The document discusses approaches to preventing cardiovascular disease, including primary and secondary prevention. It outlines various risk factors and strategies for prevention at both the population level and for high-risk individuals. These include promoting smoking cessation, controlling blood pressure and lipids, increasing physical activity, maintaining a healthy diet and weight, and using medication like aspirin to reduce the risk of cardiovascular events.

1. Preventation of Coronary
Vascular Disorders
By
ZAIDI BAQER

2. Approaches to Primary and Secondary
Prevention of CVD
• Primary prevention involves prevention of
onset of disease in persons without
symptoms Primordial prevention involves
the prevention of risk factors causative the
disease, thereby reducing the likelihood of
development of the disease.
• Secondary prevention refers to the
prevention of death or recurrence of
disease in those who are already
symptomatic

3. Risk Factor Concepts in Primary Prevention
Nonmodifiable risk factors include age, sexc,
race, and family history of CVD, which can
identify high-risk populations Behavioral risk
factors includes sedentary lifestyle, unhealthful
diet, heavy alcohol or cigarettes consumption
Physiological risk factors include hypertension,
obesity, lipid problems, and diabetes, which
may be a consequence of behavioral risk
factors.

4. Population vs. High-Risk Approach Risk factors, such as
cholesterol or blood pressure, have a wide bell-
shaped distribution, often with a “tail” of high values.
The “high-risk approach” involves identification and
intensive treatment of those at the high end of the
“tail”, often at greatest risk of CVD, reducing levels to
“normal”. But most cases of CVD do not occur
among the highest levels of a given risk factor, and in
fact, occur among those in the “average” risk group.
Significant reduction in the population burden of CVD
can occur only from a “population approach” shifting
the entire population distribution to lower
levels.Expected Shifts in Cholesterol Distribution from
High-Risk, Population, and Combined Approaches

5. Population and Community-Wide CVD Risk
Reduction Approaches Populations with high
rates of CVD are those with Western lifestyles
of high-fat diets, physical inactivity, and
tobacco use Targets of a population-wide
approach must be these behaviors causative of
the physiologic risk factors or directly causative
of CVD. Requires public health services such
as surveillance , education , organizational
partnerships (Singapore Declaration), and
legislation/policy (Anti-Tobacco policies)
Activities in a variety of community settings:
schools, worksites, churches, healthcare

6. • Guide to Primary Prevention of Cardiovascular
Diseases Risk Intervention Recommendations Smoking:
Ask about smoking status as part of routine Goal
evaluation. Reinforce nonsmoking status. complete
cessation Strongly encourage patient and family to stop
smoking. Provide counseling, nicotine replacement, and
formal cessation programs as appropriate. Blood pressure
Measure blood pressure in all adults at least every 2
control: years. Goal <140/90 mm Hg or Promote lifestyle
modification: weight control, <130/85 mm Hg physical
activity, moderation in alcohol intake, and if heart failure,
moderate sodium restriction. renal If blood pressure
140/90 mm Hg after

7. months of insufficiency lifestyle modification or
if initial blood pressure or diabetes>160/100
mm Hg or >130/85 mm Hg with heart failure,
renal insufficiency or diabetes, add blood
pressure medication. Individualize therapy to
patient's age, race, need for drugs with
specific benefits

8. • Secondary Prevention Goals and Management
Patients covered by these guidelines include
those with established coronary and other
atherosclerotic vascular disease, including
peripheral arterial disease, atherosclerotic
aortic disease, and carotid artery disease.

