Journal of the American College of Cardiology
AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 UpdateEndorsed by the National Heart, Lung, and Blood Institute
Author + information
- Sidney C. Smith Jr, MD,
- Jerilyn Allen, RN, ScD,
- Steven N. Blair, PED,
- Robert O. Bonow, MD,
- Lawrence M. Brass, MD†,
- Gregg C. Fonarow, MD,
- Scott M. Grundy, MD, PhD,
- Loren Hiratzka, MD,
- Daniel Jones, MD,
- Harlan M. Krumholz, MD,
- Lori Mosca, MD, PhD, MPH,
- Richard C. Pasternak, MD⁎,
- Thomas Pearson, MD, MPH, PhD,
- Marc A. Pfeffer, MD, PhD and
- Kathryn A. Taubert, PhD
Since the 2001 update of the American Heart Association (AHA)/American College of Cardiology (ACC) consensus statement on secondary prevention (1), important evidence from clinical trials has emerged that further supports and broadens the merits of aggressive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. This growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves quality of life for these patients.
Compelling evidence from recent clinical trials and revised practice guidelines provided the impetus for this update of the 2001 recommendations with evidence-based results (Table 1).Classification of Recommendations and Level of Evidence are expressed in ACC/AHA format, as detailed in Tables 2 and 3.⇓Recommendations made herein are based largely on major practice guidelines from the National Institutes of Health and ACC/AHA. In many cases, these practice guidelines were supplemented by research findings published after the publication of the primary reference(s). Thus, the development of the present statement involved a process of partial adaptation of other guideline statements and reports and supplemental literature searches 2–32). (For specific search criteria, see the Appendix.) The findings from additional lipid reduction trials (33–37) involving more than 50 000 patients resulted in new optional therapeutic targets, which were outlined in the 2004 update of the National Heart, Lung, and Blood Institute’s Adult Treatment Panel (ATP) III report (6). These changes defined optional lower target cholesterol levels for very high-risk coronary heart disease (CHD) patients, especially those with acute coronary syndromes, and expanded indications for drug treatment. Subsequent to the 2004 update of ATP III, 2 additional trials (8,9) demonstrated cardiovascular benefit for lipid lowering significantly below current cholesterol goal levels for those with chronic CHD. These new trials allow for alterations in guidelines, such that low-density lipoprotein cholesterol (LDL-C) should be <100 mg/dL for all patients with CHD and other clinical forms of atherosclerotic disease, but in addition, it is reasonable to treat to LDL-C <70 mg/dL in such patients. When the <70-mg/dL target is chosen, it may be prudent to increase statin therapy in a graded fashion to determine a patient’s response and tolerance. Furthermore, if it is not possible to attain LDL-C <70 mg/dL because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of >50% with either statins or LDL-C–lowering drug combinations. Moreover, this guideline for patients with atherosclerotic disease does not modify the recommendations of the 2004 ATP III update for patients without atherosclerotic disease who have diabetes or multiple risk factors and a 10-year risk level for CHD >20%. In the latter 2 types of high-risk patients, the recommended LDL-C goal of <100 mg/dL has not changed. Finally, to avoid any misunderstanding about cholesterol management in general, it must be emphasized that a reasonable cholesterol level of <70 mg/dL does not apply to other types of lower-risk individuals who do not have CHD or other forms of atherosclerotic disease; in such cases, recommendations contained in the 2004 ATP III update still pertain.
AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease⁎: 2006 Update
Classification of Recommendations and Level of Evidence⁎
Applying Classification of Recommendations and Level of Evidence
Trials involving other secondary prevention therapies also have influenced major practice guidelines used to formulate the recommendations in this update. Thus, specific recommendations for clopidogrel use in post–acute coronary syndrome or post–percutaneous coronary intervention–stented patients are now included in this 2006 update. The present update also recommends lower-dose aspirin for chronic therapy. The results of additional studies have further confirmed the benefit of aldosterone antagonist therapy among patients with impaired left ventricular function. Finally, recently published findings of a trial involving angiotensin-converting enzyme inhibitor therapy among patients at relatively low risk with stable coronary disease and normal left ventricular function influenced the recommendations (26).
The writing group has for the first time added a recommendation with regard to influenza vaccination. According to the US Centers for Disease Control and Prevention, vaccination with inactivated influenza vaccine is recommended for individuals who have chronic disorders of the cardiovascular system because they are at increased risk for complications from influenza (38).
The writing group emphasizes the importance of giving consideration to the use of cardiovascular medications that have been proved in randomized clinical trials to be of benefit. This strengthens the evidence-based foundation for therapeutic application of these guidelines. The committee acknowledges that ethnic minorities, women, and the elderly are underrepresented in many trials and urges physician and patient participation in trials that will provide additional evidence with regard to therapeutic strategies for these groups of patients.
