Statin Therapy
Statin therapy is an integral part in the prevention of recurrent ischemic events in the symptomatic ICAD cohort. Post-hoc analyses from the WASID trial found that total cholesterol greater than 200 mg/dL was associated with an increased risk of ischemic stroke, myocardial infarction, or vascular death.
In 2013, the American Heart Association released new guidelines regarding the treatment of cholesterol to reduce atherosclerotic cardiovascular risk in adults [10]. Clinical atherosclerotic cardiovascular disease (ASCVD) is the manifestation of systemic atherosclerotic disease and defined as acute coronary syndromes, a history of myocardial infarction, stable or unstable angina, a history of coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin. Recommendations for secondary prevention in patients with clinical ASCVD include the use of high-intensity statin therapy (atorvastatin 40 or 80 mg, rosuvastatin 20 or 40 mg) for patients less than 75 years of age or moderate-intensity statin therapy (atorvastatin 10 or 20 mg, rosuvastatin 5 or 10 mg, pravastatin 40 mg, or simvastatin 20 or 40 mg) for patients > 75 years of age. In the SAMMPRIS trial, an LDL cholesterol level less than 70 mg/dL was targeted [7].
Blood Pressure Management
Post-hoc analysis of data from WASID demonstrated a statistically significant increase in recurrent stroke risk with increasing mean systolic and diastolic blood pressure (BP) [11]. This was particularly true in patients with mean SBP > 160 mm Hg. This is contrary to the common perception that BP should be maintained higher in patients with intracranial stenosis. In multivariable analysis, systolic BP greater than 140 mm Hg was associated with an increased risk of ischemic stroke, myocardial infarction, or vascular death. In the SAMMPRIS trial, the recommended BP goals for patients with symptomatic ICAD were less than 140/90 mm Hg in non-diabetic patients and less than 130/80 mm Hg in diabetic patients [7]. The timing and pace of blood pressure normalization for a recently symptomatic patient with ICAD is still unclear and needs further study.
Lifestyle Modification and Secondary Risk Factors
The SAMMPRIS protocol incorporated a lifestyle coach for all patients enrolled in the study. Lifestyle modification to achieve smoking cessation, regular physical activity, weight reduction for overweight patients, and glucose control in diabetes (goal hemoglobin A1c < 7.0%) were complementary to the pharmacotherapy (aspirin, clopidogrel, statin, and antihypertensive regimen) prescribed [7].
Patients should be encouraged to participate in aerobic exercise for at least 30 minutes at least 3 times weekly. Dietary modifications modeled after the Mediterranean diet should be encouraged. These should be coupled with additional efforts to address excessive weight as needed.
Successful smoking cessation proves one of the most challenging lifestyle modifications for this group of patients and may require the employment of an extended support system with both family and medical providers. Nicotine supplementation is a common first-line aid for cessation, which may be provided in the form of gum or transdermal patches. Additional pharmacotherapy to address central mechanisms of addiction may be necessary. Many patients benefit from the addition of an antidepressant therapy such as bupropion or an adjunctive medication such as varenicline (a nicotine receptor partial agonist that helps with breaking nicotine addiction). It is important to establish a quit date and detailed, multistep plan for cessation [12].