9. Classification of recommendations
Class I - Conditions for which there is evidence and/or
general agreement that a given procedure or treatment is
beneficial, useful, and effective
• Class II - Conditions for which there is conflicting evidence
and/or a divergence of opinion about the
usefulness/efficacy of a procedure or treatment
• Class IIa - Weight or evidence/opinion is in favor or
usefulness/efficacy
• Class IIb - Usefulness/efficacy is less well established by
evidence/opinion
• Class III - Conditions for which there is evidence and/or
general agreement that a procedure/treatment is not
useful/effective and in some cases may be harmful

10. • Preventation
• Smoking cessation
• The goal is complete cessation and no exposure to environmental
tobacco smoke.
• Ask the patient about tobacco use status at every visit. I (B)
• Advise every patient who uses tobacco to quit. I (B)
• Assess the patient’s willingness to quit using tobacco. I (B)
• Assist the patient by counseling and developing a plan for quitting. I
(B)
• Arrange follow-up, referral to special programs, or pharmacotherapy
(including nicotine replacement and bupropion). I (B)
• Urge the patient to avoid exposure to environmental tobacco smoke
at work and home. I (B)

11. • Blood pressure control
• The goal is BP < 140/90 mm Hg or < 130/80 mm Hg if the
patient has diabetes or chronic kidney disease.
• For all patients, initiate or maintain lifestyle modification,
weight control, increased physical activity, alcohol
moderation, sodium reduction, and increased consumption
of fresh fruits, vegetables, and low-fat dairy products. I (B)
• For patients with BP ≥140/90 mm Hg (or 130/80 mm Hg
for individuals with chronic kidney disease or diabetes), as
tolerated, add BP medication, treating initially with beta-
blockers and/or ACE inhibitors, with addition of other
drugs, such as thiazides, as needed to achieve goal blood
pressure. I (A

12. • Diet
• Diets that include nonhydrogenated unsaturated fats as
the predominant form of dietary fat, whole grains as the
primary form of carbohydrate, fruits and vegetables,
omega-3 fatty acids (from fish, fish oil supplements, or
plant sources) offer significant protection against coronary
heart disease.
• Light-to-moderate alcohol consumption (5-25 g/d) has
been significantly associated with a lower incidence of
cardiovascular and all-cause mortality in patients with
cardiovascular disease.

13. • Lipid management
• The goal is LDL cholesterol < 100 mg/dL; if triglyceride
levels are ≥200 mg/dL, non-HDL cholesterol should be <
130 mg/dL. (Non-HDL cholesterol is total cholesterol
minus HDL cholesterol.)
• The following measures should be taken for all patients:
• Start dietary therapy. Reduce the intake of saturated fats
(to < 7% of total calories), trans-fatty acids, and
cholesterol (to < 200 mg/d). I (B)
• Adding plant stanol/sterols (2 g/d) and viscous fiber (>10
g/d) will further lower LDL cholesterol level.
• Promote daily physical activity and weight management. I
(B)

14. • LDL cholesterol level should be < 100 mg/dL. I (A)
• Further reduction of LDL cholesterol level to < 70 mg/dL is reasonable. IIa
(A)
• If baseline LDL cholesterol level is 100 mg/dL, initiate LDL-lowering drug therapy. I
(A)
• If the patient is on treatment and LDL cholesterol is 100 mg/dL, intensify LDL-
lowering drug therapy (may require LDL-lowering drug combination [standard dose of
statin with ezetimibe, bile acid sequestrant, or niacin]). I (A)
• If baseline LDL cholesterol level is 70-100 mg/dL, treating to LDL cholesterol level of
< 70 mg/dL is reasonable. IIa (B)
• If triglyceride levels are 200-499 mg/dL, non-HDL cholesterol level should be < 130
mg/dL. I (B)
• Further reduction of non-HDL cholesterol level to < 100 mg/dL is reasonable. IIa
(B)
• Therapeutic options to reduce non-HDL cholesterol level are as follows:
• More intense LDL cholesterol-lowering therapy, I (B)
• Niacin (after LDL cholesterol–lowering therapy), IIa (B)
• Fibrate therapy (after LDL cholesterol–lowering therapy), IIa (B)

