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

Area for InterventionRecommendations
Smoking
 Goal: Complete cessation. No exposure to environmental tobacco smokeClass I
  • 1. Patients should be asked about tobacco use status at every office visit (2,3,4,5,7). (Level of Evidence: B)

  • 2. Every tobacco user should be advised at every visit to quit (4,5,7,9). (Level of Evidence: A)

  • 3. The tobacco user's willingness to quit should be assessed at every visit. (Level of Evidence: C)

  • 4. Patients should be assisted by counseling and by development of a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program (4–9). (Level of Evidence: A)

  • 5. Arrangement for follow up is recommended. (Level of Evidence: C)

  • 6. All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at work, home, and public places (10,11). (Level of Evidence: B)

Blood pressure controlNote: The writing committee did not think that the 2006 recommendations for blood pressure control (below) should be modified at this time. The writing committee anticipates that the recommendations will be reviewed when the updated JNC guidelines are released.
 Goal: <140/90 mm Hg
Class I
  • 1. All patients should be counseled regarding the need for lifestyle modification: weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products (12–16). (Level of Evidence: B)

  • 2. Patients with blood pressure ≥140/90 mm Hg should be treated, as tolerated, with blood pressure medication, treating initially with β-blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve goal blood pressure (12,17,18). (Level of Evidence: A)

Lipid managementGoal: Treatment with statin therapy; use statin therapy to achieve an LDL-C of <100 mg/dL; for very high risk* patients an LDL-C <70 mg/dL is reasonable; if triglycerides are ≥200 mg/dL, non–HDL-C should be <130 mg/dL, whereas non–HDL-C <100 mg/dL for very high risk patients is reasonableNote: The writing committee anticipates that the recommendations will be reviewed when the updated ATP guidelines are released.
Class I
  • 1. A lipid profile in all patients should be established, and for hospitalized patients, lipid-lowering therapy as recommended below should be initiated before discharge (20). (Level of Evidence: B)

  • 2. Lifestyle modifications including daily physical activity and weight management are strongly recommended for all patients (19,29). (Level of Evidence: B)

  • 3. Dietary therapy for all patients should include reduced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d) (21–24,29). (Level of Evidence: B)

  • 4. In addition to therapeutic lifestyle changes, statin therapy should be prescribed in the absence of contraindications or documented adverse effects (25–29). (Level of Evidence: A)

  • 5. An adequate dose of statin should be used that reduces LDL-C to <100 mg/dL AND achieves at least a 30% lowering of LDL-C (25–29). (Level of Evidence: C)

  • 6. Patients who have triglycerides ≥200 mg/dL should be treated with statins to lower non–HDL-C to <130 mg/dL (25–27,30). (Level of Evidence: B)

  • 7. Patients who have triglycerides >500 mg/dL should be started on fibrate therapy in addition to statin therapy to prevent acute pancreatitis. (Level of Evidence: C)

Class IIa
  • 1. If treatment with a statin (including trials of higher-dose statins and higher-potency statins) does not achieve the goal selected for a patient, intensification of LDL-C–lowering drug therapy with a bile acid sequestrant or niacin§ is reasonable (31–33). (Level of Evidence: B)

  • 2. For patients who do not tolerate statins, LDL-C–lowering therapy with bile acid sequestrants and/or niacin§ is reasonable (35,36). (Level of Evidence: B)

  • 3. It is reasonable to treat very high-risk* patients with statin therapy to lower LDL-C to <70 mg/dL (26–28,37,38,166). (Level of Evidence: C)

  • 4. In patients who are at very high risk* and who have triglycerides ≥200 mg/dL, a non–HDL-C goal of <100 mg/dL is reasonable (25–27,30). (Level of Evidence: B)

Class IIb
  • 1. The use of ezetimibe may be considered for patients who do not tolerate or achieve target LDL-C with statins, bile acid sequestrants, and/or niacin.§(Level of Evidence: C)

  • 2. For patients who continue to have an elevated non–HDL-C while on adequate statin therapy, niacin§ or fibrate therapy (32,35,41) (Level of Evidence: B) or fish oil (Level of Evidence: C) may be reasonable.

