Journal of the American College of Cardiology

Volume 58, Issue 23, November 2011 DOI: 10.1016/j.jacc.2011.10.824
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AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update
A Guideline From the American Heart Association and American College of Cardiology Foundation Endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association

Sidney C. Smith Jr, Emelia J. Benjamin, Robert O. Bonow, Lynne T. Braun, Mark A. Creager, Barry A. Franklin, Raymond J. Gibbons, Scott M. Grundy, Loren F. Hiratzka, Daniel W. Jones, Donald M. Lloyd-Jones, Margo Minissian, Lori Mosca, Eric D. Peterson, Ralph L. Sacco, John Spertus, James H. Stein and Kathryn A. Taubert

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Author + information

vol. 58 no. 23 2432-2446
DOI: 
https://doi.org/10.1016/j.jacc.2011.10.824
Published By: 
Journal of the American College of Cardiology
Print ISSN: 
0735-1097
Online ISSN: 
1558-3597
History: 
  • Published online November 29, 2011.
Copyright & Usage: 
American Heart Association, Inc.

Author Information

  1. Sidney C. Smith Jr, MD, FAHA, FACC, Chair,
  2. Emelia J. Benjamin, MD, ScM, FAHA, FACC,
  3. Robert O. Bonow, MD, FAHA, FACC,
  4. Lynne T. Braun, PhD, ANP, FAHA,
  5. Mark A. Creager, MD, FAHA, FACC,
  6. Barry A. Franklin, PhD, FAHA,
  7. Raymond J. Gibbons, MD, FAHA, FACC,
  8. Scott M. Grundy, MD, PhD, FAHA,
  9. Loren F. Hiratzka, MD, FAHA, FACC,
  10. Daniel W. Jones, MD, FAHA,
  11. Donald M. Lloyd-Jones, MD, ScM, FAHA, FACC,
  12. Margo Minissian, ACNP, AACC, FAHA,
  13. Lori Mosca, MD, PhD, MPH, FAHA,
  14. Eric D. Peterson, MD, MPH, FAHA, FACC,
  15. Ralph L. Sacco, MD, MS, FAHA,
  16. John Spertus, MD, MPH, FAHA, FACC,
  17. James H. Stein, MD, FAHA, FACC and
  18. Kathryn A. Taubert, PhD, FAHA
Key Words

Since the 2006 update of the American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) guidelines on secondary prevention (1), important evidence from clinical trials has emerged that further supports and broadens the merits of intensive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral artery disease, atherosclerotic aortic disease, and carotid artery disease. In reviewing this evidence and its clinical impact, the writing group believed it would be more appropriate to expand the title of this guideline to “Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease.” Indeed, the growing body of evidence confirms that in patients with atherosclerotic vascular disease, comprehensive risk factor management reduces risk as assessed by a variety of outcomes, including improved survival, reduced recurrent events, the need for revascularization procedures, and improved quality of life. It is important not only that the healthcare provider implement these recommendations in appropriate patients but also that healthcare systems support this implementation to maximize the benefit to the patient.

Compelling evidence-based results from recent clinical trials and revised practice guidelines provide the impetus for this update of the 2006 recommendations with evidence-based results (2–165) (Table 1). Classification of recommendations and level of evidence are expressed in ACCF/AHA format, as detailed in Table 2. Recommendations made herein are largely based on major practice guidelines from the National Institutes of Health and updated ACCF/AHA practice guidelines, as well as on results from recent clinical trials. Thus, the development of the present guideline involved a process of partial adaptation of other guideline statements and reports and supplemental literature searches. The recommendations listed in this document are, whenever possible, evidence based. Writing group members performed these relevant supplemental literature searches with key search phrases including but not limited to tobacco/smoking/smoking cessation; blood pressure control/hypertension; cholesterol/hypercholesterolemia/lipids/lipoproteins/dyslipidemia; physical activity/exercise/exercise training; weight management/overweight/obesity; type 2 diabetes mellitus management; antiplatelet agents/anticoagulants; renin/angiotensin/aldosterone system blockers; β-blockers; influenza vaccination; clinical depression/depression screening; and cardiac/cardiovascular rehabilitation. Additional searches cross-referenced these topics with the subtopics of clinical trials, secondary prevention, atherosclerosis, and coronary/cerebral/peripheral artery disease. These searches were limited to studies, reviews, and other evidence conducted in human subjects and published in English. In addition, the writing group reviewed documents related to the subject matter previously published by the AHA, the ACCF, and the National Institutes of Health.

