Page 46 - GALENIKA MEDICAL JOURNAL

coronary care units and introducing fibrinolytic therapy, be- secondary prevention, the dose and choice of medications
ta-blockers, angiotensin-converting enzyme inhibitors, and are adjusted based on LDL values during follow-up, typically
anticoagulants. The development of sophisticated diagno- after 4-6 weeks, along with lifestyle modifications . Howe-
8
stic and therapeutic methods such as coronary angiograp- ver, only a small percentage of patients reach target LDL
hy, coronary bypass surgery, hemodynamic monitoring, cholesterol levels, both worldwide and in our country 27, 28 .
and percutaneous coronary angioplasty also significantly
contributed to the reduction in mortality . Hypertriglyceridemia is associated with cardiovascular
21
diseases . Patients with severe primary hypertriglyceride-
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In the chronic phase, high cholesterol levels after reco- mia should be referred to specialized centers. If triglyceride
very from AMI were associated with long-term risk of re- levels are moderately elevated, > 2.3 mmol/L, the European
current myocardial infarction, death from coronary heart Society of Cardiology recommends statin therapy for pa-
disease, and all-cause mortality, necessitating further inve- tients at high risk (Class I, Level of Evidence A). If LDL target
stigation and appropriate therapy . levels are achieved but triglyceride levels are > 2.3 mmol/L,
22
the addition of fibrates is recommended (Class IIb, Level of
Evidence B). Omega-3 ethyl esters at a dose of 2-4 g per day
Residual cardiovascular risk may also be added to statin therapy (Class IIb, Level of Evi-
dence B) .
8
According to one of today's largest registries, the Swe-
dish registry - SWEDEHEART, the risk of recurrent events in Levels of lipoprotein(a), genetically determined LDL con-
over 108.000 patients with AMI was 20% in the first year af- taining cholesterol, triglycerides, and apolipoprotein(a), are
ter the index event, and one in five patients who were stable associated with the development of atherosclerotic cardio-
within the first year had a new event during the three-year vascular disease and are determined once during a per-
30
follow-up . son's lifetime. Clinical studies are currently underway to
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investigate new therapeutic possibilities.
According to data from the GRACE registry (Global Re-
gistry of Acute Coronary Events), which included 3.721 pa- Diabetes is an independent risk factor for CVD 8, 31 . When
tients with Acute Coronary Syndrome (ACS), cardiovascular poorly controlled, diabetes contributes to increased residu-
mortality over a five-year follow-up period was 13%, and al cardiovascular risk. The ESC (European Society of Cardio-
the incidence of recurrent myocardial infarction was 9.3% . logy) recommends monitoring all risk factors, controlling
8
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Results from the REACH (Reduction of Atherothrombosis blood pressure with target values of 130/80 mmHg, and
for Continued Health) registry emphasized the significance achieving LDL-C levels < 1.4 mmol/L. To reduce major ad-
of clinical predictors in the occurrence of future coronary verse cardiovascular events (MACE), SGLT2 inhibitors (Sodi-
events, highlighting the role of atherosclerosis pathophy- um-Glucoseco-Transport 2) and GLP1 agonists (Glucagon-li-
siological mechanisms and the biological characteristics of ke Peptide-1 receptor) are recommended in therapy .
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this chronic disease.
In secondary prevention, the therapeutic goal is to ac-
The results of assessing cardiovascular risk leading to hieve optimal blood pressure values (Scheme 1) with the
8
future events through the prism of pathophysiological me- proper selection of medications whose effects have been
chanisms (metabolic, inflammatory, thrombotic) that con- investigated in large clinical studies. Renin-angiotensin-al-
tribute to the further progression of atherosclerosis have dosterone system blockers are the first-choice drugs in
been incorporated into a strategy for more effective imple- secondary prevention and are preferred in patients post-
mentation of secondary prevention measures. AMI, with heart failure, as well as with diabetes in mono or
combination therapy (with calcium antagonists or diuretics).
Beta-blockers are indicated in patients who have survived
Residual metabolic and inflammatory risk AMI and have an ejection fraction < 40%. Among this group,
highly selective long-acting beta-blockers such as bisoprolol
Lowering LDL cholesterol levels is one of the most im- and nebivolol stand out, although beta-blockers with lower
portant tasks in prevention. In secondary prevention 8, 26 , the selectivity also have their place. Mineralocorticoid receptor
target LDL cholesterol values are ≤ 1.4 mmol/L, with a redu- antagonists, in addition to their use in the therapy of pa-
ction of ≥ 50% compared to baseline values (Scheme 1). In tients with concomitant heart failure, also play a role in the
patients with established cardiovascular disease who expe- treatment of resistant hypertension 8, 32 .
rience recurrent cardiovascular events within two years,
lower target LDL values < 1.0 mmol/L may be considered. To Undoubtedly, hsCRP (High-sensitivity C-reactive protein)
achieve target LDL cholesterol levels, among other therape- is one of the most investigated markers of inflammation in
utic options, statins are recommended. If target values are the development and progression of atherosclerotic disea-
not achieved with statins, ezetimibe may be added to the se. Statins, with their pleiotropic effects, reduce CRP levels
therapy, and if success is still lacking, PCSK-9 and/or inclisi- with a significant reduction in risk in populations that have
ran may be considered. In acute coronary syndrome (ACS), achieved target LDL and hsCRP < 2 mg/L . There is evidence
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high-potency statins at high doses are recommended. In that anti-inflammatory drugs, such as colchicine at a dose of

44 DOI: 10.5937/Galmed2409049B