Acute Coronary Syndrome, Prophylaxis

Acute Coronary Syndrome – Prophylaxis

Introduction
Prophylaxis of acute coronary syndrome (ACS) focuses on primary prevention (preventing the first cardiovascular event in at-risk individuals) and secondary prevention (reducing recurrence in patients with established coronary artery disease). Strategies include lifestyle interventions, pharmacologic therapies, and risk factor management.

1. Lifestyle and Risk Factor Modification

• Smoking cessation: Most important modifiable risk factor; use nicotine replacement therapy or varenicline if needed.

• Diet: Mediterranean-style diet, rich in fruits, vegetables, whole grains, fish, and unsaturated fats; reduce saturated fats, trans fats, salt, and refined sugars.

• Physical activity: At least 150 minutes/week of moderate aerobic exercise or 75 minutes/week of vigorous activity.

• Weight control: Maintain healthy BMI (18.5–24.9) and waist circumference.

• Alcohol moderation: Limit to ≤ 1 drink/day for women and ≤ 2 drinks/day for men.

• Stress reduction: Psychological counseling, mindfulness, or cognitive behavioral therapy when indicated.

2. Pharmacologic Prophylaxis

• Antiplatelet therapy:

  • Aspirin (75–162 mg daily) for secondary prevention in all patients with prior ACS, unless contraindicated.

  • Dual antiplatelet therapy (DAPT) (aspirin + P2Y12 inhibitor such as clopidogrel, prasugrel, or ticagrelor) for 6–12 months post-PCI or ACS.

• Lipid-lowering therapy:

  • High-intensity statins (atorvastatin 40–80 mg, rosuvastatin 20–40 mg) to achieve LDL < 70 mg/dL or ≥ 50% reduction.

  • Ezetimibe or PCSK9 inhibitors (evolocumab, alirocumab) if LDL targets not achieved on statins.

• Blood pressure control:

  • ACE inhibitors or ARBs in patients with hypertension, diabetes, chronic kidney disease, or left ventricular dysfunction.

  • Beta-blockers in patients with prior ACS or reduced ejection fraction.

• Antidiabetic therapy:

  • Metformin as first-line for diabetes.

  • SGLT2 inhibitors (empagliflozin, dapagliflozin) or GLP-1 receptor agonists (liraglutide, semaglutide) in patients with diabetes and high cardiovascular risk.

• Anticoagulation (selected patients):

  • Rivaroxaban (2.5 mg twice daily) + aspirin in stable CAD with high risk but low bleeding risk (COMPASS trial regimen).

3. Preventive Screening and Monitoring

• Blood pressure monitoring: At least annually, more frequently in hypertensives.

• Lipid profile: Every 4–6 years in adults > 20 years, or more often if risk factors present.

• Blood glucose/HbA1c: Screening for diabetes in overweight adults or those with cardiovascular risk factors.

• Coronary calcium scoring / stress testing: In selected high-risk individuals to guide therapy.

4. Vaccinations

• Influenza vaccination: Reduces cardiovascular mortality in patients with heart disease.

• Pneumococcal vaccination: Recommended in older adults and those with cardiovascular comorbidities.

5. Secondary Prevention After ACS

• Cardiac rehabilitation: Structured exercise and education programs to improve outcomes.

• Long-term medication adherence: Continuation of aspirin, statin, beta-blocker, and ACE inhibitor/ARB unless contraindicated.

• Close follow-up: Regular review with cardiologist or primary care to monitor symptoms, risk factors, and therapy adherence.

6. Multidisciplinary Care

• Cardiologists: For risk stratification and therapy optimization.

• Primary care providers: For ongoing monitoring and preventive care.

• Dietitians, physiotherapists, and psychologists: For lifestyle modification and rehabilitation support.