Secondary prevention therapies form an essential component of the treatment strategies for all patients with atherosclerotic vascular disease. Their benefits in reducing combined cardiovascular events have been shown to extend to all age groups and are observed for both men and women. Because their effects are additive, it is important to integrate the critical pathways discussed in the preceding sections on hyperlipidemia, diabetes and metabolic syndrome, hypertension, chronic kidney disease, and smoking cessation into an overall management plan for the patient. In many instances this is best done by coordinating the pathways in the various subspecialty clinics through a comprehensive cardiac rehabilitation program. For example, routine laboratory values can be obtained in association with visits for cardiac rehabilitation and sent to the appropriate subspecialty clinic for review with the patient by the health care provider. The results are then used for therapeutic recommendations arising from that clinic visit based on the appropriate clinical pathway.

The American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease (1) provides a valuable resource on which to develop critical pathways. The AHA “Get With the Guidelines” program uses performance measures developed from this guideline statement as a foundation for its outcomes measures. The statement provides a level of evidence for each classification of recommendation for a given secondary prevention therapy in an easily accessible table summary (Table 27-1). In the 2006 update (1), the recommendations from major practice guidelines from the ACC/AHA and the National Institutes of Health (2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24) were combined with new evidence from research studies (25,26,27,28,29,30,31,32,33,34,35,36,37,38) to develop a comprehensive integrated set of recommendations regarding secondary prevention guidelines for patients with coronary and other atherosclerotic vascular disease (ASVD).

The management of dyslipidemia remains a central focus for secondary prevention therapy. The current guidelines (1) (Table 27-1) recommend that low-density lipoprotein cholesterol (LDL-C) should be <100 mg/dL for all patients with ASVD including coronary heart disease (CHD). They further state that it is reasonable to treat to a target LDL-C of <70 mg/dL in these patients. The evidence is especially compelling for a lower target LDL-C among patients with recent acute coronary syndromes.

Antiplatelet therapy is a second major focus for secondary prevention therapy among patients with CHD and ASVD. The use of clopidogrel therapy has been proven to improve outcomes for patients with acute coronary syndromes and after stent implantation. The minimal duration of clopidogrel therapy varies from 1 month for those receiving bare metal stents, to 3 months for those with sirolimus-eluting stents, and 6 months for those receiving paclitaxel-eluting stents. The recommended dose of aspirin for chronic therapy of patients with CHD or other ASVD is 75 to 162 mg/d taken indefinitely. This lower dosage has been recommended because of higher bleeding complications at higher doses without further benefit of reduction of cardiovascular events.