EAS 2020 — What are the best practices in secondary prevention post-acute coronary syndrome?

  • Suresh Palle
  • Conference Reports
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  • Patients experiencing an acute coronary syndrome (ACS) have a high risk for recurring events, which necessitates early implementation of optimal pharmacological and non-pharmacological secondary prevention measures.
  • Dr K. Koskinas, Switzerland, reviews the best recent practices for secondary prevention in this very high-risk patients.

Key highlights

  • Potential interventions include antithrombotic treatment, lipid-lowering treatment and treatment for metabolic disorders and inflammation.
  • In the most recent 2020 European Society of Cardiology (ESC) guidelines, non-pharmacological interventions such as improved lifestyle factors, cognitive behavioural interventions and annual influenza vaccination are listed as Class I recommendations.
  • There is a gradual shift towards tailored antithrombotic treatment post-ACS determined by each patient’s ischemic and bleeding risk.
  • Low-dose aspirin remains the recommended long-term antithrombotic treatment.
  • Addition of a second antiplatelet treatment for 12 months or even more is recommended in the absence of contraindications or excessive bleeding risk.
  • The use of prasugrel is preferred over ticagrelor in patients with non-ST-elevation ACS who proceed to percutaneous coronary intervention.
  • 12-month dual antiplatelet therapy is typically recommended for most patients; however, the duration can be reduced to 3 or 6 months and the intensity can be de-escalated from prasugrel/ticagrelor to clopidogrel in some properly selected patients.
  • However, prolonged antithrombotic treatment (>12 months; antiplatelet/anticoagulant drug+aspirin) may be considered in some patients.
  • For lipid management, the 2019 ESC/European Atherosclerosis Society guidelines recommended lower low-density lipoprotein-cholesterol (LDL-C) targets than the 2016 guidelines:
    • Very high risk:
    • High risk:
  • In all patients with ACS, high-dose statins are recommended as early as possible regardless of initial LDL-C values.
  • If LDL-C goals are not achieved after 4-6 weeks with maximally tolerated statin, combination with ezetimibe is recommended.
  • If LDL-C goals are not achieved after 4-6 weeks with statin+ezetimibe combination, the addition of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is recommended.
  • PCSK9 inhibitor should be considered early after the event (if possible, during hospitalization) in patients with ACS and LDL-C above targets despite statin+ezetimibe therapy.
  • Anti-inflammatory drugs have also shown clinical benefits in patients with established coronary artery disease.
  • In a randomized trial involving patients with chronic coronary disease, cardiovascular risk reduction was >30% with low-dose colchicine vs placebo (HR, 0.69; 95% CI, 0.57-0.83; P<.001>
  • In COLCOT trial, low-dose colchicine vs placebo significantly reduced the risk for ischemic cardiovascular events among patients with recent myocardial infarction (MI; HR, 0.77; 95 CI%, 0.61-0.96; P=.02).
  • In CANTOS trial, anti-inflammatory therapy with canakinumab vs placebo significantly reduced recurrent cardiovascular events among patients with previous MI and high-sensitivity C-reactive protein >2 mg/L (HR, 0.85; 95% CI, 0.74-0.98; P=.021).
  • Anti-inflammatory treatments are not yet recommended for clinical use, but look promising to further lower the risk for recurrent events in patients with ACS.