Acute Coronary Syndrome – long term management

Dietary Therapy

Reduce Intake of:

• Saturated fats:
  • <7% of total daily calories
• Trans fatty acids:
  • <1% of total daily calories
• Cholesterol:
  • <200 mg/day

Recommended Diet Composition

Plant-Based Foods (daily inclusion encouraged):

• Vegetables
• Fruits
• Legumes:
  • Dried peas
  • Dried beans
  • Lentils

Grain-Based Foods:

• Preferably wholegrain:
  • Wholemeal bread
  • Brown rice
  • Wholegrain pasta and noodles

Animal-Based Foods (consume in moderation):

• Lean meats (e.g., trimmed beef, kangaroo)
• Poultry without skin
• Fish (especially oily fish ≥2 serves/week)
• Reduced-fat dairy products

Fats:

• Prefer unsaturated fats:
  • Polyunsaturated fats (e.g., sunflower, soybean, safflower oils)
  • Monounsaturated fats (e.g., olive oil, avocado, nuts)

Additional Support

• Referral to a dietitian:
  • For individualised meal planning
  • Behavioural strategies to support dietary adherence
  • Address comorbidities (e.g., diabetes, dyslipidaemia, hypertension)

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🔥 Smoking Cessation

Goal: Complete cessation; eliminate exposure to passive smoke.

Impact: Smoking cessation reduces all-cause mortality by up to 50%.

Assessment: Ask about smoking status at every visit.

Pharmacotherapy:

• First-line: Nicotine Replacement Therapy (NRT)
  • Safe in stable CVD (e.g., post-MI, stable angina).
  • Avoid in recent MI, unstable angina, severe arrhythmias.
• Second-line: Bupropion
  • Reasonable in stable CVD; avoid in recent ACS (safety unproven).
• Combination: NRT + bupropion for selected patients with high relapse risk.

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🩺 Blood Pressure Management

Target: <130/80 mmHg

Initiate therapy: If SBP >120–130 mmHg, unless symptomatic hypotension.

Investigate:

• Exclude secondary hypertension in young or treatment-resistant patients.
• Refer if SBP ≥180 mmHg or DBP ≥110 mmHg.

Lifestyle Modifications:

• Weight loss, sodium restriction, physical activity, alcohol moderation, DASH-style diet.

Proteinuria:

• Non-diabetic: If ≥1+ on dipstick, perform spot protein/creatinine ratio or 24-hour collection.
• Diabetic: Use urinary ACR; if elevated, follow up with 24-hour quantification.

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🏃‍♂️ Physical Activity & Cardiac Rehabilitation

Assessment

• Evaluate patient’s baseline physical activity habits
• Consider the severity of cardiovascular disease and presence of comorbidities

Conditions Requiring Clinical Assessment and Supervision

• Unstable angina
• Uncontrolled hypertension
• Severe aortic stenosis
• Uncontrolled diabetes mellitus
• Complicated acute myocardial infarction (within 3 months)
• Untreated heart failure or cardiomyopathy
• Symptoms on low exertion (e.g., chest discomfort, dyspnoea)
• Resting heart rate >100 bpm

Discussion with Patient

• Discuss current physical activity needs and goals
• Explore barriers to participation
• Encourage safe and regular physical activity

Guidelines for Physical Activity

• Provide written instructions for physical activity (e.g., light-moderate walking)
• Start with:
  • Low-intensity activity (e.g., slow walking)
  • Short duration (5–10 minutes)
  • 1–2 types of activities initially
• Gradually increase:
  • Duration and frequency
  • Intensity over several weeks (as tolerated)
  • Variety of activities

Activity Recommendations

• Avoid vigorous activity in patients with CHD unless cleared by specialist
• Aerobic activity:
  • 30–60 minutes of moderate-intensity aerobic activity (e.g., brisk walking)
  • On ≥5 days/week, ideally daily
• Daily lifestyle activity:
  • Encourage incidental activity (e.g., walking, gardening, housework)

Cardiac Rehabilitation

• Refer to a cardiac rehabilitation program when available, particularly:
  • Post-acute coronary events
  • High-risk patients needing supervision

Goals

• Initiate at low intensity
• Gradually build up to:
  • 30–60 minutes of moderate aerobic activity most days
• Promote sustained and realistic increases in daily physical activity

Behavioural Therapy:

• Formal programs focused on:
  • Self-monitoring
  • Goal setting
  • Problem-solving
  • Cognitive restructuring
  • Relapse prevention

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⚖️ Weight Management

Anthropometric Targets

• Body Mass Index (BMI):
  • Target range: 18.5 to 24.9 kg/m²
• Waist Circumference (WC):
  • Women: <89 cm
  • Men: <102 cm

Management Approach

• Initial Goal:
  • Aim for 5% to 10% reduction in baseline body weight
• If successful:
  • Consider further weight reduction, based on clinical indication and patient capacity

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💉 Type 2 Diabetes Mellitus

HbA1c Target: ≤7% (individualised)
Rationale: Glycaemic control reduces risk of microvascular complications and may modestly reduce macrovascular events.

