updated by Prof. M Piepoli and Prof. J Hendriks, 18 August 2021
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.
How to achieve?
Achieving certain changes can be challenging. Integrated care has been identified a suitable approach to manage multifaceted and complex treatment processes, such as patients with IHD. In the treatment of atrial fibrillation (AF), it is stated that an integrated management approach should be used (2). The approach is consists of fundamentals such as a patient centred approach (with active involvement of patients in their care process), comprehensive treatment (including AF management, stroke prevention, risk factor and lifestyle modification), provided by a multidisciplinary team and supported by technology. Moreover, it is recommended to provide patient education about the potential and applicable treatment, as well as the related burden for the patient, to optimize shared decision making with a view towards potentially improved adherence to the agreed treatment regimen.
CVD prevention strategies for IHD patients
This table is derived from 2016 ESC guidelines on Cardiovascular Disease Prevention in Clinical Practice.
|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 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||A therapeutic regimen that achieves >_50% LDL-C reduction from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL).
No current statin use: this is likely to require high-intensity LDL-lowering therapy.
Current LDL-lowering treatment: an increased treatment intensity is required.
Non-HDL-C secondary goals is <2.2 mmol/L (<85mg/dL) (3)
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.|
|Psychosocial management||Psychosocial risk factor screening should be considered
Multimodal behavioural intervention is recommended
- CVD: cardiovascular disease
- IHD: ischaemic heart disease
- PA: physical activity
- ET: exercise training
- BMI: body mass index
- BP: blood pressure
- MET: metabolic equivalent.