In recent years, carotid ultrasound has become common, and many patients or health visitors have been found to have carotid plaque. Do people with carotid plaque need to be treated with statins? This is a question that is often asked by patients in clinical practice. This question cannot be generalized and should be considered in the context of the patient’s carotid artery stenosis, the presence of cardiovascular disease or cardiovascular risk factors, and low-density lipoprotein cholesterol (LDL-C) levels.
If carotid plaque has led to significant carotid stenosis (≥50% stenosis), the principles of management are the same as for confirmed coronary artery disease or ischemic stroke (both are atherosclerotic cardiovascular diseases) and should be treated immediately with statin therapy to control LDL-C to below 1.8 mmol/L. And most patients should also be considered for aspirin antiplatelet therapy.
If carotid plaque has not led to significant stenosis (<50% stenosis), the patient needs to be evaluated for the presence of cardiovascular disease or other risk factors for cardiovascular disease.
The following conditions may be present.
1. Diagnosed coronary artery disease or ischemic stroke, regardless of the presence or absence of significant stenosis in the carotid artery should receive immediate statin therapy to control LDL-C below 1.8 mmol/L;
2. Those without coronary artery disease or ischemic stroke but with diabetes mellitus and hypertension should also take statin to control LDL-C below 1.8 mmol/L;
3.Diabetes mellitus with LDL-C>2.6 mmol/L should be treated with statin and antiplatelet therapy.
Anti-thrombotic therapy
1.The routine use of warfarin is not recommended after surgery, unless the patient has other indications for long-term antithrombotic therapy (such as atrial fibrillation, venous thromboembolism, placement of prosthetic mechanical valves).
2. Routine use of other antithrombotic drugs (dabigatran, apixaban, rivaroxaban) is not recommended in the early postoperative period unless additional data confirm their safety.
Lipid management
Unless contraindicated, all patients with CABG should resume statin therapy preoperatively and early postoperatively.
2. All patients under 75 years of age should be treated with high-intensity statin therapy (atorvastatin 40-80 mg and resevastatin 20-40 mg) postoperatively.
3. For patients who do not tolerate high-intensity statin therapy or who are at higher risk of drug interactions (e.g., age >75 years), medium-intensity statin therapy should be used.
4. Statins should not be discontinued before or after CABG unless patients experience adverse reactions.
Beta-blocker therapy
1. Unless there are contraindications (e.g. bradycardia, severe airway responsive disease), all patients must be treated with beta-blockers in the perioperative period (ideally starting preoperatively) to prevent postoperative atrial fibrillation.
2. Unless contraindicated, β-blockers should be used in patients with a history of myocardial infarction.
3. Unless contraindicated, β-blockers (bisoprolol, metoprolol succinate extended-release tablets, carvedilol) should be used in those with left ventricular insufficiency.
4. Long-term beta-blocker therapy can be considered for postoperative antihypertensive treatment (without history of myocardial infarction and left ventricular insufficiency), but other antihypertensive treatments may be more effective and tolerable.
Hypertension management
1. Unless contraindicated, β-blockers should be used as soon as possible after surgery to prevent postoperative atrial fibrillation and control blood pressure as early as possible.
2. For patients with recent myocardial infarction, left ventricular dysfunction, diabetes mellitus, or chronic kidney disease, angiotensin-converting enzyme inhibitors (ACEIs) should be used postoperatively. Renal function should be carefully considered when determining the starting time and dose of medication.
3, The goal of postoperative antihypertensive therapy should be less than 140/85 mmHg, although there is a lack of assessment of optimal blood pressure control goals in the CABG population.
4.If the target blood pressure cannot be achieved during the postoperative perioperative period after the use of β-blockers and ACEI, calcium antagonists or diuretics may be added.
5.In patients without a history of myocardial infarction and left ventricular insufficiency, antihypertensive therapy other than β-blockers should be considered in the long-term postoperative blood pressure management.
6. In patients without a history of myocardial infarction, left ventricular insufficiency, diabetes mellitus, or chronic kidney disease, the routine use of ACEI in the early postoperative period is not recommended because the disadvantages outweigh the benefits and may also lead to unpredictable blood pressure reactions.
History of heart attack and left ventricular insufficiency
1. Unless contraindicated, beta-blockers (bisoprolol, metoprolol succinate extended-release tablets, carvedilol) are recommended for all patients with reduced ejection fraction (EF) (less than 40%), especially those with a history of heart failure or myocardial infarction.
2. Unless contraindicated, ACEI or angiotensin receptor antagonist (ARB, when the patient is intolerant to ACEI) is recommended for postoperative use in patients with left ventricular insufficiency (EF < 40%).
3. Unless contraindicated, it is reasonable to add an aldosterone receptor antagonist to a beta-blocker and ACEI postoperatively in patients presenting with left ventricular insufficiency (EF<35%) and New York Heart Association (NYHA) cardiac function class II-IV.
4. In patients with left ventricular insufficiency (EF<35%), the use of buried cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death is not recommended until they have received 3 months of postoperative pharmacotherapy with a clear goal and sustained left ventricular insufficiency has been established.
Diabetes mellitus
For most patients, postoperative glycated hemoglobin (HbA1c) levels controlled to less than 7% are reasonable to reduce microvascular and macrovascular complications.
Smoking cessation
1. Smoking cessation is important, and counseling should be provided to CABG patients who continue to smoke in the hospital and after discharge to improve short- and long-term clinical prognosis.
2. After the patient is discharged from the hospital, it is reasonable to provide nicotine replacement therapy, bupropion, and varenicline based on smoking cessation counseling services for CABG patients with stable disease.
3. During the patient’s hospitalization, nicotine replacement therapy, bupropion, and varenicline may be considered on the basis of smoking cessation counseling services, but the individual’s mental health should be carefully considered.
Mental health and cognitive decline
1, It is reasonable to work with primary care physicians and mental health professionals to screen for depression postoperatively.
2. In patients with postoperative comorbid clinical depression, cognitive behavioral therapy and combination therapy may be used to reduce depressive conditions.
Obesity and metabolic syndrome
1.The degree of centripetal body fat distribution (measuring waist circumference and hip circumference and calculating waist-to-hip ratio) should be assessed in patients, even if the body mass index (BMI) is normal.
2. For patients with BMI higher than 35 kg/m2, bariatric surgery should be considered if lifestyle interventions fail to achieve effective weight loss.
Vitamins and other supplements
1. Vitamin supplements may be used for specific vitamin deficiencies, but the effectiveness is not yet complete.
2. Omega-3 fatty acid and antioxidant vitamin supplements may be considered for the prevention of postoperative atrial fibrillation, but more clinical studies are needed to support the routine use of antioxidant vitamins.
Vaccination
Influenza vaccination should be administered annually to patients with CABG unless contraindicated.
4. Chronic kidney disease (stage III or IV) with LDL-C > 2.6 mmol/L requiring statin therapy.
5. The presence of hypertension or other risk factors and LDL-C>3.4mmol/L, statin therapy is recommended to reduce LDL-C to <3.4mmol/L.
The above is a simple determination method, in clinical practice, a comprehensive analysis of the patient’s other conditions should be made.