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Treatment goals for patients with ischaemic heart disease

Prevention in Ischaemic Heart Disease (IHD)

Preventive measures in risk factor control, recommended for patients with ischaemic heart disease, are reviewed, according to the recent 6th Joint Task Force European Guidelines. They require multidisciplinary intervention to succeed in lifestyle changes, as well pharmacological optimization.



Ischaemic heart disease (IHD) is associated with multiple cardiovascular conditions or risk factors and consequently, treatment can be complex. Therefore, treatment deserves a comprehensive management approach, including pharmacotherapeutic and invasive or surgical therapies, professional lifestyle interventions based on behavioural models of change, with different strategies from more basic, family-based to more structured and complex modalities, depending on the cardiovascular risk assessment and on concomitant diseases (1). Risk factor management focusing on controlling related cardiovascular risk factors, including physical activity advice, psychosocial support and appropriate prescription of and adherence to cardio-protective drugs are integral to helping patients regain as full a life as possible and improve their quality of life.

Prevention should be started immediately after an ischaemic event; it should start during the acute phase and continued in the post-acute phase, and in fact: should continue for the rest of the patient’s life.

Beyond initial assessment, several preventive measures are recommended for IHD patients (Table 1). To favour continuity of care and prevention, a discharge schedule should be set up, according to the individual needs and preferences of the patient, to select and to arrange the next care setting and health care services, to promote patient and family preventive and education issues, to organize the follow-up, and to ensure medication reconciliation. A discharge report that includes patient’s functional status, medical history, baseline information, learning needs, care plans, and services provided should be given out.

Unfortunately, large proportions of IHD patients still do not achieve the lifestyle, risk factor and therapeutic targets (EUROASPIRE IV database). A confirmation of this, is the insufficient implementation of evidence-based guidelines on prevention.  Multidisciplinary teams or nurse-coordinated risk factor management may be of help in optimizing this.

CVD prevention strategies for IHD patients

This table is derived from 2016 ESC guidelines on Cardiovascular Disease Prevention in Clinical Practice.

  Recommendations
Physical activity counselling If the patient is capable of exercise – >5 METs – without symptoms, return to routine physical activity is recommended; otherwise, the patient should resume physical activity at 50% of maximal exercise capacity and gradually increase.Physical activity should be a combination of activities like walking, climbing stairs, cycling and supervised medically prescribed aerobic ET, tailored to the patient abilities and preferences.
Exercise training Regular exercise is highly recommended. Please see the Physical exercise page for detailed recommendations.
Diet/nutritional counselling Caloric intake is recommended to be balanced by energy expenditure (physical activity) to achieve and maintain healthy BMI. A diet low in cholesterol and saturated fat, low in saturated fat with a focus on wholegrain products, vegetables, fruit and fish is recommended. Please visit the Risk Factor Control: Nutrition page page for more detailed information.
Weight control management Normal-weight IHD patients should be advised to avoid weight gain. BMI 20–25 kg/m². Waist circumference < 94 cm (men) or < 80 cm (women). On each patient visit, it is recommended to consistently encourage weight control through an appropriate balance of physical activity, caloric intake, and formal behavioural programmes when indicated to achieve and maintain a healthy BMI.
Lipid management LDL: < 1.8 mmol/L (< 70 mg/dL), or a reduction of at least 50% if the baseline is 1.8 to 3.5 mmol/L (70 and 135 mg/dL).
HDL: no target but > 1.0 mmol/L (> 40 mg/dL) in men and > 1.2 mmol/L (> 48 mg/dL) in women indicates lower risk.
Triglycerides: no target but < 1.7 mmol/L (< 150 mg/dL) indicates lower risk and higher levels indicate a need to check other risk factors.

Annual control of lipids, glucose metabolism and creatinine are recommended.
Diabetes  HbA1c < 7% (< 53 mmol/mol).
Blood pressure control  < 140/90 mmHg
Smoking cessation  No exposure to tobacco in any form or support in smoking cessation.
Alcohol
  • Limit alcohol intake to 2 glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women.
  • Aim for at least two alcohol free days in the week.
Psychosocial management Psychosocial risk factor screening should be considered

Multimodal behavioural intervention is recommended

Abbreviations:

  • CVD: cardiovascular disease
  • IHD: ischaemic heart disease
  • PA: physical activity
  • ET: exercise training
  • BMI: body mass index
  • BP: blood pressure
  • MET: metabolic equivalent.

References


[1] Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney M-T, Corra` U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen M-L, Lollgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van derWorp HB, van Dis I, Verschuren WMM. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2016; doi:10.1093/eurheartj/ehw106.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.