and G WilliamsT Pearson, E Rapaport, M Criqui, C Furberg, V Fuster, L Hiratzka, W Little, I Ockene

Writing GroupA statement for healthcare professionals from an American Heart Association

Optimal risk factor management in the patient after coronary revascularization.

ISSN: 1524-4539 Copyright © 1994 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online

72514Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX

1994, 90:3125-3133Circulation 

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3125

AHA Medical/Scientific StatementSpecial Report

Optimal Risk Factor Management in the PatientAfter Coronary RevascularizationA Statement for Healthcare Professionals

From an American Heart Association Writing Group

Thomas Pearson, MD, PhD, Cochair; Elliot Rapaport, MD, Cochair; Michael Criqui, MD;Curt Furberg, MD, PhD; Valentin Fuster, MD, PhD; Loren Hiratzka, MD; William Little, MD;

Ira Ockene, MD; George Williams, PhD, Members

R evascularization with coronary artery bypassgraft surgery (CABG) and percutaneoustransluminal coronary angioplasty (PTCA) is

well accepted as a method of relieving anginal pain andthus improving quality of life. In addition, CABG hasbeen shown to improve survival in certain subgroups ofpatients with coronary disease, which has led to thewidespread use of this procedure in revascularization.In 1991 407 000 bypasses and 303 000 PTCA procedureswere performed.' Currently, coronary atherectomy, var-ious laser techniques, and coronary stents are beingevaluated as additional approaches to revascularization.While often effective, there is the risk of complica-

tions with CABG and PTCA. These procedures are alsocostly because they require skilled personnel, sophisti-cated equipment, and hospitalization. Thus, the proba-bility of long-term success should be optimized formaximum patient benefit and the best use of healthcareresources. Short- and long-term failure rates for theseprocedures have been defined. Approximately 10% to20% of CABG procedures in the United States areperformed in patients who had previously undergonethis procedure, in large part because of the closure ofbypass grafts from thrombosis and accelerated athero-sclerosis. Restenosis rates for PTCA and atherectomy at6 months are about 40%.2,3 The patient who undergoesrevascularization probably has atherosclerotic disease inother coronary arteries and other vascular beds (eg,cerebrovascular and peripheral arteries).The renewed interest in preventive interventions in

patients undergoing revascularization is derived from avariety of sources, including improved understanding ofthe role of risk factors in atherosclerotic and thromboticdiseases, results of clinical observations documentingthe role of these risk factors in revascularization failure,the results of clinical trials that specifically tested theability to prevent disease progression and recurrence,and evidence that such interventions are cost-effective

"Optimal Risk Factor Management in the Patient After Coro-nary Revascularization" was approved by the SAC/Steering Com-mittee of the American Heart Association on June 16, 1994.

Requests for reprints should be sent to the Office of ScientificAffairs, 7272 Greenville Ave, Dallas, TX 75231-4596.© 1994 American Heart Association, Inc.

and sometimes cost-reducing. This report summarizesthese scientific data and makes recommendations forthe assessment and treatment of risk factors followingCABG, PTCA, and other revascularization procedures.

Can Atherosclerotic Progression and ItsComplications Be PreventedAfter Revascularization?

Overview of the Pathogenesis of Bypass GraftClosure and Post-PTCA RestenosisSaphenous Vein Bypass Graft DiseaseVein graft disease can be divided into three phases4:* An early (within 1 month) postoperative phase

caused by technical factors and superimposed throm-botic occlusion

* An intermediate phase (within the first postopera-tive year) characterized by intimal hyperplasia, resultingin narrowing of the graft lumen, which may also pro-mote thrombosis

* A late phase (after the first postoperative year)related to graft atherosclerosis and superimposedthrombosis similar to that affecting native coronaryarteries

Occlusion rates of 5% to 15% per distal anastomosisat 1 month after surgery and 15% to 25% at 12 monthshave been reported.5-7 At the end of 10 years up to 50%of vein grafts will become occluded.8

Post-PTCA RestenosisAlthough the success rate of PTCA for dilating

arterial stenoses is high, restenosis occurs in 40% to60% of vessels, most frequently within the first 6months after the procedure.9 Restenosis is incom-pletely understood but appears to involve at leastthree processes: (1) a phenomenon of recoil, (2) muralthrombosis organized by connective tissue, and (3)intimal hyperplasia as a response to the injury perpet-uated until endothelialization takes place. The occur-rence of restenosis has not been reduced by thesubstitution of lasers or atherectomy devices for an-gioplasty231041 nor by the neutralization of growthfactors, which appear to be responsible for smoothmuscle cell proliferation.12 The possibility of reducing

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restenosis by using stents or by opening the artery as muchas possible (maximum luminal gain aiming at less relativeloss) is now being investigated. Early acute closure (within24 hours of PTCA) is primarily mediated through throm-bosis and is decreased by administration of aspirin andheparin. However, long-term administration of aspirin isnot effective in preventing later restenosis.13

Thus, the role of thrombosis and progression ofatherosclerosis through smooth muscle cell hyperplasiaare thought to be particularly important in saphenousvein bypass grafts and post-PTCA arteries. The nextsection discusses the ability to modify these processes,thus preventing clinical events.

