Non-Pharmacological Management
Lifestyle Modification
Lifestyle modifications (i.e. smoking cessation, dietary changes and increased exercise) have been shown to reduce mortality and morbidity following acute coronary events,1 and are recommended by the European Society of Cardiology (ESC).2,3
In an analysis based on a large randomized clinical trial,1 patients who continued to smoke and did not adhere to advice on either diet or exercise had nearly four times the risk of myocardial infarction (MI), stroke or death compared with those who had never smoked and who made beneficial dietary and exercise modifications.
Smoking cessation
Among patients with acute coronary syndrome (ACS), smoking is strongly associated with ST-segment elevation MI (STEMI), suggesting that smoking has a clear prothrombotic effect.3 Additionally, the risks of MI1 and of death4 have been found to be significantly lower among quitters than in persistent smokers following an MI.
Smoking cessation is difficult to achieve, but the period of enforced abstinence during the acute phase of ACS offers an opportunity for patients to stop smoking completely. Resumption of smoking is common when patients return home, so ongoing counselling and support is needed during rehabilitation.3
ESC guidelines recommend both counselling and pharmacotherapy for smoking cessation.3 Nicotine replacement therapy has been proven to be effective and safe for ACS patients;5 bupropion and antidepressants may also be useful.3
Diet and exercise
A healthy diet that is low in salt and saturated fat is essential.2 Currently, guidelines recommend:3
- eating a wide variety of foods
- adjusting calorie intake to avoid a body mass index (BMI) >25 kg/m2
- increased consumption of fruit and vegetables, wholegrain cereals and bread, fish (especially oily fish), lean meat, and low-fat dairy products
- replacing trans and saturated fats with unsaturated fats from vegetable and marine sources
- limiting salt intake, especially if blood pressure is increased.
Moderate alcohol intake may be beneficial,2 but there is little or no evidence that dietary supplements (other than fish oils) or diets with a low glycaemic index are beneficial in secondary prevention.3 Fluid restriction may be advisable in patients with severe heart failure.
In addition to dietary modification, the ESC recommends 30 minutes of moderate intensity aerobic activity on at least 5 days per week for patients with ACS.2,3 Aerobic activity may help to lower blood pressure and improve the lipid profile,2 as well as helping patients to lose weight.
In an analysis of outcomes in the OASIS (Organization to Assess Strategies in Acute Ischemic Syndromes) trial,1 post-ACS patients who adhered to advice about diet and exercise had a significantly reduced risk of subsequent MI, stroke or death compared with those who did not.
Weight loss
Weight loss is encouraged in overweight or obese individuals because of its favourable effects on the lipid profile and glycaemic control.2 The long-term goal is to achieve a BMI <25 kg/m2, or a waist circumference <102cm in men or <88cm in women. A realistic short-term goal is to achieve a 10% reduction in bodyweight from baseline, with further reductions if initial weight loss attempts are successful and the losses are sustained. It has not been established, however, that bodyweight reduction per se reduces mortality in patients with ACS.3
References:
1. Chow CK, Jolly S, Rao-Melacini P, et al. Association of diet, exercise and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation 2010;121:750-8.
2. Bassand J-P, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 2007;28:1598-660.
3. van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2008;29:2909-45.
4. Aberg A, Bergstrand R, Johansson S, et al. Cessation of smoking after myocardial infarction. Effects on mortality after 10 years. Br Heart J 1983;49:416-22.
5. Meine TJ, Patel MR, Washam JB, et al. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. Am J Cardiol 2005;95:976-8.