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Coronary artery disease: Risk stratification and patient selection for more aggressive secondary prevention
François Schiele1, Fiona Ecarnot1, Romain Chopard1
1Department of Cardiology, University Hospital Besançon and EA3920, University of Burgundy Franche-Comté, Besançon, France.
Insights
Intensifying secondary prevention therapy for stable coronary artery disease is possible but requires careful patient selection to balance benefits against risks like bleeding or high costs. Strategies include anti-thrombotics and lipid-lowering agents.
Area of Science:
- Cardiology
- Vascular Medicine
- Pharmacology
Background:
- Stable coronary artery disease (CAD) management focuses on preventing myocardial consequences of atherosclerosis and complications like recurrent acute coronary syndrome or stroke.
- Secondary prevention is crucial for CAD patients, but intensifying therapy requires careful risk-benefit assessment due to potential risks and costs.
Purpose of the Study:
- To evaluate strategies for intensifying secondary prevention in stable CAD.
- To identify patient subgroups who may benefit from intensified anti-thrombotic or lipid-lowering therapies.
- To outline criteria for selecting patients for intensified treatment based on residual risk and therapeutic risk.
Main Methods:
- Review of existing literature on secondary prevention in stable CAD.
- Analysis of risks and benefits associated with intensified anti-thrombotic therapy.
- Evaluation of intensified lipid-lowering strategies, including statins, ezetimibe, and PCSK9 inhibitors.
Main Results:
- Intensified anti-thrombotic therapy reduces ischemic events and cardiovascular mortality but increases hemorrhagic risk; specific patient groups (e.g., elderly, history of intracranial hemorrhage) are not candidates.
- Patients with prior/recurrent myocardial infarction, especially smokers or those with diabetes, may benefit from intensified anti-thrombotics.
- Intensified lipid-lowering therapy with statins, ezetimibe, or PCSK9 inhibitors has low risk, but PCSK9 inhibitor cost necessitates consideration of LDL cholesterol levels and disease progression.
Conclusions:
- Careful patient selection is essential for intensifying secondary prevention in stable CAD.
- Risk stratification is key to optimizing anti-thrombotic and lipid-lowering therapies.
- Treatment intensification decisions should consider individual patient factors, including comorbidities, risk of events, and cost-effectiveness.
Abstract:
In patients with stable coronary artery disease, clinical outcomes are predominantly characterized by the consequences of atherosclerosis on the myocardium, but also by complications of atherosclerosis, notably recurrent acute coronary syndrome or stroke. Secondary prevention therapy is therefore key in this patient population. Intensification of secondary prevention therapy is possible, at the price of a therapeutic risk or a high cost, therefore justifying careful selection of patients with a high residual risk and low therapeutic risk. Two lines of therapy can be intensified, independently of each other, namely anti-thrombotics and lipid-lowering agents. Intensification of anti-thrombotic therapy is efficacious in terms of ischaemic events and cardiovascular mortality, but incurs an excess haemorrhagic risk. Patients aged over 65 years of age and those with a history of intra-cranial haemorrhage are not eligible for intensification of anti-thrombotic therapy. Conversely, patients with prior or recurrent myocardial infarction may benefit from this strategy, especially if they are current smokers or have diabetes mellitus. Intensification of lipid-lowering therapy can be achieved through an association of high-intensity statins with ezetimibe or PCSK9 inhibitors. This strategy engenders little risk, but the cost of PCSK9 inhibition is high, and should be considered based on the level of low-density lipoprotein cholesterol achieved with statin treatment at the maximal tolerated dose. In addition to this patient selection based on low-density lipoprotein cholesterol levels, the presence of diabetes or documented progression of atherosclerosis should be considered.
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