Prevention of Early Thrombosis in Saphenous VeinBypass GraftsThe importance of platelets in the pathogenesis of

thrombosis following vein grafting or PTCA suggeststhat antiplatelet agents should inhibit early thromboticgraft occlusion of saphenous vein bypass grafts andpost-PTCA coronary arteries. It should also decreasethe frequency of late vein graft occlusive events relatedto thrombosis superimposed on intimal hyperplasia thatoccurs in the first postoperative year or on the athero-sclerosis that occurs later. Studies of saphenous veinbypass grafts have demonstrated the importance ofinitiating platelet inhibitor therapy in the perioperativeperiod, preferably before but not later than 48 hoursafter surgery.'4-19 When therapy was started more than48 hours after surgery, no reduction in the vein graftocclusion rate was observed. Recent studies from theVeterans Administration7 suggest that one dose ofaspirin daily is as effective as aspirin given three timesdaily in reducing vein graft closure. In fact, 100 mgaspirin daily was as effective as higher doses.20 Preoper-ative administration of aspirin was associated with in-creased bleeding complications and no additional ben-efit in early vein graft patency when compared withaspirin started 6 hours after surgery.21

Trials comparing aspirin with aspirin plus dipyridam-ole have not shown an additional benefit of the lat-ter.22,23 Likewise, there is only a statistically nonsignifi-cant trend toward improved graft patency rate withsulfinpyrazone. Ticlopidine (250 mg twice daily) mayalso reduce the incidence of vein graft occlusion butmay have additional side effects.24 Ticlopidine may beuseful for patients who are allergic to aspirin. Heparinand oral anticoagulants have some benefits for preven-tion of graft occlusion, but perioperative use of theseagents may be undesirable because of the risk of bleed-ing during surgery.21 On occasion, a small percentage ofpeople can develop neutropenia.

Prevention of Early Thrombosis in CoronaryArteries After PTCA

Thrombosis likely plays a major role among themultifactorial pathophysiological processes accountingfor early occlusion after PTCA. Accordingly, in threeprospective13,2526 and two retrospective27,28 angiographicstudies, pretreatment with aspirin alone,13'2728 aspirinplus dipyridamole,252728 or ticlopidine alone25 signifi-cantly reduced the incidence of acute thrombotic occlu-sion and periprocedural Q-wave infarction in patientswho underwent coronary angioplasty. A recent pros-pective study29 indicated that aspirin alone was as

effective as the combination of aspirin and dipyridamolein reducing acute thrombotic occlusion. Importantly, inmost studies heparin was used with the platelet inhibi-tors mentioned above.

Prevention of Late Bypass Graft Closure andPost-PTCA Restenosis

Internal mammary arteries used as vascular conduitshave patency rates of approximately 90% at 10 years,which is considerably greater than those of vein grafts.Because of this high patency rate, it is difficult todemonstrate that interventions have an additional ben-eficial effect on internal mammary grafts.30 However,most patients receive saphenous vein grafts in additionto an internal mammary graft and thus still benefit fromearly institution of aspirin, smoking cessation, and treat-ment of lipid abnormalities.

Additional interventions may be effective when anti-platelet therapy with aspirin is started early after sur-gery and continued for at least 1 year afterward toimprove graft patency. There is substantial evidencethat the vein grafts are deleteriously affected by ciga-rette smoking. The frequency of graft atherosclerosis isincreased in smokers31 with a significant associationbetween smoking after the first operation and graftthrombosis as well.32 Vein graft stenosis and occlusionare related to levels of low-density lipoprotein (LDL)cholesterol and lipoprotein(a) and inversely related tolevels of high-density lipoprotein (HDL) cholester-01.8,32,33 In patients with dyslipidemia, treatment withcolestipol and niacin improves venous graft patency andlessens progression of native vessel disease.34No intervention has been proven to be beneficial in

avoiding post-PTCA restenosis. Evidence of the effec-tiveness of fish oil started 1 week before PTCA isconflicting.35 Restenosis may occur more frequently inpatients with low HDL cholesterol,36'37 which suggeststhat lipid abnormalities may play a role in restenosis.Whether lipid-modifying drugs alter restenosis is con-troversial.38,39 The literature on the effect of smoking onthe outcome of PTCA is conflicting. Several studieshave suggested that there is no relation between smok-ing and restenosis rates,40-42 but in two recent studies inwhich logistic regression analysis was used, continuedsmoking was found to be an independent predictor ofrestenosis.4344 Given the known harm of smoking inpatients with CHD, it is appropriate to strongly recom-mend smoking cessation to patients who undergoPTCA. The efficacy of calcium antagonists is unknown,although some physicians administer them for severalmonths after PTCA.

