The levels of evidence [A-D] and strength of recommendation [I-III] are defined at the end of the "Major Recommendations" field.
Smoking Cessation
Goal: Complete Cessation
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Ask about smoking status and document in medical record regularly [IC].
Advise quit attempt [IA] and assess willingness.
Assist with a quit plan [IC], consider pharmacological interventions, educate, and follow-up as quitting often requires multiple attempts.
Counseling can assist a patient in quitting with or without pharmacological therapy [IA].
Pharmacological therapy [IA] is used to reduce nicotine withdrawal symptoms and includes:
1) nicotine replacement, 2) bupropion hydrochloride, and 3) varenicline (On 2/1/2008 the Food and Drug Administration [FDA] issued an alert regarding serious neuropsychiatric symptoms occurring in patients taking varenicline, but it still continues to be considered first line therapy).
Nicotine transdermal formulations are contraindicated in patients with arrhythmias, worsening angina, severe angina, and within 2 weeks of myocardial infarction. It is recommended to use them with caution in patients with CAD.
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| Antiplatelet Agents and Anticoagulants |
In patients with established CAD, aspirin should be prescribed at a dose of 81-162 mg daily [IA]. (See text in the original guideline document regarding those with coronary event while already on aspirin.)
In patients with recent acute coronary syndromes who are treated with medical therapy, the addition of clopidogrel should be considered at a dose of 75 mg daily for at least 1 month [IA] and ideally up to 1 year post-event. NSTEMI (non-ST-elevation myocardial infarction) [IA], STEMI (ST-elevation myocardial infarction) [IIC]. Benefit of prolonged dual therapy is not proven.
Clopidogrel at a dose of 75 mg daily (or ticlopidine) should be considered indefinitely in those patients with established coronary artery disease who are intolerant of aspirin [IA].
Following stent placement:
Aspirin should be used at a dose of 162 to 325 mg daily for at least 1 month after a bare-metal stent, 3 months after a sirolimus-eluting stent, and 6 months after a paclitaxel-eluting stent. After that period of time, the dose of aspirin can be reduced to 75 to 162 mg daily but continued indefinitely [IA].
Clopidogrel at a dose of 75 mg daily should be prescribed for at least 4 weeks after a bare-metal stent, but ideally up to 1 year. For drug-eluting stents, clopidogrel should be used at a dose of 75 mg daily for 1 year [IB]. Continuation of clopidogrel beyond 1 year may be considered in patients at low-risk for bleeding and high-risk for late stent thrombosis [IID].
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Blood Pressure Control
Goal:
<135/80
more aggressive control may be warranted, particularly for renal disease
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A general blood pressure (BP) goal of <135/80 is reasonable based on available data. Few studies have targeted or achieved systolic BP below 140 mmHg, so recommendations for systolic BP goals are largely based on extrapolations and expert opinion.
The Joint National Commission on Prevention, Detection, and Treatment of High Blood Pressure (JNC7) recommended a goal of BP <140/90 mmHg in patients with coronary artery disease (CAD) and a lower BP goal (<130/80 mmHg) in patient with diabetes mellitus or proteinuric kidney disease. Published trials, some after JNC 7, provide some support for a BP goal less than 130/80 mm Hg in patients with atherosclerotic cardiovascular disease. A similar BP goal was recommended in the 2007 American Heart Association statement on the treatment of blood pressure in ischemic heart disease and the 2007 European Society of Hypertension/European Society of Cardiology guidelines on the management of hypertension.
For patients not at target, recommend initiation of lifestyle modification and blood pressure medications [IA]. Useful lifestyle interventions include sodium reduction, weight control, increased physical activity, and alcohol moderation. First line agents beta-blockers, angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin-receptor blocker (ARB), and thiazides to achieve goal.
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Lipid Management
Goal:
Low-density lipoprotein cholesterol (LDL-C) ≤ 100
If at very high risk, <70 mg/dl is a reasonable therapeutic option
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Obtain a full fasting lipid panel (total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides) [IA].
Assess and recommend lifestyle modification when indicated [IA].
Assess the patient for secondary causes of lipid disorders and optimize if identified.
LDL-C should be less than 100 mg/dL [IA], further reduction to LDL-C<70 mg/dL is reasonable [IIA]. If baseline LDL-C is 70-100 mg/dL, it is reasonable to treat to LDL-C<70 mg/dL [IIA].
Consider statin therapy for all patients –moderate potency statin even if low LDL-C [IA]. (Note: in diabetes mellitus (DM) patients age <40 with no other coronary heart disease (CHD) risk, statin is only marginally cost-effective.)
Non-statin lipid agents (fibrates, Niacin, resins, ezetimibe) have less or no evidence for improved outcomes compared to statins [IA].
Combination therapy (statin + any other lipid agent) improves lipids, but may increase myopathy risk, and has not yet been shown to improve outcomes compared to statins [IIC].
Note: use of resins relatively contraindicated if triglycerides ≥ 200 mg/dL.
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| Beta-blockers |
It is beneficial to start and continue oral beta-blocker therapy indefinitely in all patients who have had a myocardial infarction, acute coronary syndrome, or left ventricle dysfunction with or without heart failure symptoms, unless contraindicated [IA] unstable angina (UA)/NSTEMI [IB].
Patients with moderate or severe left ventricular (LV) failure should receive oral beta-blocker therapy with a gradual titration scheme (carvedilol, metoprolol succinate, bisoprolol) [IB].
Prescribing beta-blockers is reasonable for low-risk patients (i.e., normal left ventricular function, revascularized, no high-risk features) recovering from UA/NSTEMI in the absence of absolute contraindications [IIA].