In the 11 years since the guidelines were first published, 2 other developments have made them even more important in clinical care. First, the aging of the population continues to expand the number of patients living with a diagnosis of cardiovascular disease (now estimated at 13 million for coronary heart disease alone) who might benefit from these therapies. Second, multiple studies of the use of these recommended therapies in appropriate patients, although showing slow improvement, continue to support the discouraging conclusion that many patients in whom therapies are indicated are not receiving them in actual clinical practice. The AHA and ACC recommend the use of programs such as the AHA’s Get With The Guidelines (39) or the ACC’s Guidelines Applied to Practice (40) to identify appropriate patients for therapy, provide practitioners with useful reminders based on the guidelines, and continuously assess the success achieved in providing these therapies to the patients who can benefit from them.
Appendix
| Recommendation | References and Supplemental Search Criteria |
|---|---|
| SMOKING: | Primary reference(s) used: 2, 3, 21, 22 |
| Supplemental search done? No | |
| BLOOD PRESSURE: | Primary reference(s) used: 2, 4 |
| Supplemental search done? Yes | |
| Database(s) used: PubMed and EMBASE for all English-language human studies | |
| Key words: | |
| PubMed: blood pressureOR hypertensionAND practice guidelinesand/or preventionand/or clinical trialand/or pharmacology | |
| EMBASE: secondary preventionOR guidelinesAND blood pressureAND Cochrane reviewOR controlled clinical trialOR randomized controlled trialAND pharmacologyOR hypertensionAND Cochrane reviewOR controlled clinical trialOR randomized controlled trialAND pharmacology | |
| Years searched: 2003–March 2005 | |
| Supplemental search did not alter recommendations. | |
| LIPID MANAGEMENT: | Primary reference(s) used: 2, 5, 7 |
| Supplemental search done? Yes | |
| Database used: PubMed for all English-language human studies | |
| Key words: cholesterol/lipids/lipoproteinsAND clinical trialsand/or meta-analysisand/or practice guidelines | |
| Years searched: 2002–November 2005 | |
| Supplemental search added references 6, 8–12, and 33–37and altered the recommendations. | |
| PHYSICAL ACTIVITY: | Primary reference(s) used: 2, 13–16, 21, 22 |
| Supplemental search done? No | |
| WEIGHT MANAGEMENT: | Primary reference(s) used: 2, 17–19, 21, 22 |
| Supplemental search done? No | |
| DIABETES MANAGEMENT: | Primary reference(s) used: 2, 20–22 |
| Supplemental search done? No | |
| ANTIPLATELET AGENTS/ANTICOAGULANTS: | Primary reference(s) used: 2, 21–25, 27, 29 |
| Supplemental search done? Yes, for use of ASA after CABG | |
| Database(s) used: PubMed for all English-language studies | |
| Key words: antiplatelet agents, coronary artery bypass graft patency | |
| Years searched: 2000–March 2005 | |
| Supplemental search did not alter the recommendations. | |
| RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM BLOCKERS: | Primary reference(s) used: 2, 21, 22, 27, 28 |
| Supplemental search done? Yes | |
| Database used: PubMed for all English-language studies | |
| Key words: ACE inhibitoror angiotensin receptor antagonistor aldosterone antagonistAND clinical trialsand/or meta-analysisand/or practice guidelines | |
| Years searched: 2003–March 2005 | |
| Supplemental search added references 25 and 30–32 and altered the recommendations. | |
| β-BLOCKERS: | Primary reference(s) used: 2, 21, 22, 27, 28 |
| Supplemental search done? Yes | |
| Database used: PubMed for all English-language studies | |
| Key words: beta blockersAND clinical trialsand/or meta-analysisand/or practice guidelines | |
| Years searched: 2002–March 2005 | |
| Supplemental search did not alter recommendations. | |
| INFLUENZA VACCINATION: | Primary reference(s) used: 38 |
| Supplemental search done? No |