Thus, available data support the following strategiesto minimize occurrence of acute closure and restenosisafter PTCA: administration of aspirin (and heparin) atthe time of PTCA, long-term administration of aspirin(80 to 325 mg/d), and smoking cessation.

Prevention of Atherosclerotic Progression in NativeCoronary Arteries

Serial coronary arteriography in patients with under-lying coronary artery disease has been used in a numberof clinical trials designed to determine whether specificinterventions can prevent the progression of coronaryatherosclerosis or even result in regression. Most ofthese studies have been directed toward interventions

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AHA4 Writing Group Risk Factor Management After Revascularization

that lower total and LDL cholesterol. In addition,several of these interventions raised HDL cholesterollevels: diet, lipid-altering drugs, major lifestyle change,behavioral modification, and ileal bypass surgery. Stud-ies on the ability of calcium entry blockers to preventatherosclerosis have also been undertaken. Although aglobal scoring system by an arteriographic reading panelthat gave an overall measure of atherosclerotic changewas used in some trials,34,45 serial quantitative coronaryarteriography provides a more reproducible and accu-rate method for following serial changes and is increas-ingly being used.An overview of these trials46 demonstrates that pro-

gression can be slowed significantly, that regression canbe demonstrated in a minority of patients, and thatplaques prone to rupture can also be stabilized, prevent-ing coronary events. The favorable serial changes in thecoronary circulation correlate with the ability to bothlower LDL cholesterol and raise HDL cholesterol.Furthermore, in the POSCH Trial, the global coronarychange score, determined after repeat serial coronaryarteriography 3 years after randomization, predictedsubsequent coronary events.45 Finally, a 1-year lifestylemodification study47 revealed significant changes in thecoronary circulation, supporting the view that diet anddrug interventions can produce detectable improve-ment in underlying coronary atherosclerosis as early as1 year after such interventions are initiated.

Prevention of Clinical Events WithSpecific Interventions

Following coronary artery bypass surgery, smokingcessation favorably alters morbidity and mortality. Inthe Coronary Artery Surgery Study, after 10 years offollow-up, survival was 80% among those who smokedat entry into the study but then stopped, compared with69% among those who continued to smoke. Continuedsmoking imposed an almost twofold relative risk ofdeath.48 After 10 years of follow-up, smokers were morelikely to have angina, to be unemployed, to have greaterlimitation of activity, and to have more hospital admis-sions. Smokers had an average of 8.8 additional days inthe hospital, compared with nonsmokers, with an esti-mated additional hospital care expenditure of over$4700 per smoker, an additional hospital expense of$1.80 per pack of cigarettes smoked.48A variety of drug and dietary interventions to lower

LDL cholesterol and raise HDL cholesterol can reducethe likelihood of subsequent mortality and significantmorbidity in patients with native coronary artery dis-ease. Serum lipid- modifying drug and dietary interven-tions reduce the likelihood of myocardial infarction andreinfarction by approximately 25%. Total mortality isless affected, with a reduction in risk of approximately10%, which is of borderline statistical significance.These studies lack sufficient statistical power to detectdifferences in total mortality rates.34,45,47,49-51

Clinical events in patients in randomized lipid-lower-ing trials using serial coronary arteriography alsoshowed a significant reduction in the likelihood of suchevents, especially when progression was decreased orregression took place; the benefit was often seen quitesoon (ie, within 1 to 2 years of initiation).46'49 Finally,cholesterol-lowering drugs are cost-effective or evencost-saving when used in secondary prevention.21

Assessment of Risk Factors in the Patient UndergoingSurgical or Nonsurgical Revascularization

Risk Factor Assessment Therapeutic Goal

Elevated LDL Fasting lipid profile <100 mg/dLcholesterol (<2.6 mmol/L)

Decreased HDL Fasting lipid profile >35 mg/dLcholesterol (>0.9 mmol/L)

Hypertension Blood pressures <140/90 mm Hgconfirmed on two visits

Physical inactivity Interview >20 min ofphysical activity orlevel walking, 1 1/2to 2 mi/d, 3 timesper week as aminimum