(see text in the original guideline document for cautions regarding beta-blocker use in the acute setting)
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| Renin-angiotensin-aldosterone system blockers |
ACE inhibitors are first line therapy in all patients who have: heart failure or asymptomatic left ventricular dysfunction (left ventricular ejection fraction [LVEF] ≤ 40%); ST elevation myocardial infarction (MI); in non-ST elevation MI with anterior infarct, diabetes, or systolic dysfunction; proteinuric chronic kidney disease; or severe left ventricular hypertrophy [IA]. The data support a similar effect for angiotensin-receptor blocker's in all these settings (STEMI [IA], UA/NSTEMI [IIA]).
ACE inhibitors are reasonable for patients recovering from unstable angina or NSTEMI in the absence of left ventricular dysfunction, hypertension or diabetes mellitus, unless otherwise contraindicated. The data for benefit are mixed [IIA].
In patients with either symptomatic heart failure or diabetes mellitus, prescribe long-term aldosterone receptor blockade for unstable angina or acute coronary syndrome patients without significant kidney dysfunction (estimated creatinine clearance should be greater than 30 mL per min) or hyperkalemia (potassium should be less than or equal to 5 mEq per liter) who are already receiving therapeutic doses of an ACE inhibitor, and have an left ventricular ejection fraction less than or equal to 40% [IA]. (See caution in text in original guideline document.)
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Diabetes Management
Goals:
- Check LDL annually
- Consider statin
- BP ≤ 130-135/80
- Smoking status and cessation
- Glycemic control:
- Tight for Type 1 (Glycosylated Hemoglobin [HbA1c] <7%)
- Reasonable for Type 2 (level debatable), consider < 8%
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Check lipid profile- fasting or with direct LDL- annually
Prescribe moderate dose statin (e.g., generic simvastatin 40 mg po daily) [IA]. In patients <40 years of age and without CAD, statins are optional.
Goal LDL <100 mg/dL recommended [IA]; lower target levels not yet clearly defined in trials. (See lipid section above.)
Target blood pressure ≤ 130-135ƒ‡/80 [IA].
Check smoking status annually and recommend nonsmoking, educate and encourage cessation [IC].
Tight glycemic control in Type I diabetes [IA].
Glycemic control has not been of proven benefit in prevention of macrovascular complications of Type 2 diabetes. The target level is under debate and less stringent goals might be appropriate.
For individuals with CAD, Healthcare Effectiveness Data and Information Set (HEDIS) is recommending a level < 8%, although no new data to guide this specific recommendation.
In patients with Type 2 diabetes and microvascular complications or other compelling comorbidities, tight control (HbA1C < 7%) is recommended.
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| Pain Control |
At the time of admission for acute coronary syndrome discontinue all cyclooxygenase-2 inhibitors (COX-2) inhibitors and non-steroidal anti-inflammatory drugs, EXCEPT aspirin as above [IC].
In patients with established CAD requiring analgesia, COX-2 inhibitors and non-steroidal anti-inflammatory drugs with COX-2 activity should be avoided whenever possible [IC]. To minimize risk, a stepwise approach to pain management is recommended (see text in the original guideline document).
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| Depression Screening |
Screen patients with CAD for depression [IB]. Care providers should treat or refer when indicated. Patients often present with somatic complaints. Initial screening can be performed by asking:
During the past month, have you been bothered by:
- Little interest or pleasure in doing things?
- Feeling down, depressed or hopeless?
If the patient responds "yes" to either question, consider more detailed assessment.
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| Physical Activity |
Assess risk with a physical activity history and/or exercise test to guide prescription [IB].
Encourage 30-60 minutes of moderate intensity aerobic activity on 5-7 days per week, supplemented by an increase in daily lifestyle activities [IIB].
Encourage resistance training 2 days per week [IID].
Advise medically supervised programs for high risk patients (e.g., recent acute coronary syndromes or revascularization, stable angina, heart failure) [IB].
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| Weight Management |
Assess body mass index and/or waist circumference on each visit, and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake and formal behavioral programs when indicated to achieve and maintain a body mass index between 18.5 and 24.9 kg/m2 [IB].
If waist circumference (measured horizontally at iliac crest) is ≥ 35 inches in women and ≥ 40 inches in men, initiate lifestyle change and consider treatment strategies for metabolic syndrome as indicated [IB].
Initial goal of weight loss strategy should be to reduce body weight 10% from baseline. With success further weight loss can be attempted if indicated through further assessment [IB].
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| Nutrition |
Achieve and maintain ideal body weight by limiting foods high in calories and low in nutrient density, including those high in sugar, such as soft drinks and candy.
Eat a variety of fruits, vegetables, legumes, nuts, soy products, low-fat dairy products, and whole grain breads, cereals and pastas.
Eat baked or broiled fish at least twice per week [IIB].
Choose oils and margarines low in saturated fats and trans fat and high in omega-3 fat [IB], such as canola, soybean, walnut and flaxseed oils, including those fortified with stanols and sterols. Monounsaturated fats like olive oil are also preferred over saturated fats.
Avoid foods high in saturated and trans fats, such as red meat, whole milk products, and pastries. Limit intake of saturated fats to less than 7% of daily calories, trans fatty acids and cholesterol to less than 200 mg per day [IB].
Limit alcohol to no more than 2 drinks per day (men) or 1 drink per day (women).
Eat less than 6 g of salt or less than 2400 g of sodium per day.
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| Immunizations |
Influenza vaccination annually (inactivated, injectable) [IB].
Pneumococcal polysaccharide vaccine [IB].
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