Survivors of a first attack remain at a significantly higher risk of death compared with the general population for at least seven years after the first heart attack. This highlights the importance not only of best clinical care during the acute phase of the first event but underscores the role of secondary prevention in improving long-term prognosis of patients who suffer their first heart attack.
The European Society of Cardiology (ESC) has recently released a consensus document on secondary prevention strategies following a first heart attack which outlines the components of “secondary prevention” for both patients and healthcare providers. The consensus statement is published online on September 6, 2016 in the European Journal of Preventive Cardiology. The document notes that while “first-time attacks” are due to “ruptured coronary plaques”/ “clot formation”, most “secondary events” are due to the “progression of the existent atherosclerotic process”; hence, the need to pay meticulous attention to the so-called “modifiable risk factors”.
The ESC emphasises on a healthy lifestyle as the most effective way to prevent a recurrent heart attack along with preventive medications and regular follow ups. “Risk factors” should be identified and managed. Healthy diet, physical activity, weight control, cessation of smoking, and stopping alcohol abuse are components of risk factor modification. Smoking cessation after a heart attack showed a relative risk reduction for second attacks of 46%.
Obesity, diabetes, high blood-pressure, and abnormal cholesterol levels must also be tackled on a war-footing. Further, inadequate use of drug therapies to achieve blood pressure and lipid goals in coronary heart disease (for fear of rare side-effects) also aggravates the problem. “DASH” (dietary advice for systemic hypertension) has much to commend it. It involves a diet rich in fruits, vegetables, low fat or nonfat dairy. It also includes whole grains, lean meats, fish and poultry; nuts (walnuts and almonds) and beans. This diet has high fibre and low fat. In addition to lowering blood pressure, the DASH eating plan lowers cholesterol and makes it easy to lose weight. It is a healthy way of eating, designed to be flexible enough to meet the lifestyle and food preferences of most people.
“Pharmacologic prevention” options include the use of (high-intensity) statin therapy and use of blood thinners like Aspirin lifelong. Moderate alcohol consumption (1-2 drinks per day) is associated with a reduced overall heart attack mortality compared with both abstinence and heavy drinking. Additional antioxidant effects have been attributed to “red wine”, but this is not proved. The pattern and amount of alcohol intake appears to be more important than the type. There are several companies that manufacture “antioxidant pills” and “herbals” but a meta-analysis of controlled secondary prevention trials suggests no benefit for these pills.
A “high blood cholesterol level” increases your risk of a second heart attack. The lower your cholesterol the better but, in rare cases, having a “very low” level of low-density lipoprotein (LDL, or “bad cholesterol”), or, a very low total cholesterol level has been hypothetically linked with certain “non-cardiac health problems”. Doctors are still trying to find out more about the connection between very low cholesterol and possible health risks. There is no consensus on how to define very low LDL cholesterol but, LDL would be considered very low, if it is less than 40 mg/dl.
The potential risk of lowering LDL cholesterol to “very low levels” has not been confirmed, and its association with health risks is still under debate. In some cases it is not clear if low cholesterol causes the health problem or the other way around. For example, people with depression often have low cholesterol levels but, significantly, it has not been proved that lowering cholesterol with statin therapy causes depression.
On the other hand, the benefits of lowering total and LDL cholesterol have been demonstrated extensively in individuals with heart disease aiming at preventing a recurrent heart attack. If you’re concerned about your cholesterol level, consult your doctor. If you’re taking statins, don’t stop without first consulting him. He or she can determine the cholesterol range most appropriate for you.
Coronary interventions such as “angioplasty” and “coronary bypass surgery” have, beyond the shadow of a doubt, come as the greatest boon to those who suffered a first attack and are endeavoring to forestall a repetition. But we must keep in mind that these interventional procedures do not buy us a “cure”; at best they are “palliative procedures” that add years to life.
Therefore, it bears repeating that, considering that most secondary events are due to progression of atherosclerotic process, it is imperative that we pay minute attention to each and every modifiable risk factor that puts us at jeopardy of a second heart attack.
Overall, current national recommendations for secondary prevention services include the consistent collection and monitoring of data to enable efficient delivery of clinical care, appropriate allocation of resources, and monitoring of the performance of services. The Indian Government does not have proper policy guidelines to cover its urban and rural population as well. Indian cardiologists emphasize the “smart” use of data, information that is already available to support our “tottering” system in need of self-improvement, to prevent that possible second heart attack that could well-nigh prove fatal.
(Dr Francisco Colaço is a
seniormost consulting physician, pioneer of
Echocardiography in Goa)