Smoking Interview Complete cessation

Obesity Body weight for height < 130% of idealbody weight

Diabetes Fasting blood glucose <140 mg/dL

Stress Interview Improved copingskills

LDL indicateslipoprotein.

low-density lipoprotein; HDL, high-density

Within the context of native coronary artery disease,other interventions have accomplished secondary pre-vention. The use of aspirin, beta blockers, and, mostrecently, angiotensin converting enzyme (ACE) inhibi-tors in postinfarction patients decreases subsequentmortality among patients with underlying coronary ar-tery disease. Changes in lifestyle such as smokingcessation, exercise programs, and behavior modificationare effective secondary prevention measures and shouldbe used in the treatment of postrevascularization pa-tients. Taken as a comprehensive program, a meta-analysis of trials of cardiac rehabilitation programssuggests a 25% reduction in coronary events from thisintervention.52

Evaluation of Risk Factors in the PatientUndergoing Revascularization

Risk Factors That Should Be Assessed (Table)Serum Lipid Levels

Every patient with known coronary artery diseaseshould have a complete lipid profile after an overnightfast, as should patients with clinical atherosclerosis ofthe aorta, arteries to the limbs, or carotid arteries. Theprofile should include measurements of total choles-terol, HDL cholesterol, LDL cholesterol, and totaltriglycerides, which should be made in a laboratory thatparticipates in a suitable standardization program. LDLcholesterol can be accurately estimated in patients withtriglyceride levels of less than 400 mg/dL (4.5 mmol/L)after direct measurement of total cholesterol, HDLcholesterol, and triglyceride (LDL-C = TC-HDL-C-TG/5). In patients with triglyceride levels greater than400 mg/dL, direct measurement of LDL cholesterol byultracentrifugation may be necessary. Following thegeneral recommendations of the National CholesterolEducation Program Adult Treatment Panel II,s3 twomeasurements of all fractions should be made 1 to 8weeks apart.

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Desirable levels of serum lipids in patients withestablished coronary artery disease are as follows: LDLcholesterol less than 100 mg/dL (2.6 mmol/L), HDLcholesterol greater than 35 mg/dL (0.9 mmol/L), andtriglycerides less than 200 mg/dL. These can serve asone set of goals for therapy.53,54

Blood PressureSystolic and diastolic blood pressure should be mea-

sured in both the right and the left arm after the patienthas rested quietly for 5 minutes. The patient should sitwith his or her arm bared, supported, and positioned atheart level. The patient should not have smoked oringested caffeine within 30 minutes before measure-ment. The appropriate cuff size should be used.55 Mea-surements should be made on a mercury sphygmoma-nometer, a recently calibrated aneroid manometer, or avalidated electronic device. The disappearance of thesound (phase V) should be used for the diastolicreading. Two pressures separated by 2 minutes shouldbe taken in succession and the average of both systolicand diastolic pressures calculated. If the first two read-ings differ by more than 5 mm Hg, additional readingsshould be obtained. Initial elevated levels should beconfirmed on at least two subsequent visits. Thesegeneral recommendations are in agreement with the1993 Report of the Joint National Committee on De-tection, Evaluation, and Treatment of High Blood Pres-sure.56 A confirmed systolic blood pressure of 140 mmHg or diastolic blood pressure greater than 90 mm Hgdeserves attention.

Physical InactivityEven modest levels of physical activity may offer

benefit.57 The patient should be asked in some detailabout his or her level of physical exertion in bothoccupational and nonoccupational activities before theonset of coronary symptoms. The patient should also bespecifically asked to recall the frequency of physicalactivity during the previous week and amount of exer-cise engaged in during leisure time. Most patients withlong-term coronary artery disease should be encour-aged to participate in physical activity.58 However, ex-ercise should be safe, as indicated by the patient'shistory or further testing (eg, exercise ECG). Thetreatment goal is difficult to define scientifically, but alevel of exercise vigorous enough to make the patientbreathe hard and/or sweat, performed at least threetimes per week, is a useful rule of thumb. An alternativeapproach for the patient with known coronary arterydisease is level walking at a brisk pace for at least 1 1/2to 2 miles a day, three times per week as a minimum(preferably daily).

SmokingA thorough history of smoking should be obtained,

including duration and frequency of past and currentuse of cigarettes or other forms of tobacco. This assess-ment of likelihood for recidivism in the patient who hasrecently quit smoking is important. Symptoms of nico-tine withdrawal and the presence of other smokers atwork and/or at home may lead to recidivism. Smoking ora high likelihood of recidivism is justification for further

ObesityAn assessment of obesity in CABG patients has

important implications for both in-hospital and fol-low-up periods. Obesity is associated with prolongedtotal bypass time.5960 Through multivariate analysisobesity was found to be an independent risk factor forperioperative morbidity, including respiratory failure,leg wound complications, myocardial infarction, ar-

rhythmias, and sternal dehiscence. With a mean fol-low-up time of 36.9 months, obese patients had a

greater incidence of significant recurrent angina asso-ciated with further weight gain. Even mild obesity isassociated with impaired lung function and increasedalveolar arterial oxygen gradients in patients undergo-ing bypass surgery.61 Height and weight should bemeasured and recorded for all patients, and relativebody weight should be correlated to tables of standardweight to height to calculate percent ideal bodyweight. Patients whose body weight is greater than130% of ideal should be targeted for intensive diet andexercise intervention after revascularization.

Diabetes MellitusThe effects of diabetes mellitus on the atherosclerotic

process are multifactorial and result from lipid abnor-malities, abnormalities of platelet function, and abnor-malities of other metabolic pathways.62-64 Insulin resis-tance and compensatory hyperinsulinemia may beespecially important mechanisms of the excess cardio-vascular risk imposed on diabetic patients.65-69 Optimalcontrol of glucose metabolism by itself may have a majorimpact on existing atherosclerosis. Moreover, diabetesappears to be an important risk factor for late cardiacmortality after bypass surgery.70 Many of the more

important atherosclerosis intervention trials have spe-cifically excluded persons with diabetes.7'A fasting serum glucose measurement should be

obtained for each patient. A level greater than 140mg/dL suggests glucose intolerance. Additional tests,such as a glucose tolerance test, may be used to betterdefine the diagnosis in the postoperative period.

Psychosocial Factors and StressModification of psychosocial factors may reduce the

risk of subsequent events in patients with known coro-nary disease, although this issue remains highly contro-versial. The Recurrent Coronary Prevention Project, astudy of 1000 type A men who had already experienceda myocardial infarction (MI), showed that type Abehavior was substantially reduced by behavioral mod-ification focused on time, urgency, and hostility.72 Fur-thermore, there was a 45% lower rate of recurrentcardiac events (fatal and nonfatal MIs) in the behavior-modification group over the 3 years of the intervention,compared with those who had not received training inbehavior modification. The Lifestyle Heart Trial dem-onstrated regression of coronary atherosclerotic lesionsin a small group of intensively treated patients whoreceived stress management training.47 Although theevidence showing intervention through stress modifica-tion to reduce risk in postintervention patients is pre-liminary, assessment for psychosocial factors seems

appropriate. In addition to the accumulating evidencesmoking cessation efforts. that such factors might play a role in the progression of

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ASIA Writing Group Risk Factor Management After Revascularization

coronary artery disease, stress clearly affects the pa-tient's ability to comply with the overall postinterven-tion regimen, to alter other risk factors, and to have animproved quality of life. Each patient should be as-sessed for level of perceived stress at home and at work.Also, the extent to which various demands and copingwith these demands affect ability to alter other riskfactors should be determined.

Optimal Timing of Risk Factor AssessmentCoronary risk factors should be assessed before or as

part of surgical and nonsurgical interventions. If thepatient is stable, risk factors should be modified beforeintervention. Because of the confounding effects ofhospitalization, surgery, and perioperative care, an ac-curate assessment of lipid profiles, blood pressure, andblood sugar is not always possible after CABG or MI.However, attention to known risk factors in the stablepatient before CABG or PTCA is both feasible andimportant. In patients whose risk factors have not beenevaluated, all risk factors and the success or failure ofprevious modification efforts should be reassessed dur-ing postoperative follow-up and on an ongoing basisafterward. Current data suggest that blood lipids shouldbe assessed 8 to 12 weeks after major surgical proce-dures and MI because total and LDL cholesterol levelsmay be depressed after these cardiac events and mayreturn to baseline only after 2 to 3 months.71 Measure-ments made earlier than 2 to 3 months after CABG orMI should be viewed with this in mind.

Management and Follow-up of Risk FactorsOverviewRole of the Physician

Cardiovascular specialists should lead the effort toestablish comprehensive and coordinated programs inrisk factor modification. The opportunity and responsi-bility to promote good health as well as disease preven-tion lies with physicians and should not be delegated.All patients who undergo surgical and nonsurgical cor-onary revascularization come to the cardiovascular spe-cialist with advanced disease for which risk factormodification has beneficial effects on long-term morbid-ity and mortality. The general population receives a

variety of medical and nonmedical advice on the impor-tance of coronary risk factor modification. The imme-diate and long-term importance of risk factor identifi-cation and modification must be stressed to patientswith coronary artery disease and their families. Com-plete risk factor assessments, including a fasting lipidprofile, should be performed in all first-degree relativesof patients with onset of coronary artery disease beforeage 55 through 60, including children older than 2 years.The cardiovascular specialist should take responsibilityfor carrying out these risk factor assessments, eitherpersonally or by other healthcare providers. The physi-cian should not miss the opportunity to emphasize theimportance of specific risk factor modification behaviorsto individual patients. The physician should also try toensure successful compliance. Patients and their fami-lies are likely to be more receptive to these concepts atthe time of major interventions, when there is at least a

temporary disruption in normal lifestyle.