View this table:
Table 1

AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: Intervention Recommendations With Class of Recommendation and Level of Evidence

View this table:
Table 2

Applying Classification of Recommendation and Level of Evidence

With regard to lipids and dyslipidemias, the lipid reduction trials published between 2002 and 2006 (18,25,166–168) included >50,000 patients and 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 (169). 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 (26,27) demonstrated cardiovascular benefit for lipid lowering significantly below current cholesterol goal levels for those with chronic coronary heart disease. These trials allowed for alterations in the 2006 guideline, 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 patients at highest risk. The benefits of lipid-lowering therapy are in proportion to the reduction in LDL-C, and when LDL-C is above 100 mg/dL, an adequate dose of statin therapy should be used to achieve at least a 30% lowering of LDL-C. 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. For patients with triglyceride levels ≥200 mg/dL, non–high-density lipoprotein cholesterol values should be used as a guide to therapy. Although no studies have directly tested treatment to target strategies, the target LDL-C and non–HDL-C levels are derived from several randomized controlled trials where the LDL-C levels achieved for patients showing benefit are used to suggest targets. Thus, references for the studies from which targets are derived are listed and targets are considered as level of evidence C. Importantly, this guideline statement for patients with atherosclerotic disease does not modify the recommendations of the 2004 ATP III update for patients without atherosclerotic disease who have diabetes mellitus 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. The writing group agreed that no further changes be made in the recommendations for treatment of dyslipidemia pending the expected publication of the National Heart, Lung, and Blood Institute's updated ATP guidelines in 2012. Similar recommendations were made for the treatment of hypertension by the writing group pending the publication of the updated report of the National Heart, Lung, and Blood Institute's Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, expected in the spring of 2012.

Trials involving other secondary prevention therapies also have influenced major practice guidelines used to formulate the recommendations in the present update. Thus, specific recommendations for clopidogrel use in post–acute coronary syndrome or post–percutaneous coronary intervention stented patients were included in the 2006 update, and recommendations regarding prasugrel and ticagrelor are added to this guideline on the basis of the results of the TRITON–TIMI 38 trial (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction) and PLATO (Study of Platelet Inhibition and Patient Outcomes). The present update continues to recommend 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. The results of several trials involving angiotensin-converting enzyme inhibitor therapy among patients at relatively low risk with stable coronary disease and normal left ventricular function influenced the current recommendations (32). Finally, the recommendations for β-blocker therapy have been clarified to reflect the fact that evidence supporting their efficacy is greatest among patients with recent myocardial infarction (<3 years) and/or left ventricular systolic dysfunction (left ventricular ejection fraction ≤40%). For those patients without these Class I indications, β-blocker therapy is optional (Class IIa or IIb).

The writing group confirms the recommendation introduced in 2006 for this guideline 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 (147). Additionally, the writing group added new sections on depression and on cardiovascular rehabilitation.

The writing group continues to emphasize the importance of giving consideration to the use of cardiovascular medications that have been proven 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 15 years since these 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 16.3 million for CHD alone) (170) 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 ACCF recommend the use of programs such as the AHA's Get With The Guidelines (171), the American Cancer Society/American Diabetes Association/AHA's Guideline Advantage Program (172), and the ACC's PINNACLE (Practice INNovation And CLinical Excellence) program (173) to identify appropriate patients for therapy, provide practitioners with useful reminders based on the guidelines, and continually assess the success achieved in providing these therapies to the patients who can benefit from them. In this regard, it is important that the healthcare provider not only implement the therapies according to their class of recommendation but also assess for and assist with patient compliance with these therapies in each patient encounter. Discussion of the literature and supporting references for many of the recommendations summarized in the present guideline can be found in greater detail in the upcoming ACCF/AHA guideline for management of patients undergoing PCI (174), ACCF/AHA guideline for management of patients with peripheral artery disease (175,176), the AHA effectiveness-based guidelines for cardiovascular disease prevention in women (46), and in the AHA/American Stroke Association guidelines for the prevention of stroke in patients with stroke or transient ischemic attack (123).

Finally, the practitioner should exercise judgment in initiating the various recommendations if the patient has recently experienced an acute event.

