Case — advice to a 65-year-old man with diabetes, hypertension, dyslipidaemia and BMI 35, seen in clinic after two coronary stents

Antiplatelet therapy — the most urgent point. Aspirin 75 mg daily lifelong, plus a P2Y inhibitor (ticagrelor, 12 prasugrel or clopidogrel) for 12 months after an acute coronary syndrome or 6 months after elective PCI; shorten to 1–3 months if bleeding risk is high, then continue single antiplatelet therapy. Emphasise in the strongest terms that dual antiplatelet therapy must NOT be stopped prematurely — stent thrombosis carries about 40% mortality. Advise him to carry a stent card, to consult his cardiologist before any surgical or dental procedure, and to report bleeding rather than stopping the tablets himself. Add a proton pump inhibitor for gastroprotection.

Lipids. He has established ASCVD, so target LDL-cholesterol below 55 mg/dL (1.4 mmol/L) with at least a 50% reduction from baseline. Start or continue a high-intensity statin — atorvastatin 40–80 mg or rosuvastatin 20– 40 mg. If the target is not met, add ezetimibe 10 mg, then consider a PCSK9 inhibitor or bempedoic acid. Check a lipid profile and liver function at 6–12 weeks. Explain that the statin is taken for plaque stabilisation, not for the cholesterol number alone, and counsel on muscle symptoms so that he reports rather than silently stops the drug.

Blood pressure. Target below 130/80 mmHg given diabetes and coronary disease, avoiding a diastolic pressure below 70 mmHg (the "J-curve" concern in coronary disease). Preferred agents in this patient: an ACE inhibitor or ARB (cardioprotective, renoprotective in diabetes) plus a beta-blocker if the ejection fraction is reduced or angina persists, and a calcium channel blocker or thiazide-like diuretic as needed. Advise home blood pressure monitoring and single-pill combinations to reduce tablet burden and improve adherence.

Diabetes. Target HbA1c around 7% (53 mmol/mol), individualised and relaxed if there is hypoglycaemia risk or frailty. Because he has established cardiovascular disease and obesity, choose glucose-lowering agents for their cardiovascular benefit, not merely for glycaemic control — metformin as background, plus an SGLT2 inhibitor (cardiovascular and renal benefit, heart failure prevention) and/or a GLP-1 receptor agonist (atherosclerotic benefit plus substantial weight loss). Avoid pioglitazone (fluid retention and heart failure) and minimise sulfonylureas and insulin because of hypoglycaemia. Arrange annual retinal screening, foot examination and urine albumin-creatinine ratio.

Weight, diet and exercise. A BMI of 35 is class II obesity: aim for an initial 5–10% weight loss. Advise a Mediterranean-style or DASH diet, salt below 5 g/day, reduced refined carbohydrate and saturated fat, more fruit, vegetables, whole grains, nuts and fish, and alcohol limitation. Refer to a structured cardiac rehabilitation programme — this is one of the most strongly evidence-based interventions after PCI, improving survival, quality of life, physical and cognitive function and mental health. Build up to 150 minutes per week of moderate aerobic activity plus resistance training twice weekly. Screen for obstructive sleep apnoea, which is highly likely at this BMI.

General advice, safety-netting and follow-up. Absolute smoking cessation with pharmacological support. Give influenza, pneumococcal and COVID-19 vaccination. Teach him to recognise recurrent angina and to use sublingual GTN, with clear instructions to call emergency services if pain persists beyond 15 minutes or is severe. Advise on driving restrictions after PCI per local regulations, and on safe resumption of sexual activity (nitrates must never be combined with phosphodiesterase-5 inhibitors). Screen for depression and anxiety, which are common and worsen outcomes. Discuss adherence explicitly and simplify the regimen. Arrange follow-up at 4–6 weeks with repeat lipids, renal function, electrolytes, HbA1c and blood pressure, and reassess the ejection fraction if it was reduced.

SELECT (NEJM 2023) — in patients with established cardiovascular disease and overweight or obesity but WITHOUT diabetes, weekly semaglutide 2.4 mg reduced major adverse cardiovascular events by 20%, establishing obesity itself as a modifiable cardiovascular target and pharmacological weight loss as secondary prevention in its own right. In a patient who also has diabetes, the parallel evidence from SUSTAIN-6 and LEADER (GLP-1 receptor agonists) and EMPA-REG OUTCOME, CANVAS and DECLARE-TIMI 58 (SGLT2 inhibitors) supports using these agents for cardiovascular protection. Current ACC/AHA and ESC guidance therefore recommends an SGLT2 inhibitor and/or a GLP-1 receptor agonist in patients with type 2 diabetes and established ASCVD, independently of HbA1c.