After assessment of risk, the role and responsibility ofthe cardiovascular specialist is to emphasize the impor-tance of nonpharmacologic intervention, to develop withthe patient the overall treatment, to establish treatmentgoals, and to provide a means for monitoring or follow-up.The physician's involvement in the intervention plan iscrucial to its implementation; the patient needs to under-stand the entire treatment plan, both nonpharmacologicand pharmacologic, as well as the role of other healthcareprofessionals.

Role of Other Healthcare ProfessionalsCounseling can entail a considerable amount of time,

including multiple inpatient sessions and follow-up withthe patient and family members. A multidisciplinaryteam of nurses, registered dietitians, and exercise phys-iologists has the advantage of offering specific skills incounseling, nutrition, exercise, and smoking cessation.The team requires coordination, usually with the help ofa team leader, and benefits from communication be-tween the physician, team members, and the patientabout the overall treatment plan and goals.

Role of the FamilyThe patient usually does not eat, smoke, exercise, or

take medications in isolation but usually as part of afamily unit. Family members are valuable members ofthe intervention team and need to encourage the pa-tient toward treatment goals. It may be necessary toinclude the family in the intervention by changing familyeating, smoking, or exercise habits in order for thepatient to continue interventions initiated in the hospi-tal. Such interventions are usually valuable for familymembers because they often share the patient's riskfactors. Screening for risk factor aggregation in siblingsand children will further encourage modification oflifestyle for the patient and family.

Role of the Primary Care ProviderThe revascularization procedure brings the patient in

contact with the inpatient team for a relatively briefperiod. It is likely that long-term follow-up of theseinterventions will be performed by the primary carephysician. Consultation notes or referral letters fromthe cardiovascular specialist should describe the treat-ment plan to reduce risk factors, the goals of interven-tions, steps taken in the hospital, and the need forfollow-up.

Role of Health Insurers, Employers, andGovernment Agencies

Support is required for posthospitalization risk factormanagement programs, including cardiac rehabilitationprograms, smoking cessation programs, lipid profiletesting, diet and drug therapies to reduce blood pres-sure and serum lipids, and public education programs.Continued reinforcement of these principles is impor-tant to improve success rates and help reduce theotherwise negative impact of recurrent disease onhealthcare expenditures and disability benefits.

Specific Nonpharmacologic InterventionsFat-Modified Diet

Because most patients with coronary artery diseasehave an LDL cholesterol level greater than 100 mg/dL

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(2.6 mmol/L) and the diet recommended for all Amer-icans is a fat-modified diet, steps should be taken toimplement the Step II diet recommended by the Na-tional Cholesterol Education Program.53 The Step IIdiet limits saturated fat to less than 7% of calories, totalfat to less than 30% of calories, and dietary cholesterolto less than 200 mg/d. Several strategies foster imple-mentation of this diet:

1. The inpatient diet should be consistent with theStep II diet.

2. A registered dietitian (RD) or other qualifiednutritional counselor should meet with the patient andthe family member who shops and cooks for the family.An assessment of the family's current eating patternsmay be helpful in counseling.

3. Literacy-appropriate brochures or other writtenmaterials should be given to the patient and family tohelp them make correct food choices.

4. The cardiovascular specialist should recommend tothe primary care physician long-term follow-up of rec-ommended dietary changes by an RD or qualifiednutritionist. The RD may also supervise additionaldietary changes.

Blood Pressure ControlThe patient who had hypertension before a coronary

event may benefit from continued intervention consis-tent with the Fifth Joint National Committee Report.56Nonpharmacologic interventions should focus on re-striction of dietary sodium and weight reduction. Sev-eral specific strategies can be recommended:

1. The inpatient diet should be consistent with amoderate sodium restriction (2 to 3 g of sodium perday), with greater restrictions if necessary for control ofheart failure, etc.

2. An RD or other qualified nutritional counselorshould meet with the patient and key family members togive advice about low-salt diets, avoidance of excessivealcohol intake (more than 1 oz [30 mL] per day), andcaloric restriction.

3. Literacy-appropriate brochures and other writtenmaterials should be available to help the patient under-stand the importance of salt restriction, avoidance ofexcessive alcohol intake, and weight loss.