15. • Physical activity
• The goal of physical activity is 30 minutes, 7 days per week (minimum
5 d/w). The US guidelines for physical activity suggest low, moderate,
and high activity levels. A meta-analysis by Sattlemair et al attempted
to quantify these amounts and found that "some physical activity is
better than none" and "additional benefits occur with more physical
activity."[118]
• For all patients, assess risk with a physical activity history and/or an
exercise test to guide prescription. I (B)
• For all patients, encourage 30-60 minutes of moderate-intensity
aerobic activity (eg, brisk walking) on most, preferably all, days of the
week, supplemented by an increase in daily lifestyle activities (eg,
walking breaks at work, gardening, household work). I (B)
• Encourage resistance training 2 days per week. IIb (C)
• Advise medically supervised programs for high-risk patients (eg,
recent acute coronary syndrome or revascularization, heart failure). I
(B)

16. • Weight management
• The goal of weight management is body mass index of 18.5-24.9 kg/m2 and
waist circumference of < 40 inches in men and < 35 inches in women. The
American Heart Association released a Scientific Statement in 2011 regarding
weight management strategies for busy ambulatory surgery settings.[119]
• Assess body mass index and/or waist circumference on each visit and
consistently encourage weight maintenance or reduction through an appropriate
balance of physical activity, caloric intake, and formal behavioral programs when
indicated to maintain or achieve a body mass index between 18.5 and 24.9 kg/m
2. I (B)
• If waist circumference (measured horizontally at the iliac crest) is 35 inches in
women and 40 inches in men, initiate lifestyle changes and consider treatment
strategies for metabolic syndrome as indicated. I (B)
• 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)

17. • Antiplatelet agents and anticoagul
• Start aspirin 75-162 mg/d, and continue indefinitely in all patients
unless contraindicated. I (A) For patients undergoing coronary artery
bypass grafting, aspirin should be started within 48 hours after
surgery to reduce saphenous vein graft closure. Dosing regimens
ranging from 100-325 mg/d appear to be efficacious. Doses higher
than 162 mg/d can be continued for up to 1 year. I (B)
• Start and continue clopidogrel 75 mg/d in combination with aspirin for
up to 12 months in patients after acute coronary syndrome or
percutaneous coronary intervention with stent placement (at least 1
month, but ideally 12 months, for bare metal stent; at least 12 months
for drug-eluting stents). I (B) Patients who have undergone
percutaneous coronary intervention with stent placement should
initially receive higher-dose aspirin at 162-325 mg/d for 1 month for
bare metal stent, 3 months after sirolimus-eluting stent, 6 months
after paclitaxel-eluting stent, after which daily long-term aspirin use
should be continued indefinitely at a dose of 75-162 mg

18. • Renin, angiotensin, and aldosterone system
blockers
• Consider the following with ACE inhibitors:
• Start and continue indefinitely in all patients with left ventricular ejection fraction
≥40% and in those with hypertension, diabetes, or chronic kidney disease, unless
contraindicated. I (A)
• Consider for all other patients. I (B)
• Among lower-risk patients with normal left ventricular ejection fraction in whom
cardiovascular risk factors are well controlled and revascularization has been
performed, use of ACE inhibitors may be considered optional. IIa (B)
• Consider the following with angiotensin receptor blockers:
• Use in patients who are intolerant of ACE inhibitors and have heart failure or
have had an MI with left ventricular ejection fraction ≤40%. I (A)
• Consider in other patients who are intolerant of ACE inhibitors. I (B)
• Consider use in combination with ACE inhibitors in systolic dysfunction heart
failure. IIb (B)

19. • Beta-blockers
• Start and continue indefinitely in all patients who have had MI, ACS,
or LV dysfunction with or without heart failure symptoms, unless
contraindicated. l (A)
• Consider chronic therapy for all other patients with coronary or other
vascular disease or diabetes, unless contraindicated. lla (C)
• Influenza vaccination
• Patients with cardiovascular disease should have an influenza
vaccination. I (B