  • 3. For all patients, it may be reasonable to recommend omega-3 fatty acids from fish or fish oil capsules (1 g/d) for cardiovascular disease risk reduction (44–46). (Level of Evidence: B)

Physical activityClass I
 Goal: At least 30 minutes, 7 days per week (minimum 5 days per week)
  • 1. For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least fit, least active high-risk cohort (bottom 20%) (54,55,58). (Level of Evidence: B)

  • 2. For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription (47–52,58). (Level of Evidence: B)

  • 3. The clinician should counsel patients to report and be evaluated for symptoms related to exercise. (Level of Evidence: C)

Class IIa
  • 1. It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week (59). (Level of Evidence: C)

Weight managementClass I
 Goals:
  • 1. Body mass index and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage weight maintenance/reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2 (60–62,65–70). (Level of Evidence: B)

  • 2. If waist circumference (measured horizontally at the iliac crest) is ≥35 inches (≥89 cm) in women and ≥40 inches (≥102 cm) in men, therapeutic lifestyle interventions should be intensified and focused on weight management (66–70). (Level of Evidence: B)

  • 3. The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated. (Level of Evidence: C)

  Body mass index: 18.5 to 24.9 kg/m2
  Waist circumference: women <35 inches (<89 cm), men <40 inches (<102 cm)
Type 2 diabetes mellitus managementNote: Recommendations below are for prevention of cardiovascular complications.
Class I
  • 1. Care for diabetes should be coordinated with the patient's primary care physician and/or endocrinologist. (Level of Evidence: C)

  • 2. Lifestyle modifications including daily physical activity, weight management, blood pressure control, and lipid management are recommended for all patients with diabetes (19,22–24,29,56,58,59,62,66,74,162). (Level of Evidence: B)

Class IIa
  • 1. Metformin is an effective first-line pharmacotherapy and can be useful if not contraindicated (74–76). (Level of Evidence: A)

  • 2. It is reasonable to individualize the intensity of blood sugar–lowering interventions based on the individual patient's risk of hypoglycemia during treatment. (Level of Evidence: C)

Class IIb
  • 1. Initiation of pharmacotherapy interventions to achieve target HbA1c may be reasonable (71,72,74–80). (Level of Evidence: A)

  • 2. A target HbA1c of ≤7% may be considered. (Level of Evidence: C)

  • 3. Less stringent HbA1c goals may be considered for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbidities, or those in whom the goal is difficult to attain despite intensive therapeutic interventions. (Level of Evidence: C)

Antiplatelet agents/anticoagulantsClass I
  • 1. Aspirin 75–162 mg daily is recommended in all patients with coronary artery disease unless contraindicated (64,81,82,116). (Level of Evidence: A)

  • • Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin (117). (Level of Evidence: B)

  • 2. A P2Y12 receptor antagonist in combination with aspirin is indicated in patients after ACS or PCI with stent placement (83–85). (Level of Evidence: A)

  • • For patients receiving a bare-metal stent or drug-eluting stent during PCI for ACS, clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily should be given for at least 12 months (84,86,113,114). (Level of Evidence: A)

  • 3. For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg daily for 1 year appear to be efficacious (87–90). (Level of Evidence: A)

  • 4. In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75–325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily, respectively) should be started and continued (91,104,116). (Level of Evidence: A)

Antiplatelet agents/anticoagulants cont'd
  • 5. For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with aspirin (75–325 mg daily) or clopidogrel (75 mg daily) should be started and continued (92,107,116,117). (Level of Evidence: A)

  • 6. Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis (93,94,105,110). (Level of Evidence: A)

  • • If there is a compelling indication for anticoagulant therapy, such as atrial fibrillation, prosthetic heart valve, left ventricular thrombus, or concomitant venous thromboembolic disease, warfarin should be administered (95,99–102). (Level of Evidence: A) (NOTE: Patients receiving low-dose aspirin for atherosclerosis should continue to receive it.)

  • • For patients requiring warfarin, therapy should be administered to achieve the recommended INR for the specific condition (81,96). (Level of Evidence: B)

  • • Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely (97,98,110). (Level of Evidence: A)

Class IIa
  • 1. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by thienopyridine therapy after stent implantation, earlier discontinuation (eg, <12 months) is reasonable. (Level of Evidence: C) (Note: the risk for serious cardiovascular events because of early discontinuation of thienopyridines is greater for patients with drug-eluting stents than those with bare-metal stents.)

  • 2. After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses (84,85,118–122). (Level of Evidence: B)

  • 3. For patients undergoing coronary artery bypass grafting, clopidogrel (75 mg daily) is a reasonable alternative in patients who are intolerant of or allergic to aspirin. (Level of Evidence: C)

Class IIb
  • 1. The benefits of aspirin in patients with asymptomatic peripheral artery disease of the lower extremities are not well established (108,109). (Level of Evidence: B)

  • 2. Combination therapy with both aspirin 75 to 162 mg daily and clopidogrel 75 mg daily may be considered in patients with stable coronary artery disease (112). (Level of Evidence: B)

Renin-angiotensin-aldosterone system blockers
 ACE inhibitorsClass I
  • 1. ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction ≤40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated (124,125). (Level of Evidence: A)