4. Initiation of phase I cardiac rehabilitation and refer-ral to an outpatient cardiac rehabilitation exercise pro-gram should emphasize regular, safe physical activity.

Physical ActivityThe return to usual (or greater) levels of physical

activity has important physical, psychological, occupa-tional, and social consequences for the typical patientwith coronary artery disease. Cardiac rehabilitationprograms appear to be associated with reduced recur-rence of cardiac events and death and should be incor-porated into the overall risk reduction program. Aphase I cardiac rehabilitation program should be initi-ated while the patient is in the hospital. Referral tophase II and III programs or recommendation to theprimary care physician for referral is encouraged. Thecardiac rehabilitation program should be relatively con-venient for the patient. Close contact with the primarycare physician about the patient's progress should be

Smoking CessationSmoking cessation is by far the most effective means

of reducing the risk of recurrent infarction, decreasingthis risk by at least 50% in a short period of time.73Initiation of a smoking cessation program while thepatient is in the hospital takes advantage of heightenedawareness of risk and vulnerability. This opportunityshould be taken to induce smoking cessation in both thepatient and family members. Several steps should betaken:

* The patient should be prohibited from smoking,and family members should be restricted from smokingin patient areas while the patient is in the hospital.Ideally, all hospitals should be smoke-free.

* Regardless of the patient's professed intention toquit smoking, a nurse or other counselor should speakwith the patient and key family members while thepatient is in the hospital. The goal should be a smoke-free home and work environment.

* Literacy-appropriate written materials or bro-chures should emphasize both the importance of smok-ing cessation and techniques to prevent recidivism.

* Follow-up by the primary care physician or a

trained smoking cessation counselor or enrollment in aformal program should be recommended to preventrecidivism.

Weight ReductionAs part of the dietary advice to the obese patient to

reduce fat and sodium, specific additional nutritionalrecommendations about weight loss should be made.Increased caloric expenditure through a cardiac reha-bilitation program should also be emphasized.

Stress ReductionSpecific interventions to reduce strain or negative

reactions to stress are not well established. In general,the patient may be advised to do the following:

* Avoid stress by changing conditions that bring on

stress.* Develop a plan to relieve unavoidable stress (eg,

physical activity).* Seek professional counseling (the primary care

physician may make a referral).

Specific Pharmacologic InterventionsDrug therapy is an integral part of the proper manage-

ment of patients undergoing surgical and nonsurgicalrevascularization. The goals of treatment are fourfold:

1. To prevent early graft and post-PTCA closure2. To prevent late graft closure and post-PTCA re-

stenosis3. To slow, halt, or, preferably, reverse atheroscle-

rotic progression in arteries that have not undergonerevascularization

4. To prevent new or recurrent coronary events

Platelet-Active DrugsAspirin (100 to 325 mg/d) markedly reduces early

vein graft occlusion when administered perioperatively.Aspirin with heparin is of benefit in the prevention ofearly post-PTCA occlusion. Because of its proven effi-cacy in preventing coronary and cerebrovascular events,

maintained. aspirin therapy should be continued indefinitely.

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Lipid-Lowering DrugsIn patients with abnormal lipid levels, combination

therapy with older compounds such as niacin and resinsor the use of newer HMG-CoA reductase inhibitors isindicated to slow progression and possibly cause regres-sion of coronary atherosclerosis. In the long term theseagents may reduce the risk of coronary events. The goalof lipid-lowering therapy should be an LDL cholesterollevel less than 100 mg/dL (2.6 mmol/L) and an HDLcholesterol level greater than 35 mg/dL (0.9 mmol/L). Itmay be advisable to reduce triglyceride levels to lessthan 200 mg/dL as well.

Blood Pressure -Reducing DrugsIn patients whose blood pressure remains at or above

140/90 mm Hg over a 3- to 6-month period despitesuccessful implementation of lifestyle modifications,antihypertensive medications should be started, espe-cially in patients with end organ damage and/or otherknown risk factors for cardiovascular disease. Initialdrug therapy is monotherapy. Diuretics and ,8 blockersare the two classes of drugs preferred for initial drugtherapy. ACE inhibitors, calcium antagonists, a recep-tor blockers, and the a-X3 blockers should be reservedfor special indications or when diuretics and P blockershave proved unacceptable or ineffective.56

Other Classes of Drugsa Blockers, ACE inhibitors, and anticoagulants re-

duce cardiovascular complications in subgroups of pa-tients with coronary artery disease. ,B Blockers reducethe risk of all-cause mortality and coronary mortality,including sudden cardiac death and nonfatal MI inpostinfarction patients. ACE inhibitors reduce the riskof these same complications in postinfarction patientswith left ventricular dysfunction. Warfarin in a lowerdose (international normalized ratio [INR] of about 2)has recently been shown to reduce thromboemboliccomplications, including embolic stroke, in patients withatrial fibrillation and possibly in those with significantleft ventricular dysfunction. It is reasonable to assumethat patients who have undergone CABG or PTCA andwho have evidence of either heart failure or atrialfibrillation would benefit from treatment with ACEinhibitors or low-dose warfarin, respectively.

