Table 1

AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease: 2001 Update

GoalsIntervention Recommendations
Smoking:
 Goalcomplete cessation
Assess tobacco use. Strongly encourage patient and family to stop smoking and to avoid secondhand smoke. Provide counseling, pharmacological therapy, including nicotine replacement and buproprion, and formal smoking cessation programs as appropriate.
BP control:
 Goal<140/90 mm Hg or <130/85 mm Hg if heart failure or renal insufficiency <130/80 mm Hg if diabetes
Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients with blood pressure ≥130 mm Hg systolic or 80 mm Hg diastolic. Add blood pressure medication, individualized to other patient requirements and characteristics (ie, age, race, need for drugs with specific benefits) ifblood pressure is not <140 mm Hg systolic or 90 mm Hg diastolic orif blood pressure is not <130 mm Hg systolic or 85 mm Hg diastolic for individuals with heart failure or renal insufficiency (<80 mm Hg diastolic for individuals with diabetes).
Lipid management:
 Primary goalLDL <100 mg/dL
Start dietary therapy in all patients (<7% saturated fat and <200 mg/d cholesterol) and promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids. Assess fasting lipid profile in all patients, and within 24 hr of hospitalization for those with an acute event. If patients are hospitalized, consider adding drug therapy on discharge. Add drug therapy according to the following guide:
LDL <100 mg/dL (baseline or on-treatment) Further LDL-lowering therapy not required Consider fibrate or niacin (if low HDL or high TG)LDL 100–129 mg/dL (baseline or on-treatment) Therapeutic options: Intensify LDL-lowering therapy (statin or resin*) Fibrate or niacin (if low HDL or high TG) Consider combined drug therapy (statin+fibrate or niacin) (if low HDL or high TG)LDL ≥130 mg/dL (baseline or on-treatment) Intensify LDL-lowering therapy (statin or resin*) Add or increase drug therapy with lifestyle therapies
Lipid management:
 Secondary goalIf TG ≥200 mg/dL, then non-HDLshould be <130 mg/dL
If TG ≥150 mg/dL or HDL <40 mg/dL: Emphasize weight management and physical activity. Advise smoking cessation. If TG 200–499 mg/dL: Consider fibrate or niacin afterLDL-lowering therapy*If TG ≥500 mg/dL: Consider fibrate or niacin beforeLDL-lowering therapy*Consider omega-3 fatty acids as adjunct for high TG
Physical activity:
 Minimum goal30 minutes 3 to 4 days per week Optimaldaily
Assess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30 to 60 minutes of activity, preferably daily, or at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, household work). Advise medically supervised programs for moderate- to high-risk patients.
Weight management:
 GoalBMI 18.5–24.9 kg/m2
Calculate BMI and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy. Start weight management and physical activity as appropriate. Desirable BMI range is 18.5–24.9 kg/m2. When BMI ≥25 kg/m2, goal for waist circumference is ≤40 inches in men and ≤35 inches in women.
Diabetes management:
 GoalHbA1c<7%
Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c. Treatment of other risks (eg, physical activity, weight management, blood pressure, and cholesterol management).
Antiplatelet agents/ anticoagulants:Start and continue indefinitely aspirin 75 to 325 mg/d if not contraindicated. Consider clopidogrel 75 mg/d or warfarin if aspirin contraindicated. Manage warfarin to international normalized ratio=2.0 to 3.0 in post-MI patients when clinically indicated or for those not able to take aspirin or clopidogrel.
ACE inhibitors:Treat all patients indefinitely post MI; start early in stable high-risk patients (anterior MI, previous MI, Killip class II [S3gallop, rales, radiographic CHF]). Consider chronic therapy for all other patients with coronary or other vascular disease unless contraindicated.
β-Blockers:Start in all post-MI and acute ischemic syndrome patients. Continue indefinitely. Observe usual contraindications. Use as needed to manage angina, rhythm, or blood pressure in all other patients.

BP indicates blood pressure; TG, triglycerides; BMI, body mass index; HbA1c, major fraction of adult hemoglobin; MI, myocardial infarction; and CHF, congestive heart failure.

  • * The use of resin is relatively contraindicated when TG >200 mg/dL.

  • Non-HDL cholesterol=total cholesterol minus HDL cholesterol.