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New Guidelines for High-Risk Heart Patients

Hormone Therapy Out; Beta-Blockers, ACE Inhibitors In

Two leading groups of heart doctors are updating preventive guidelines for people at high risk for a heart attack by recommending the use of two specific classes of drugs, encouraging more lifestyle changes and making a conspicuous deletion.

A joint recommendations from the American Heart Association (AHA) and the American College of Cardiology are aimed at anyone who has already had a heart attack or has severe atherosclerosis, blockage of the arteries, says Dr. Sidney C. Smith, chief science officer of the heart association and chairman of the committee that updated the six-year-old guidelines. The advice applies to more than 12 million Americans, the AHA estimates.

“Over the past six years, several large studies have led us to believe that the recommendations have to be updated,” Smith says. Some notable changes:
Hormone replacement therapy for menopausal women who have had heart attacks has been dropped because studies show it does not prevent second attacks.

Cardiologists are advised to prescribed ACE inhibitor cheap generic drugs indefinitely for anyone who has had a heart attack, and beta-blocker drugs are recommended for heart attack survivors and anyone with severe atherosclerosis. The drugs reduce blood pressure.

Instead of recommending 30 minutes of physical activity three or four times a week, the new guidelines call for daily exercise.

In addition to telling people to stop smoking, the guidelines recommend avoiding secondhand smoke.

A greater emphasis on use of drugs that prevent blood clots — not only aspirin but also newer medications.

A “Mediterranean diet,” low in fat, rich in fruits and vegetables is recommended, including more meals with fish, especially fish rich in omega-3 fatty acids, such as salmon.

And a new push to have doctors and patients pay more than lip service to preventive measures, Smith says.

“There is continuing evidence that large numbers of patients are not benefiting from the therapies that have been recommended,” he says.

Some of that is due to the failure of doctors to write the proper prescriptions when heart attack patients go home from the hospital, Smith says. For example, only a third of discharged heart-attack patients are prescribed cholesterol-lowering drugs, whose benefit has been proved over and over. Money also plays a role, Smith says; most notably, the lack of a prescription drug plan in Medicare creates a cost barrier for many patients.

“But even when the medications are prescribed and paid for, many patients do not take them as they are told to,” Smith says.

The AHA has started a “Get with the Guidelines” project to encourage use of the new recommendation by hospitals.

“We have miles to go before we rest in terms of real benefits for patients if they receive these medications and follow the other guidelines,” Smith says.

There is “no earth-shattering message” in the updated guidelines, says Dr. Noel Bairey Merz, chairman of the American College of Cardiology’s prevention committee. “It is a continuing process. As new knowledge emerges, we try to incorporate them in the guidelines.”

The emphasize on lifestyle factors such as diet and exercise is important, Merz says: “We need to continue to emphasize regimen as much as medication.”

“There is increasingly compelling evidence that more and more folks can benefit from this kind of treatment,” Merz says. “And it is treatment. In the practice of modern medicine, we treat to prevent.”

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