Appendix: References and Supplemental Search Criteria Used to Support Each Recommendation and Level of Evidence
Disclosures
| Writing Group Member | Employment | Research Grant | Other Research Support | Speakers Bureau/Honoraria | Ownership Interest | Consultant/Advisory Board | Other |
|---|---|---|---|---|---|---|---|
| Sidney C. Smith Jr, MD | University of North Carolina, Chapel Hill | None | None | Honoraria: ⁎Bayer, ⁎BMS, ⁎Sanofi-Aventis | None | ⁎Sanofi-Aventis, ⁎GlaxoSmithKline, ⁎Eli Lilly, ⁎Pfizer, ⁎Merck | ⁎Astra-Zeneca (Data Safety Monitoring Board) |
| Jerilyn Allen, RN, ScD | Johns Hopkins University, School of Nursing | None | None | None | None | ⁎Board of Directors, Preventive Cardiovascular Nurses Association; Board of Directors, Southeast Lipid Association | None |
| Steven N. Blair, PED | Cooper Institute | †HealthTech, †Jenny Craig | None | Donates all honoraria to The Cooper Institute | None | †Miavita, †Life Fitness, †Jenny Craig | All items listed pertain to the Cooper Institute. Does not personally receive money from any of these. |
| Robert O. Bonow, MD | Northwestern University, School of Medicine | None | None | ⁎Bristol-Myers Squibb Medical Imaging | None | ⁎Bristol-Myers Squibb Medical Imaging, King Pharmaceuticals | These are no relationship to current writing committee; they are included for completeness. |
| Lawrence M. Brass, MD | Yale University | Bristol-Myers Squibb, Sanofi/Synthelabo⁎ | None | Bristol-Myers Squibb, Sanofi/Synthelabo, Solvay Pharmaceuticals, Wyeth | None | AstraZeneca, Bristol-Myers Squibb, Johnson&Johnson, Merck, ONO Pharmaceuticals, Sanofi/Synthelabo, Solvay Pharmaceuticals, Wyeth | None |
| Gregg C. Fonarow, MD | University of California, Los Angeles | †GlaxoSmithKline, †Pfizer, †Medtronic | None | †GlaxoSmithKline, †Pfizer, †Merck–Schering Plough, †Bristol-Myers Squibb–Sanofi, ⁎AstraZeneca, ⁎Wyeth | None | †GlaxoSmithKline, †Pfizer, †Merck–Schering Plough, †Bristol-Myers Squibb–Sanofi, ⁎AstraZeneca, ⁎Wyeth | None |
| Scott M. Grundy, MD, PhD | University of Texas Southwestern | †Abbott, †GlaxoSmithKline | †Donald W. Reynolds Foundation, †VA Hospital | ⁎Merck, Schering-Plough, ⁎GlaxoSmithKline, ⁎Pfizer, ⁎Kos, ⁎Bristol-Myers Squibb, ⁎Lilly | ⁎None | ⁎Pfizer, ⁎Sanofi-Aventis, ⁎Abbott, ⁎AstraZeneca, ⁎GlaxoSmithKline | None |
| Loren Hiratzka, MD | TriHealth, Inc | None | None | None | None | None | None |
| Daniel Jones, MD | University of Mississippi Medical Center | None | None | None | None | None | None |
| Harlan M. Krumholz, MD | Yale University | †CV Therapeutics | None | None | None | ⁎CV Therapeutics, †VHA Inc (Consultant), †United Healthcare (Advisory), †CFMC (Clin Coordinator), †MMS (Editorial Board) | |
| Lori Mosca, MD, PhD, MPH | New York Presbyterian | †NIH | ⁎Pfizer | ⁎Kos, ⁎Abbott, ⁎AstraZeneca, ⁎Pfizer, ⁎Sanofi-Aventis | None | ⁎Kos, ⁎Pfizer, ⁎Sanofi-Aventis, ⁎Schering-Plough | None |
| Thomas Pearson, MD, MPH, PhD | University of Rochester | †World Heart Federation, ⁎Schering-Plough, ⁎Pfizer, ⁎Merck, ⁎Sanofi-Aventis | None | ⁎Kos, ⁎Abbott, ⁎AstraZeneca, ⁎Pfizer, ⁎Schering-Plough, ⁎Bayer, ⁎Merck | None | †Meditech, ⁎Johnson&Johnson, Merck, ⁎Bayer, ⁎Sanofi-Aventis | None |
| Marc A. Pfeffer, MD, PhD | Brigham & Women’s Hospital | Amgen, Atherogenics, Novartis, Bristol-Myers, Squibb, Sanofi-Synthelabo† | None | None | The Brigham & Women’s Hospital has been awarded patents related to the use of inhibitors of the renin-angiotensin system in selected surviors. He is co-inventor. However, the licensing agreement is not linked to sales.† | †AstraZeneca, †Genzyme, †Guidant, †Mitsubishi, ⁎Abbott, ⁎Amgen, ⁎Bristol-Myers Squibb, ⁎CSL, ⁎Novartis, ⁎Sankyo, ⁎Pfizer | None |
| Kathryn A. Taubert, PhD | American Heart Association | None | None | None | None | None | None |
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “Significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “Modest” if it is less than “Significant” under the preceding definition.
