Secondary prevention

Having once had a myocardial infarction is to a first approximation the most reliable predictor of a patient having a high risk for a (further) heart attack. Thus in an individual secondary prevention measures can therefore be more accurately targetted than primary prevention measures for ischaemic heart disease.

Secondary prevention of cardiovascular and cerebrovascular disease

Lifestyle

Avoiding smoking, a diet rich in fresh fruit, vegetables and fish and taking moderate exercise are the main factors.

Therapeutics

Aspirin or equivalent is the most effective drug in secondary prevention of myocardial infarction. When the cost differences between it and clopidogrel and persantin are considered the cost-effectiveness were strikingly different. In some health economies once clopidogrel became generic it became more cost effective than aspirin in secondary stroke prevention Thus this might change for some populations as the costs of development are amortised and the production cost reduces.

Controlling blood pressure is important. It seems likely that much of the effectiveness depends on the overall BP achieved, rather than on differences between the specific drugs used to do it. Most of the population benefit from blood pressure control is on stroke incidence.

Adding a beta-blocker and an ACE inhibitor for the first year or two after an MI is shown to reduce further MIs and progression to heart failure.

Statins reduce plaque formation and further MIs. They have a net benefit on mortality and this is complex, being dependent perhaps on high dose early and lower doses later where reduction in pneumonia due to the statin might be as important as their effect on atheroma related disease.