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Prevention of Cardiovascular Ischemic Events: High-Risk and Secondary Prevention

Atherosclerosis is a chronic disease involving the coronary, carotid, and aorto-femoral vascular beds that represents the major cause of death worldwide.1,2 Coronary artery disease (CAD) is the major cause of morbidity and mortality in the world. Efforts at preventing the clinical manifestations of atherosclerosis have yielded impressive results in the past 3 decades and constitute the major focus of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)3 and the Joint Task Force of European and other Societies on Coronary Prevention.4 The primary prevention of CAD represents one of the most important aspects of preventive medicine today. The secondary prevention of CAD has become the major focus of healthcare teams dealing with cardiovascular medicine. “Secondary prevention” was initially designated for patients who had a myocardial infarction. More recently, the term has been used to encompass patients with objective evidence of coronary artery, cerebrovascular, or peripheral disease.3 With the realization that patients with diabetes had a prognosis at least as grave as patients with CAD,5,6 the term secondary prevention has yielded its place for a more comprehensive strategy aimed at treating patients at high risk of CAD. These include patients with multiple risk factors, a 10-year risk of cardiovascular event >20%, diabetes (especially those with one additional cardiovascular risk factor), atherosclerotic vascular disease, and a previous myocardial infarction. This population thus represents the top stratum of cardiovascular risk and has a prognosis equivalent to or worse than post-myocardial infarction patients.

Over the past 15 years, clinical practice guidelines have been adapted to take into account novel information derived from large-scale intervention studies (Figure 1). Current strategies, in terms of public health and targeted therapy, are aimed at identifying global cardiovascular risk in an individual and treating all risk factors, starting initially by therapeutic …