Established ASCVD, secondary prevention
Patients with prior myocardial infarction, ischemic stroke, TIA, revascularization, or documented atherosclerotic vascular disease.
ICD-10 I258 drugs
Also known as: Secondary prevention after CV event
Drugs used for this condition
- AAcetylsalicylic acidFirst line · Antiplatelet agents (low dose) / NSAIDs (analgesic dose)Low-dose aspirin (75–100 mg daily) is the cornerstone of secondary prevention in established ASCVD. It reduces the risk of recurrent MI, stroke, and vascular death by 20–25 %. Prescribed lifelong if no absolute contraindications exist. After ACS or stenting, dual antiplatelet therapy (aspirin plus clopidogrel, ticagrelor, or prasugrel) is given for 6–12 months.
- AAtorvastatinFirst line · HMG-CoA reductase inhibitors (statins)High-intensity statins (atorvastatin 40–80 mg daily) are the foundation of secondary prevention after ACS, MI, ischemic stroke, TIA, revascularization, or in established atherosclerotic vascular disease. Target per ESC/EAS 2019 is a ≥ 50 % LDL reduction from baseline and LDL below 1.4 mmol/L. Cholesterol Treatment Trialists meta-analyses show a 20 % reduction in major vascular events per 1 mmol/L LDL lowering.
- AClopidogrelFirst line · Antiplatelet agents – P2Y12 receptor inhibitorsClopidogrel plus aspirin (DAPT) is the standard after acute coronary syndrome and percutaneous coronary intervention. The CURE trial showed a 20 % reduction in the composite of vascular death, MI, and stroke. DAPT duration is 6–12 months depending on stent type and bleeding risk. Clopidogrel monotherapy is an alternative when aspirin is not tolerated.
- ARosuvastatinFirst line · HMG-CoA reductase inhibitors (statins)High-intensity statin (rosuvastatin 20–40 mg daily) for secondary prevention in established ASCVD. ESC/EAS 2019 target: LDL reduction over 50% from baseline and below 1.4 mmol/L. The JUPITER trial showed a 44% reduction in cardiovascular events in patients with elevated CRP. Interchangeable with atorvastatin in the high-intensity regimen.
- ASemaglutideFirst line · GLP-1 receptor agonistsPer ESC 2023 and AHA/ACC 2024, in T2D patients with established atherosclerotic CVD, GLP-1 agonists (semaglutide, liraglutide, dulaglutide) and SGLT2 inhibitors are first-choice regardless of HbA1c. MACE reduction is established in large RCTs (SUSTAIN-6, REWIND, LEADER).
- ASimvastatinFirst line · HMG-CoA reductase inhibitors (statins)Simvastatin demonstrated efficacy in landmark RCTs – 4S (30% reduction in all-cause mortality) and HPS (24% reduction in vascular events). These trials laid the evidence foundation for the entire statin class. In current practice, atorvastatin and rosuvastatin are preferred due to more potent LDL reduction and fewer interactions. Simvastatin remains a reasonable choice at doses up to 40 mg.
- BColchicineCase-by-case decision · Antigout agentsCOLCOT (NEJM 2019, over 4,700 patients) and LoDoCo2 (NEJM 2020, 5,522 patients) showed low-dose colchicine 0.5 mg daily in chronic CAD or post-ACS reduced MACE by 23–30 %. ESC 2024 includes colchicine in secondary prevention recommendations for patients with residual inflammatory risk. The effect is attributed to anti-inflammatory action. Off-label in Russia.
- BRivaroxabanCase-by-case decision · Direct oral anticoagulants (factor Xa inhibitors)The COMPASS trial (over 27,000 patients with chronic CAD or peripheral artery disease) showed that rivaroxaban 2.5 mg twice daily plus aspirin 100 mg reduced MACE (vascular death, MI, stroke) by 24 % compared with aspirin alone, at the cost of a 70 % increase in major bleeding. Use is justified in patients at high ischemic and low hemorrhagic risk. The decision is individualized using HAS-BLED, age, and comorbidities.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit