricular ejection fraction ≤ 40%, no significant renal dysfunction, no hyperkalemia

beta blockers recommended, unless contraindicated, for patients with
heart failure or prior myocardial infarction with left ventricular ejection fraction ≤ 40%; beta blockers for at least 6 months may reduce mortality after myocardial infarction although not statistically significant in contemporary observational study
left ventricular ejection fraction ≤ 40% without heart failure or prior myocardial infarction
prior acute coronary syndrome with normal left ventricular function
all other patients with coronary or other vascular disease

antihypertensive therapies
target blood pressure < 140/90 mm Hg recommended for most patients; in patients with CAD reaching systolic blood pressure ≤ 130 mm Hg appears associated with reduced risk of heart failure and stroke but increased risk of hypotension
initial antihypertensive drug choice suggestions include use of ACE inhibitors in patients with CAD  and beta blockers following myocardial infarction

annual influenza vaccination recommended

interventions which are not recommended for secondary prevention include
hormone replacement therapy
antioxidant vitamins such as vitamin E and/or vitamin C supplements
folic acid
omega-3 fatty acid supplements as they appear ineffective for secondary prevention
chelation therapy (IV infusion of ethylenediaminetetraacetic acid [EDTA])

Referência:
Dynamed: "Secondary prevention of coronary artery disease" - Disponível em:http://web.ebscohost.com/dynamed/detail?sid=bd8cedb4-3d4c-42bc-ae7e-ac7cf93f74af%40sessionmgr114&vid=0&hid=102&bdata=Jmxhbmc9cHQtYnImc2l0ZT1keW5hbWVkLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=dme&AN=900316