Class	Example	Rationale
SGLT2 inhibitors	Empagliflozin, Dapagliflozin	Reduce HF hospitalisation, CV death, progression of CKD.
GLP-1 receptor agonist	Semaglutide (2.4 mg weekly)	CV benefit (SELECT trial), weight loss, anti-inflammatory effects. Appropriate in non-diabetics with obesity.

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💊 Pharmacological Therapy Summary

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1. Antiplatelet Therapy

1. Aspirin Monotherapy

• Aspirin 100–150 mg daily should be:
  • Continued indefinitely post-ACS unless:
    • Not tolerated (e.g., allergy, GI intolerance)
    • Indication for anticoagulation (e.g., atrial fibrillation)
• If aspirin-intolerant or allergic:
  • Use clopidogrel 75 mg daily as an alternative

2. Dual Antiplatelet Therapy (DAPT)

(Aspirin + P2Y12 Inhibitor: clopidogrel, prasugrel, ticagrelor)

• Indicated for all patients post-ACS (STEMI/NSTEMI/UA), regardless of:
  • PCI with stent
  • Medical management alone
• Duration: Up to 12 months
• Consider extended DAPT (>12 months) if:
  • High ischaemic risk (e.g., prior MI, complex stenting)
  • Low bleeding risk
• Consider early cessation (<12 months) if:
  • High bleeding risk outweighs benefit

3. P2Y12 Inhibitor Options After ACS/PCI

• Clopidogrel 75 mg daily
• Prasugrel 10 mg daily (5 mg if ≥75 yrs or <60 kg)
• Ticagrelor 90 mg BD
• Used in combination with aspirin for 12 months post:
  • Drug-eluting stents (DES)
  • Bare-metal stents (BMS)

4. Coronary Artery Bypass Grafting (CABG)

• Start aspirin within 6 hours post-op to:
  • Reduce saphenous vein graft occlusion
• Continue long-term unless contraindicated

5. Stroke/TIA with Carotid or Vertebral Atherosclerosis

• Acceptable regimens:
  • Aspirin alone: 75–325 mg daily
  • Clopidogrel alone: 75 mg daily
  • Aspirin + ER dipyridamole: 25 mg + 200 mg BD

6. Symptomatic Peripheral Artery Disease (PAD)

• Use antiplatelet monotherapy:
  • Aspirin 75–325 mg daily
  • OR Clopidogrel 75 mg daily

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STATINS

• Initiate high-potency statin therapy during ACS admission (regardless of baseline LDL-C):
  • Atorvastatin 40–80 mg daily
  • Rosuvastatin 20–40 mg daily
• Continue or intensify existing therapy post-ACS as appropriate
• Reassess lipids (TC, LDL-C) at 4–6 weeks post-initiation or dose escalation
• Adjust/add non-statin agents if LDL-C targets not achieved

2. Ezetimibe (Add-On Therapy)

• Add ezetimibe 10 mg daily if LDL-C targets are not met with maximally tolerated statin
• Mechanism: inhibits intestinal cholesterol absorption

3. PCSK9 Inhibitors

• Consider if LDL-C remains elevated despite maximal statin ± ezetimibe
• Agents:
  • Alirocumab (Praluent)
  • Evolocumab (Repatha)
  • Inclisiran (Leqvio – siRNA, PBS-listed Dec 2023)
• Benefits:
  • Reduce LDL-C by up to 60%
  • Decrease MI, stroke, revascularisation, and vascular death

4. Triglyceride-Specific Agents

• Icosapent ethyl 2 g BD (VASCEPA®) if:
  • Fasting TG ≥ 1.7 mmol/L
  • LDL 1.0–2.6 mmol/L despite statin ± ezetimibe
  • PBS-listed 2024 in combination with statin
• Fibrates (e.g., fenofibrate 145 mg) or omega-3 ethyl esters if:
  • TG > 5 mmol/L (consider for cardiovascular risk)
  • TG > 10 mmol/L (for pancreatitis prevention)

✅ Special Populations

Younger Patients (Men <55, Women <60 with ACS)

• Use Dutch Lipid Clinic Network (DLCN) score to assess for familial hypercholesterolaemia (FH)
  • If score suggests FH:
    • Refer for genetic testing
    • Cascade screen family members
    • Start statin therapy in relatives if needed

Women

• Often under-prescribed statins post-ACS despite equal benefit
• Ensure statins are prescribed in all women at high vascular risk

Older Adults

• Offer statins in those with occlusive vascular disease (e.g., prior MI)
• Benefit: reduces risk of recurrent vascular events
• Assess frailty, polypharmacy, life expectancy before initiating

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2. ACE Inhibitors / ARBs

1. ACE Inhibitors (First-line)

Indications:

• Should be started early and continued indefinitely in patients with:
  • Left ventricular ejection fraction (LVEF) ≤40%
  • Hypertension
  • Diabetes mellitus
  • Chronic kidney disease (CKD)