DiscussionAlthough these recommendations have been aimed at

patients who have undergone revascularization, they areclearly appropriate for all patients with establishedcoronary artery disease and other atherosclerotic dis-eases. All such patients need intervention in basicpathophysiological processes, namely smooth musclecell proliferation and thrombosis. Thus, althoughCABG and PTCA patients are particularly prone tothese pathological processes, these processes also play arole in atherosclerotic disease of the native coronaryarteries as well as cerebral and peripheral arteries. Thegoal of treating all patients with coronary artery diseaseshould be the prevention of sequelae of these twopathological processes. Thus, the recommendationsgiven here should be extended to myocardial infarctionpatients or those patients who have been diagnosed with

coronary artery disease and in whom medical therapyhas been elected.These recommendations are supported by scientific

literature and are quite straightforward. Frequentlyrisk factors are not assessed as part of the revascular-ization process. Little attention is paid to these inter-ventions by the physician performing revasculariza-tion, and revascularization units are not organized toprovide services in these areas. Follow-up recommen-dations often overlook these prognostically importantinterventions. The goal of this report is to clarify boththe rationale and the means by which appropriateinterventions can be carried out. These are consistentwith providing optimal care to the patient who hasundergone revascularization.

Recommendations for Further Research

Model SystemsModel systems that identify risk factors and initiate

nonpharmacologic and pharmacologic interventionsshould be tested for cost-effectiveness and impact onpatients' quality of life. A variety of strategies might beinvestigated, including the use of other technologiessuch as telecommunications and computers.

Vascular Biology of RevascularizationA great deal of research on saphenous vein grafts is

ongoing, including investigation of preservation beforeimplantation to prevent early thrombotic occlusion andstudies to better understand late intimal hyperplasiaand possible preventive strategies.

Additional research is ongoing regarding restenosisafter angioplasty, atherectomy, and other invasive ap-proaches to open stenotic coronary arteries throughinterventional catheter techniques. Such research canbe broadly divided into the following four categories:

* Interventional technology (eg, use of stents)* Antithrombotic approaches to prevent thrombus

formation and therefore subsequent organization (ie,clinical trials are currently under way with monoclonalplatelet antibodies, antithrombin agents, such as hiru-din and hirulog, etc)

* Drug approaches designed to inhibit the ability ofsmooth muscle cells to undergo intimal hyperplasia(thus far this approach has failed, but new drugs arebeing tested)

* Gene therapy for early repair of damaged endothe-lium to prevent intimal hyperplasiaGene therapy for the coronary endothelium is an

exciting experimental approach. Viruses that have beengenetically altered to incorporate metabolic inhibitorsof smooth muscle cell proliferation are being studied inthe hope that they can be introduced locally by cathetersat the site of endothelial damage, thereby inhibiting thesubsequent excessive reparative process that appears tounderlie intimal hyperplasia.

Progression of Atherosclerosis in theNative ArteriesA great deal of additional research is being directed

toward the prevention of atherosclerosis and the poten-tial regression of existing atherosclerosis. The role ofestrogen replacement therapy in postmenopausalwomen with underlying atherosclerosis is being ex-

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3132 Circulation Vol 90, No 6 December 1994

plored to see if it will effectively decrease the rate ofprogression of underlying atherosclerosis and decreasethe resultant clinical events. The potential benefits ofantioxidants, both in the form of vitamins such asvitamin E, vitamin C, and beta carotene, as well as drugssuch as probucol, are being actively investigated inclinical trials. The potential value of ACE inhibitors inthe prevention of coronary events in affected individualsis also being studied. Research continues on the poten-tial role of Lp(a) in the pathogenesis of atherosclerosis,and interventional studies directed toward lowering thisrisk factor are under way. Numerous transgenic animalmodels that overexpress various apolipoproteins andother gene products are being developed to betterunderstand lipoprotein metabolism and to evaluate newtherapeutic approaches.

It is beyond the purview of this report to review all ofthe experimental approaches under way today to furtherenhance our ability to prevent the problems of resteno-sis, bypass vein graft closure, and progression of under-lying atherosclerosis. At present, however, risk factoridentification and modification remains the most impor-tant approach.

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