Class IIa
  • 1. It is reasonable to use ACE inhibitors in all other patients (126). (Level of Evidence: B)

 ARBsClass I
  • 1. The use of ARBs is recommended in patients who have heart failure or who have had a myocardial infarction with left ventricular ejection fraction ≤40% and who are ACE-inhibitor intolerant (130–132). (Level of Evidence: A)

Class IIa
  • 1. It is reasonable to use ARBs in other patients who are ACE-inhibitor intolerant (133). (Level of Evidence: B)

Class IIb
  • 1. The use of ARBs in combination with an ACE inhibitor is not well established in those with systolic heart failure (132,134). (Level of Evidence: A)

 Aldosterone blockadeClass I
  • 1. Use of aldosterone blockade in post–myocardial infarction patients without significant renal dysfunction# or hyperkalemia** is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and β-blocker, who have a left ventricular ejection fraction ≤40%, and who have either diabetes or heart failure (136,137). (Level of Evidence: A)

β-BlockersClass I
  • 1. β-Blocker therapy should be used in all patients with left ventricular systolic dysfunction (ejection fraction ≤40%) with heart failure or prior myocardial infarction, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce mortality.) (138,140,141) (Level of Evidence: A)

  • 2. β-Blocker therapy should be started and continued for 3 years in all patients with normal left ventricular function who have had myocardial infarction or ACS (139,142,143). (Level of Evidence: B)

Class IIa
  • 1. It is reasonable to continue β-blockers beyond 3 years as chronic therapy in all patients with normal left ventricular function who have had myocardial infarction or ACS (139,142,143). (Level of Evidence: B)

  • 2. It is reasonable to give β-blocker therapy in patients with left ventricular systolic dysfunction (ejection fraction ≤40%) without heart failure or prior myocardial infarction. (Level of Evidence: C)

β-Blockers cont'dClass IIb
  • 1. β-Blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. (Level of Evidence: C)

Influenza vaccinationClass I
  • 1. Patients with cardiovascular disease should have an annual influenza vaccination (144–147). (Level of Evidence: B)

DepressionClass IIa
  • 1. For patients with recent coronary artery bypass graft surgery or myocardial infarction, it is reasonable to screen for depression if patients have access to case management, in collaboration with their primary care physician and a mental health specialist (148–152). (Level of Evidence: B)

Class IIb
  • 1. Treatment of depression has not been shown to improve cardiovascular disease outcomes but may be reasonable for its other clinical benefits. (Level of Evidence: C)

Cardiac rehabilitationClass I
  • 1. All eligible patients with ACS or whose status is immediately post coronary artery bypass surgery or post-PCI should be referred to a comprehensive outpatient cardiovascular rehabilitation program either prior to hospital discharge or during the first follow-up office visit (55,154,161,163). (Level of Evidence: A)

  • 2. All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery or PCI (Level of Evidence: A) (55,154,155,161), chronic angina (Level of Evidence: B) (161,163), and/or peripheral artery disease (Level of Evidence: A) (158,164) within the past year should be referred to a comprehensive outpatient cardiovascular rehabilitation program.

  • 3. A home-based cardiac rehabilitation program can be substituted for a supervised, center-based program for low-risk patients (153,159,160). (Level of Evidence: A)

Class IIa
  • 1. A comprehensive exercise-based outpatient cardiac rehabilitation program can be safe and beneficial for clinically stable outpatients with a history of heart failure (159,159a–159c). (Level of Evidence: B)

JNC indicates the report of the National Heart, Lung, and Blood Institute's Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines; ACE, angiotensin-converting enzyme; ATP, Adult Treatment Panel; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; HbA1c, hemoglobin A1c; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; TIA, transient ischemic attack; INR, international normalized ratio; and ARB, angiotensin receptor blocker.

  • * Presence of established CVD plus 1) multiple major risk factors (especially diabetes), 2) severe and poorly controlled risk factors (especially continued cigarette smoking), 3) multiple risk factors of the metabolic syndrome (especially high triglycerides ≥200 mg/dL plus non–HDL-C ≥130 mg/dL with low HDL-C <40 mg/dL), and 4) patients with ACSs.

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

  • The use of bile acid sequestrants is relatively contraindicated when triglycerides are ≥200 mg/dL and is contraindicated when triglycerides are ≥500 mg/dL.

  • § Dietary supplement niacin must not be used as a substitute for prescription niacin.

  • The combination of high-dose statin plus fibrate (especially gemfibrozil) can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination.

  • Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.

  • # Estimated creatinine clearance should be >30 mL/min.

  • ** Potassium should be <5.0 mEq/L.