Disclosures

Writing Group MemberEmploymentResearch GrantOther Research SupportSpeaker's Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOther
Sidney C. Smith, JrUniversity of North CarolinaNoneNoneNoneNoneNoneNoneNone
Emelia J. BenjaminBoston University School of MedicineNoneNoneNoneNoneNoneNoneNone
Robert O. BonowNorthwestern UniversityNoneNoneNoneNoneNoneNoneNone
Lynne T. BraunRush University Medical CenterNIH-Coinvestigator, Reducing Health Disparity in African American Women: Adherence to Physical Activity*NoneNoneNoneNoneNoneNone
Mark A. CreagerBrigham and Women's HospitalMerck†; Sanofi Aventis†NoneNoneNoneNonePfizer*; Sanofi Aventis*; Merck (via TIMI group)*; AstraZeneca*None
Barry A. FranklinWilliam Beaumont HospitalNoneNoneI receive honoraria throughout the year for talks to hospitals (ie, medical grand rounds) and cardiac rehabilitation state associations*NoneNoneSmart Balance Scientific Advisory Board*None
Raymond J. GibbonsMayo ClinicKing Pharmaceuticals†; TherOx†; VeloMedix†NoneNoneNoneNoneCardiovascular Clinical Studies*; Medscape (heart.org)*; Molecular Insight Pharmaceuticals*; TherOx*; Lantheus Medical Imaging*None
Scott M. GrundyUT Southwestern Medical CenterSankyo†Perot Foundation†NoneNoneNoneAstraZeneca*; Merck*; Merck/Schering-Plough*; Pfizer* (Relationships ended 3 years ago)None
Loren F. HiratzkaCardiovascular and Thoracic Surgeons/Tri-Health IncNoneNoneNoneNoneNoneNoneNone
Daniel W. JonesUniversity of MississippiNoneNoneNoneNoneNoneNoneNone
Donald M. Lloyd-JonesNorthwesternNoneNoneNoneNoneNoneNoneNone
Margo MinissianCedars Sinai Medical CenterRWise Study, Co-Investigator, Gilead Sciences†NoneNoneNoneNoneNoneNone
Lori MoscaColumbia UniversityNIH*NoneNoneNoneNoneAdvise & Consent, Inc.*; Gilead Science*; Rowpar Pharmaceuticals, Inc.†; Sanofi-Aventis*None
Eric D. PetersonDuke University Medical CenterBristol-Myers Squibb/Sanofi†; Eli Lilly†; Merck/Schering-Plough†; Johnson & Johnson†NoneNoneNoneNoneNoneNone
Ralph L. SaccoUniversity of MiamiNINDS–Northern Manhattan Study*NoneNoneNoneNoneBoehringer Ingelheim* (ended March 2009); GlaxoSmithKline (ended March 2009)*; Sanofi Aventis* (ended March 2009); DSMB (Atrial Fibrillation Trial–institutionally sponsored by Population Health Research Institute at McMaster University, Hamilton, Ontario)*None
John SpertusMid America Heart InstituteACCF†; AHA†; Amgen†; Bristol-Myers Squibb/Sanofi†; Cordis†; Eli Lilly†; NIH†Atherotech†; Roche Diagnostics†NoneNoneHolds copyright to Kansas City Cardiomyopathy Questionnaire†; holds copyright to Peripheral Artery Questionnaire*; holds copyright to Seattle Angina Questionnaire†St. Jude Medical*; United HealthCare*; Amgen*None
James H. SteinUniversity of Wisconsin School of Medicine and Public HealthSanofi-Aventis† (ended July 2009); Siemens Medical Solutions† (ended July 2009); SonoSite† (ended September 2009)NoneAbbott* and Takeda* (no permanent remuneration; all money to charity. Both were terminated December 2008)NoneNoneAbbott,* Lilly,* and Takeda* (research trial DSMBs)Takeda* (training grant to institution ended June 2009); Wisconsin Alumni Research Foundation* (royalties related to carotid ultrasound and cardiovascular disease risk prediction)
Kathryn A. TaubertWorld Heart FederationNoneNoneNoneNoneNoneNoneNone

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 1) the person receives $10,000 or more during any 12-month period, or 5% or more of the person's gross income; or 2) 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