Common Agents and Dosing:

• Ramipril:
  • Start: 2.5 mg BD
  • Target: 5–10 mg BD
• Perindopril:
  • Start: 2.5 mg daily
  • Target: 5–10 mg daily

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2. ARBs (Alternative if ACEI-intolerant)

Indications:

• Use in patients with:
  • Heart failure
  • Post-MI with LVEF ≤40%
  • Intolerance to ACE inhibitors (e.g., cough, angioedema)

Common Agent and Dosing:

• Valsartan:
  • Start: 80 mg BD
  • Target: 160 mg BD

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β-Blocker

Indications

• All patients with:
  • Left ventricular systolic dysfunction (LVEF ≤40%)
  • Heart failure OR
  • Prior myocardial infarction (MI)
• Unless contraindicated (e.g., bradycardia, severe asthma, advanced AV block)

(Only these have mortality benefit in heart failure and post-MI)

Drug	Starting Dose	Target Dose
Metoprolol CR/XL	23.75 mg daily	Up to 200 mg daily
Carvedilol	6.25 mg twice daily	Up to 25 mg twice daily
Bisoprolol	1.25 mg daily	Up to 10 mg daily

Duration of Therapy

• In patients with normal LV function post-MI/ACS:
  • Continue β-blocker therapy for at least 3 years
• In those with LV dysfunction (LVEF ≤40%) or HF:
  • Continue indefinitely, as tolerated

Chronic Use Consideration

• May be considered in patients with coronary artery disease or other vascular disease for:
  • Anti-anginal effects
  • Secondary prevention

Monitor for:

• Bradycardia, hypotension
• Worsening heart failure symptoms
• Bronchospasm in at-risk individuals

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SGLT-2 Inhibitors (Post-ACS Therapy)

✅ Recommendations:

• Indicated for patients with:
  • Type 2 diabetes and established CVD
  • Heart failure with reduced ejection fraction (HFrEF)
  • CKD with or without diabetes
• May also benefit non-diabetic patients with heart failure or CKD

Agents and Dosing:

• Empagliflozin: 10 mg daily (↑ to 25 mg if tolerated)
• Dapagliflozin: 10 mg daily

Benefits:

• Reduces CV mortality, hospitalisation for HF
• Renal protective effects

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Semaglutide (GLP-1 RA) in Obesity and CVD

✅ Recommendations:

• Consider in overweight or obese patients post-ACS without diabetes if:
  • BMI ≥30 kg/m² or ≥27 kg/m² with comorbidity
  • Established CVD or multiple risk factors

Dosing:

• Semaglutide 2.4 mg SC weekly

🧪 SELECT Trial Highlights:

• Population: Adults with CVD, obesity, no diabetes
• Reduced risk of composite outcome:
  • CV death, nonfatal MI, nonfatal stroke
  • HR 0.80 (95% CI 0.72–0.90)

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Colchicine Therapy in ACS

✅ Recommendations:

• May be considered selectively in high-risk post-ACS patients with:
  • Persistent inflammation (e.g., elevated CRP)
  • Not routinely recommended

🧪 Evidence Summary:

• Some trials show ↓ risk of:
  • Stroke
  • Coronary revascularisation
• No consistent benefit for:
  • All-cause mortality
  • Cardiovascular death
  • Recurrent MI
  • Unplanned revascularisation
• Recent RCT post-MI: no significant benefit
• Further meta-analyses ongoing to clarify role

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🧠 Preventive and Supportive Strategies in Cardiovascular Disease

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1. Influenza Vaccination

• All patients with cardiovascular disease (CVD) should receive an annual influenza vaccine
• Rationale:
  • Reduces risk of influenza-related complications
  • May reduce CVD events triggered by systemic inflammation

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2. Depression Screening

• Reasonable to screen for depression in patients with CVD, especially post-ACS
• Only where collaborative care is available, involving:
  • Primary care physician
  • Case manager
  • Mental health specialist (e.g., psychologist or psychiatrist)

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3. Outpatient Cardiac Rehabilitation Program

Program Components:

✅ Supervised Exercise

• Progressive physical activity tailored to individual fitness and risk profile
• Includes:
  • Aerobic training
  • Resistance/strength training
  • Flexibility/stretching
• Regular monitoring of vitals (e.g., BP, HR) during sessions
• Goals:
  • Gradual improvement in cardiovascular fitness
  • Achievement of personalised activity targets

✅ Education

• Focus on lifestyle modification:
  • Heart-healthy diet
  • Smoking cessation
  • Weight and blood pressure control
  • Stress management strategies

✅ Psychosocial Counselling

• Helps patients:
  • Cope with emotional impact of CVD
  • Address psychological stressors
  • Access support networks

✅ Multidisciplinary Team Involvement

• Collaborative input from:
  • Cardiologists
  • Nurses
  • Exercise physiologists
  • Dietitians
  • Psychologists or mental health professionals