Makindo Medical Notes

🫀 Secondary Prevention Post-ACS / IHD

Secondary prevention aims to reduce recurrent cardiovascular events and improve long-term survival. It should be initiated prior to discharge.

📋 Prior to Discharge – Risk Assessment

• Assess LVEF, residual ischaemia, completeness of revascularisation.
• Check risk markers: LDL-C, HDL-C, triglycerides, fasting glucose, renal function.
• ⚠️ LDL-C should be measured on admission (levels may fall post-ACS).

💊 Antithrombotic Therapy

• Dual Antiplatelet Therapy (DAPT): Aspirin (75–100 mg OD) + P2Y12 inhibitor (e.g. ticagrelor, prasugrel, or clopidogrel). Continue ≥12 months if low bleeding risk.
• Triple Therapy: For AF / prosthetic valves: triple therapy ≤1 week, then anticoagulant + single antiplatelet up to 12 months.
• After 12 months → usually aspirin monotherapy.

🩸 Anticoagulation (selected cases)

• AF with CHA₂DS₂-VASc ≥2 → anticoagulant ± antiplatelet (guided by bleeding risk).
• LV thrombus post-MI → LMWH bridging to warfarin (or DOAC if appropriate).
• Prolonged immobility post-MI → LMWH prophylaxis.

🧬 Lipid Management

• LDL-C target: <1.4 mmol/L and ≥50% reduction from baseline.
• Statins: High-dose (Atorvastatin 80 mg nocte). Proven mortality reduction post-ACS.
• Consider ezetimibe or PCSK9 inhibitor if LDL-C target not achieved.

💊 Key Medications

• Beta-blockers: Indicated if LVEF ≤40% (Class I, LOE A).
• ACE inhibitors: Ramipril 2.5 mg → titrate to 10 mg daily. If intolerant → ARB (valsartan/losartan).
• Aldosterone antagonist: Eplerenone 25 mg OD in STEMI + LVEF ≤40% with DM or HF symptoms.
• Polypill strategy: Fixed-dose combinations may improve adherence.

🚭 Lifestyle & Risk Modification

• Smoking cessation: Offer NRT, varenicline/bupropion if appropriate. Refer to NHS stop-smoking services.
• Diet: Mediterranean diet (fish, nuts, 5-a-day, low sat fat, ↑ soluble fibre).
• Exercise: Mobilise early; target 150 min/week moderate intensity. Enrol in cardiac rehabilitation.

📊 Quick Summary Table

💡 Exam tip: Post-ACS secondary prevention is about “Drugs + Lifestyle + Rehab”. Always mention cardiac rehabilitation and HCC surveillance in cirrhotics.