↵⁎ Modest
↵† Significant
Writing Group Disclosures
| Reviewer | Employment | Research Grant | Other Research Support | Speakers Bureau/Honoraria | Ownership Interest | Consultant/Advisory Board | Other |
|---|---|---|---|---|---|---|---|
| Jonathan Abrams, MD | University of New Mexico Health Science Center | None | None | None | None | None | None |
| Joseph Alpert, MD | University of Arizona Department of Medicine | None | None | None | None | None | None |
| Jeffrey L. Anderson, MD | LDS Hospital Cardiology | Bristol-Myers Squibb (grant pending) | None | Bristol-Myers Squibb, Dia Dexus, Guilford, Merck, Johnson&Johnson/Merck, Merck-Schering, Sanofi-Aventis | None | Bristol-Myers Squibb, Guilford, Merck, Johnson&Johnson/Merck, Merck-Schering | None |
| Eric R. Bates, MD | University of Michigan Medical Center | None | None | None | None | None | None |
| Vera Bittner, MD | University of Alabama at Birmingham | NHLBI, Pfizer, AtheroGenics | None | Pfizer, Merck, Kos, Reliant | None | CV Therapeutics, Reliant | None |
| Ann Bolger, MD | University of California San Francisco | None | None | None | None | None | None |
| Roger S. Blumenthal, MD | Johns Hopkins Hospital | Merck, Pfizer | None | Pfizer, Merck, Astra Zeneca, Kos, Schering-Plough | None | None | None |
| Prakash Deedwania, MD | University of California San Francisco | Pfizer, AstraZeneca | None | None | None | Pfizer, AstraZeneca, Novartis | None |
| Mark J. Eisenberg, MD | McGill University | None | None | None | None | None | None |
| Gerald Fletcher, MD | Mayo Clinic | None | None | None | None | None | None |
| Alan D. Forker, MD | St. Lukes Hospital | Pfizer, Merck, Kos, Novartis, Sankyo, Bristol-Myers Squibb | None | Pfizer, Merck, Takeda | None | None | None |
| Timothy Gardner, MD | Clinical Practices of the University of Pennsylvania | None | None | None | None | None | None |
| Cindy L. Grines, MD | William Beaumont Hospital | Berlex, Pfizer, GlaxoSmithKline, Aventis, Guidant Eli Lilly, SCIMED, Johnson&Johnson, Amersham Health, Otsuka, Esperion Therapeutics, Innercool Therapies, AstraZeneca | None | None | None | Innercool Therapies, Pfizer, Sanofi-Synthelabo, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, GlaxoSmithKline Global Cardiovascular Advisory Board | None |
| Suzanne Hughes, MSN, RN | None | None | Kos Pharmaceuticals | None | Guidant Corporation, Johnson&Johnson Merck | Freelance writer—honoraria paid by the ACCF; Associate Editor, Cardiosource | None |
| Edgar J. Kenton, MD | Lankenau Hospital | None | None | None | None | None | None |
| Marian Limacher, MD | University of Florida | Boehringer Ingelheim | NIH, NHLBI | Kos Pharmaceuticals | None | NIH Advisory Committee on Research on Women’s Health | None |
| Jonathan R. Lindner, MD | University of Virginia | None | None | None | None | None | None |
| Janet B. Long, MSN, ACNP | University Cardiology Foundation | None | None | AstraZeneca | None | None | None |
| Patrick McBride, MD | University of Wisconsin Medical School | None | None | Kos, Merck, Pfizer, Sanyko, Schering Plough | None | Merck | None |
| Dale Owen, MD | None | None | None | None | None | None | None |
| Rita F. Redberg, MD, MSc | None | None | None | None | None | None | None |
| Samuel J. Shubrooks, Jr, MD | Harvard Medical School | None | None | None | None | None | None |
| Robert A. Vogel, MD | University of Maryland Hospital | Pfizer, Novartis, Schering-Plough | None | Pfizer, Merck | None | None | None |
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.
Reviewers’ Disclosures
Footnotes
↵⁎ Dr Pasternak withdrew from the Writing Group on June 22, 2004, when he accepted an offer of employment as Vice President, Clinical Research, Cardiovascular and Atherosclerosis, at Merck Research Laboratories. The remaining members of the Writing Group were advised of his change in status before this Scientific Statement was finalized, and they affirmed their support of the Statement with subsequent revisions after his departure.
↵† Deceased.
This document was approved by the American Heart Association Science Advisory and Coordinating Committee on November 11, 2005, and by the American College of Cardiology Foundation Board of Trustees on November 10, 2005.
The American Heart Association and American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationships with industry for writing committee members, as well as peer reviewers of the document, are located before the references.
When this document is cited, the American College of Cardiology requests that the following citation format be used: Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol2006;47:2130–9. doi:10.1016/j.jacc.2006.04.026.
This article has been copublished in the May 16, 2006, issue of the Circulation(Circulation 2006;113).
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