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INTRODUCTION

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Guideline-directed medical therapy (GDMT) is an intrinsic part of management of patients with stable ischemic heart disease (SIHD) whether or not revascularization is performed. GDMT for patients with coronary disease is synonymous with secondary prevention and consists of pharmacologic and lifestyle interventions. This chapter synthesizes the evidence base behind guideline-recommended therapies for secondary prevention. Outside of the use of aspirin, we will not discuss strategies of antiplatelet therapy for post-percutaneous coronary intervention (PCI) patients, which are reviewed elsewhere. Additionally, management of anginal symptoms is outside the scope of this chapter, and angina management in patients with SIHD will be discussed only briefly in the context of other targets for secondary prevention and risk factor modification. We will begin by reviewing the GDMT targets for risk factor modification in the 2012 SIHD guidelines.1 Following this, we will review the other medical therapies that have been shown to prevent death and myocardial infarction (MI) among patients with SIHD.

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RISK FACTOR GOALS

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Lipid Management

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Elevated concentration of low-density lipoprotein (LDL) cholesterol is a major risk factor for the development and progression of atherosclerosis. Therefore, the principal lipid modification strategy recommended by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) and the recent American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the treatment of blood cholesterol is to lower LDL.2,3 All patients with coronary disease should be treated with a high-potency statin if tolerated (see below). This does not lessen the importance of nutrition, physical activity, and weight management to reduce the risk of coronary events.1 Effective dietary strategies to lower LDL cholesterol include replacing dietary saturated fatty acids and trans-fatty acids with unsaturated fatty acids or complex carbohydrates and reducing dietary cholesterol. Specifically, the 2012 SIHD guidelines recommended limiting saturated fat to <7% of total calories; trans-fats to <1% of total; and cholesterol to <200 mg/dL of total.1 While limiting saturated fat intake to <7% of total calories reduces both LDL cholesterol and high-density lipoprotein (HDL) cholesterol, reducing saturated fat intake lowers LDL more than HDL and has highly beneficial effects on the overall lipid profile and measures of total atherogenic particles, such as non-HDL cholesterol.4 Currently people in the United States derive between 11% and 15% of total calories from saturated fat. Earlier literature from randomized trials5 and practice guidelines2 demonstrated that targeting saturated fat to <7% of total calories lowers LDL by 10% to 15% and reduces risk of ischemic heart disease. In particular, saturated fats with chain lengths of 14 (myristic) and 16 (palmitic) carbons, primarily found in dairy products and red meat, appear most potent in raising serum cholesterol. A meta-analysis by Chowdhury et al6 reviewed prospective observational studies of dietary fatty acids (32 studies) and fatty acid biomarkers (17 studies) along with randomized controlled trials of fatty acid supplementation (27 studies) and concluded that evidence does not support guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of saturated fatty acids. This meta-analysis required revisions of errors in the original publication and generated numerous critical letters to the editor. With the revision, the authors showed the inverse association of intake of long-chain ω-3 polyunsaturated fatty acids (PUFAs) with cardiovascular disease (CVD) risk is indeed significant. They were criticized for including the Sydney Diet Heart Study, a randomized controlled trial that replaced saturated fats with an experimental diet that included a trans-fat–based margarine. When that study was excluded, the remaining randomized controlled trials found a benefit from ...

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