    ReviewerEmploymentResearch GrantOther Research SupportSpeaker's Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/Advisory BoardOther
    Elliott M. AntmanBrigham & Women's HospitalNoneNoneNoneNoneNoneNoneNone
    Jeffrey L. AndersonIntermountain Medical CenterNoneNoneNoneNoneNoneAstraZeneca*None
    Gary J. BaladyBoston Medical CenterNoneNoneNoneNoneNoneNoneNone
    Eric R. BatesUniversity of MichiganNoneNoneNoneNoneNoneAstraZeneca*; Daiichi Sankyo*; Eli Lilly*; Merck*; Sanofi Aventis*None
    Vera BittnerUniversity of Alabama at BirminghamClinical site PI for multicenter trials funded by: Roche/Genentech†; Gilead; GSK†; NIH/Abbott†; NIH/Yale†NoneNoneNoneNoneRoche/Genentech*; Amarin*; Pfizer*None
    Ann F. BolgerUniversity of California, San FranciscoNoneNoneNoneNoneNoneNoneNone
    Victor A. FerrariUniversity of PennsylvaniaNoneNoneNoneNoneNoneBoard of Trustees, Society for Cardiovascular Magnetic Resonance (no monetary value)*; Editorial Board, Journal of Cardiovascular Magnetic Resonance (no monetary value)*None
    Stephan FihnDepartment of Veterans Affairs and University of WashingtonNoneNoneNoneNoneNoneNoneNone
    Gregg FonarowUCLANHLBI†; AHRQ†NoneNoneNoneNoneNovartis†; Medtronic*None
    Federico GentileCentro Medico diagnostic, Naples-ItalyNoneNoneNoneNoneNoneNoneNone
    Larry B. GoldsteinDuke UniversityNoneNoneNoneNoneNoneNoneNone
    Jonathan HalperinMount Sinai Medical CenterNoneNoneNoneNoneNoneBoehringer Ingelheim†; Astellas Pharma, US*; Bristol-Myers Squibb*; Daiichi Sankyo*; Johnson & Johnson*; Pfizer, Inc*; Sanofi-Aventis*None
    Courtney JordanUniversity of MinnesotaNoneNoneNoneNoneNoneNoneNone
    Noel Bairey MerzCedars-Sinai Medical CenterGilead†NHLBI†Mayo Foundation*; SCS Healthcare†; Practice Point Communications*; Inst for Professional Education*; Medical Education Speakers Network*; Minneapolis Heart Institute*; Catholic Healthcare West*; Novant Health*; HealthScience Media Inc*; Huntsworth Health*; WomenHeart Coalition*; Los Robles Medical Center*; Monterrey Community Hospital (honorarium, donated to ACC)*; Los Angeles OB-GYN Society*; Pri-Med*; North American Menopause Society*NoneMedtronic†UCSF*; Society for Women's Health Research*; Interquest*; Dannemiller*; Navvis & Co*; Springer SBM LLC*; Duke*; NHLBI*; Italian National Institutes of Health*; Gilead*None
    L. Kristin NewbyDuke UniversityNoneNoneNoneNoneNoneNoneNone
    Patrick O'GaraBrigham & Women's HospitalNoneNoneNoneNoneNoneLantheus Medical Imaging*None
    Thomas W. RookeMayo ClinicNoneNoneNoneNoneNoneMerck–Adjudication (Event) Committee*None
    Vincent SorrellUniversity of ArizonaNoneNoneLantheus Medical Imaging†NoneNoneNoneNone

    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. A relationship is considered to be “significant” if 1) the person receives $10,000 or more during any 12-month period, or 5% or more of the person's gross income; or 2) 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.

    • Reviewer Disclosures

    Footnotes

    • The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

    • This document was approved by the American Heart Association Science Advisory and Coordinating Committee on October 5, 2011, and by the American College of Cardiology Foundation Board of Trustees on September 29, 2011.

    • The American Heart Association requests that this document be cited as follows: Smith SC Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011: published online before print November 3, 2011, 10.1161/CIR.0b013e318235eb4d.

    • Copies: This document is available on the World Wide Web sites of the American Heart Association (my.americanheart.org) and the American College of Cardiology (www.cardiosource.org). To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay{at}wolterskluwer.com.

    • Reprinted with permission from Circulation. Published online ahead of print November 3, 2011.

    • Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.

    • Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

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