An article written by Dr Edward Leatham, Consultant Cardiologist

Tags: Cholesterol, Stent, CAVG, Coronary heart disease, LDL, NH1  search website using Tags to find related stories.

Thirty years ago, undergoing a coronary stent procedure was a major event. Whether it was for a heart attack, unstable angina, or a planned intervention, patients typically stayed in hospital for several days. This extended hospital stay allowed for comprehensive advice and support—covering smoking cessation, physical activity, and effective secondary prevention—to ensure a healthier future.

In 2024, much has changed. Stent technology has greatly improved, and today, most procedures are completed on a day-case basis. Restenosis and stent thrombosis rates are lower, and advanced non-invasive imaging techniques, such as CT angiography, can easily assess stent patency and detect new or progressing coronary artery disease. However, the success of these procedures may inadvertently lead some patients to believe they are “fixed” and no longer need to focus on long-term risk reduction. As a result, they may return to the healthcare system years later with another blockage or stent failure—often due to insufficient secondary prevention measures.

To help prevent this, here are ten key points every patient who has had a coronary stent or bypass operation should know:

1. You Remain at Elevated Risk:
   Once you have had a stent or bypass, you are at higher lifetime risk for future cardiac events compared to individuals who have never shown symptoms. This is why secondary prevention (measures taken after your first event) is crucial to reduce the likelihood of future heart disease.
2. Personalised Dual Antiplatelet Therapy (DAPT):
   Anyone who has required bypass surgery should be taking a single antiplatelet drug for life. The duration and combination of dual antiplatelet therapy after a stent should be tailored to each patient. Factors such as stent location, bleeding risk, and the need for other procedures influence how long you remain on two antiplatelets. In certain high-risk patients who tolerate therapy well, lifelong dual antiplatelet use may be considered rather than stopping one agent at 12 months. Your interventional cardiologist is best placed to determine the most appropriate duration based on your individual circumstances.
3. Advanced Imaging for Follow-Up:
   Modern CT angiography makes it straightforward to check stent patency and detect restenosis. In addition, advanced techniques—such as the CaRi-Heart® platform (developed by Caristo in Oxford)—allow assessment of coronary inflammation through the Fat Attenuation Index (FAI). Evaluating inflammatory activity can help determine if the underlying drivers of coronary heart disease have been sufficiently suppressed. If they have not, additional measures can be taken to reduce inflammation and prevent future events.
4. Cardiac Rehabilitation is Vital:
   Although many cardiac rehabilitation programmes were disrupted during COVID-19, these programmes are a proven way to prevent further heart events. Structured exercise, education, and lifestyle support all form integral parts of cardiac rehabilitation and should be offered to every patient following a stent or bypass.
5. More Ambitious LDL Cholesterol Targets: New guidelines suggest aiming for even lower LDL cholesterol (LDL-C) targets. According to the 2023 NICE guidelines, many patients need higher doses of statins or additional treatments to reduce LDL-C below 2 mmol/L, and ideally <1.8 mmlol/L. (Reference: Lipid Optimisation Pathway) Achieving this lower target can significantly reduce the risk of future events.
6. Alternative Lipid-Lowering Therapies: If you do not reach sufficiently low LDL levels with statins and adjunctive treatments such as ezetimibe, other options are available. PCSK9 inhibitors, delivered via injection, can further reduce LDL levels. These treatments are now accessible through NHS funding for high-risk patients who need extra lipid control.
7. Long-Term Exercise and Physical Activity: Regular exercise is as important after a stent or bypass as it was beforehand. Physical activity improves cardiovascular health, helps maintain a healthy weight, reduces stress, and lowers the likelihood of future cardiac problems. Incorporate sustained, moderate exercise into your daily routine.
8. Weight Management and New Therapies:
   Recent studies highlight that increased BMI is a significant risk factor for future heart problems. Weight loss—through diet, lifestyle changes, and, if needed, pharmacological interventions such as GLP-1 agonists—can reduce future admissions and deaths. Additionally, SGLT-2 inhibitors have been shown to improve event-free survival, even in non-diabetic patients with coronary heart disease and reduced left ventricular function (HFrEF)
   
9. Diabetes and Pre-Diabetes Require Attention:
   Diabetes and pre-diabetes are well-known risk factors for future events and in-stent restenosis. Historically, cardiologists often deferred glucose management to diabetologists and GPs. However, many patients with pre-diabetes are unaware of the importance of glucose control, diet, and lifestyle changes. Improving glucose regulation through diet, exercise, and appropriate medications can significantly reduce future cardiac risks.
   
10. Optimising Metabolic Health:

Reflecting the importance of points 7, 8, and 9, many cardiologists are now taking a more active role in optimising their patients’ metabolic health. Tools such as continuous glucose monitoring (CGM) and metabolic testing, along with interventions such as metformin, GLP-1 agonists, and SGLT-2 inhibitors for those at highest risk, are increasingly used. By closely managing metabolic health, clinicians help patients achieve better long-term outcomes and reduce the risk of future cardiac events.

In Summary:
Having a stent or bypass is not the end of the story—it is the beginning of a new chapter in managing your cardiovascular health. With the right combination of medications, lifestyle changes, rehabilitation programmes, and vigilant follow-up using advanced diagnostic techniques, you can greatly reduce your risk of future events. Stay engaged with your healthcare team, keep informed about new therapies and guidelines, and commit to sustainable lifestyle adjustments to ensure the best possible long-term health.

For other stories related to cholesterol, coronary heart disease, and LDL, explore the archives by entering a tag under the search function above.

Other related articles

1. SECONDARY PREVENTION AFTER ACS ECS 2018
2. NICE Cardiovascular disease: risk assessment and reduction, including lipid modification
3. Secondary prevention following a myocardial infarction NICE updated 2024

4. CT Imaging of Coronary Stents: Past, Present, and Future

5. LDL: the lower the better

6. Glucose variability: a new risk factor for cardiovascular disease 2023

7. Impact of long-term glucose variability on coronary atherosclerosis progression in patients with type 2 diabetes: a 2.3 year follow-up study

8. Five Reasons Why a Cardiologist Might Recommend a Continuous Glucose Monitor (CGM) to their Patient

The Naked Heart is an educational project owned and operated by Dr Edward Leatham. It comprises a series of blog articles, videos and reels distributed on Tiktok, Youtube and Instagram  aimed to help educate both patients and healthcare professionals about cardiology related issues.

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