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OUTPATIENT MANAGEMENT OF
CORONARY AND OTHER VASCULAR DISEASE
Antiplatelet Agents/
Anticoagulants
Start aspirin 75 to 162 mg/d and continue indefinitely in all patients unless contraindicated.
Gastrointestinal side effects are dose-dependent. Since the benefits of aspirin have been measured at
doses as low as 81 mg. enteric-coated 81 mg tablets are reasonable and almost always tolerated.
For patients undergoing CABG, aspirin should be started with in 48 hours after surgery to reduce
saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg/d appear to be
efficacious. Doses higher than 162 mg/d can be continued for up to 1 year.
Start and continue clopidogrel 75mg/d in combination with aspirin for up to 12 months in patients
after acute coronary syndrome or percutaneous coronary intervention with stent placement (>
1 month
for bare metal stent, >
3 months for sirolimus-eluting stent, and >6 months for paclitaxel-eluting
stent).
Patients who have undergone percutaneous coronary intervention with stent placement should
initially receive higher-dose aspirin at 325mg/d for 1 month for bare metal stent, 3 months for
sirolimus-eluting stent, and 6 months for paclitaxel-eluting stent
Manage Warfarin to international normalized ratio= 2.0to 3.0 for paroxysmal or chronic atrial
fibrillation or flutter, and in post myocardial infarction patients when clinically indicated (e.g., atrial
fibrillation, left ventricular thrombus).
Use of Warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of
bleeding and should be monitored closely.
Patients with true aspirin allergy (laryngospasm, anaphylaxis) should receive Clopidogrel.
Renin-Angiotensin-
Aldosterone System
Blockers
ACE Inhibitors
Start and continue indefinitely in all patients with left ventricular ejection fraction <
40% and in those
with hypertension, diabetes, or chronic kidney disease, unless contraindicated.
Among lower-risk patients with normal left ventricular ejection fraction in whom cardiovascular risk
factors are well controlled and revascularization has been performed, use of ACE inhibitors may be
considered optional.
Angiotensin receptor blockers
• Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial
infarction with left ventricular ejection fraction <40%.
• Consider in other patients who are ACE inhibitor intolerant.
Aldosterone Blockade
Use in post-myocardial infarction patients, without significant renal dysfunction (creatinine
<2.5mg/dl in men, <2.0mg/dl in women) or hyperkalemia (Potassium should be <5.0MEq/L), who
are already receiving therapeutic doses of an ACE inhibitor and Beta-Blocker, have a left ventricular
ejection fraction <
40%, and have either diabetes or heart failure.
Refer to the Clinical Practice Guideline for the Outpatient Management of CHF in Adults.
B-blockers
Goal:
All patients post MI
Start and continue indefinitely in all patients who have had myocardial infarction, acute coronary
syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless
contraindicated.
Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes
unless contraindicated.
Blood Pressure
Goal:
<140/90 mm Hg or
<130/80 mm Hg if
Diabetes or Renal Insufficiency
Identify and treat reversible causes.
Accurate BP measurements with appropriate size cuff at every visit.
Advocate & monitor lifestyle changes (weight control, physical activity, alcohol moderation, if
moderate sodium restriction, emphases on fruits/vegetables and low-fat dairy products)
Pharmacological management goals. All patients on optimal dose of drug therapy for insufficiency
adequate hypertension control. (see Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).
Cigarette Smoking
Goal:
Complete Cessation
ASK – Identify use of all tobacco products at every visit.
ADVISE – Strongly urge and educate users on the importance of quitting at every visit.
ASSESS – Determine the patient’s willingness to quit.
ASSIST – Counsel the patient and help to develop quit plan and set quit date.
Prescribe pharmacotherapies found to be effective (unless contraindicated);
Combination treatment with sustained release bupropin and nicotine withdrawal products has been
shown to be the most effective.
ARRANGE – Follow up soon after quit date.
AVOIDANCE-- of exposure to environmental tobacco smoke at work and home.
