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Thursday, November 20, 2008

Update 2006: AHA/ACC Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease

Last updated: 07/31/2006

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The American Heart Association and the American College of Cardiology have recently updated their guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease based on discoveries from more recent clinical trials. These trials help illustrate the need for aggressive comprehensive risk factor management, which can improve survival, decrease recurrent events and the need for interventional procedures, and improve quality of life.

The highlights of this guideline update are included below.

Smoking

Goal: complete cessation

  • Ask about tobacco use
  • Advise users to quit
  • Assess willingness to quit
  • Assist with counseling and plan
  • Arrange follow-up or referrals
  • Recommend pharmacotherapy
  • Recommend avoiding exposure to tobacco

Blood pressure control

Goal: Less than 140/90 mm Hg; less than 130/80 mm Hg for patients with diabetes or chronic kidney disease

  • For all patients, initiate lifestyle modifications
  • If hypertensive, use pharmacotherapy
    • Favor beta-blockers and/or ACE inhibitors with the addition of a thiazide diuretic if needed
    • Follow recommendations of JNC 7 for com-pelling indications

Physical activity

Goal: 30 minutes, 7 days per week, minimum 5 days per week

  • Assess activity
  • Encourage 30-60 minutes of moderate intensity aerobic activity
  • Encourage resistance training 2 days per week
  • Advise medically supervised programs for high risk patients

Lipid management

Goal: LDL cholesterol (LDL-c) less than 100mg/dL; if triglycerides are greater or equal to 200 mg/dL, non-HDL cholesterol (non-HDL-c) should be less than 130 mg/dL

Target therapy for LDL-c less than 100 mg/dL; reductions to less than 70 mg/dL may be reasonable

If baseline LDL-c is 70-100mg/dL, it is reasonable to treat to less than 70 mg/dL

For all patients:

  • Start dietary therapy, reduce intake of saturated fats, trans-fatty acids and cholesterol
  • Add plant stenols/sterols and viscous fiber
  • Promote daily physical activity and weight management
  • Increase consumption of omega-3 fatty acids in fish or capsule form

For patients with an event:

  • Assess fasting lipid profile within twenty-four hours for all patients hospitalized for an acute cardiovascular or coronary eventv
  • Initiate LDL lowering therapy if LDL-c is greater than 100mg/dL
  • May need combination therapy if on-treatment LDL-c remains greater than 100 mg/dL
  • Options to lower non-HDL-c include
    • More intense LDL-c lowering therapy
    • Niacin therapy
    • Fibrate therapy
  • If triglycerides are greater than 500 mg/dL, start niacin or fibrate therapy (prior to LDL-c lowering therapy) to prevent pancreatitis

Weight management

Goal: Body Mass Index (BMI) 18.5-24.9 kg/m2

Waist circumference less than 40 inches for men and less than 35 inches for women:

  • Assess BMI/waist circumference each visit
  • Consistently encourage weight reduction
  • Initiate lifestyle modification if not at goal
  • Start with 10% reduction in body weight

Diabetes management

Goal: Hemoglobin A1c less than 7%

  • Initiate lifestyle modification and pharma-cotherapy to help reach goal
  • Begin vigorous modification of risk factors
  • Coordinate diabetic care with primary care physician or endocrinologist

Antiplatelet agents/anticoagulants

  • Start aspirin 72-162 mg indefinitely unless contraindicated
  • For patients undergoing coronary artery bypass grafting, aspirin should be started within forty-eight hours after surgery; doses higher than 162 mg can be continued for up to 1 year
  • Start clopidogrel 75 mg daily in combination with a higher dose of aspirin (325 mg daily) for up to 12 months in patients after acute coronary syndrome or percutaneous coronary intervention with stent placement
  • Greater or equal to 1 month for bare metal stent
  • Greater or equal to 3 months for sirolimus eluding stent
  • Greater or equal to 6 months for paclitaxel-eluting stent
  • Manage warfarin INR to 2-3 for paroxysmal or chronic atrial fibrillation or flutter, and in post myocardial infarction patients when clinically indicated
  • Warfarin with aspirin and/or clopidogrel is associated with increased risk of bleeding; monitor closely

Renin-angiotensin-aldosterone system blockers

ACE inhibitors (unless contraindicated)

  • Start and continue indefinitely in patients with left ventricular ejection fraction less than or equal to 40%
  • Start and continue indefinitely in patients with hypertension, diabetes or chronic kidney disease
  • Consider for all other patients

Angiotension Receptor Blockers

  • Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial infarction with left ventricular ejection fraction less than 40%
  • Consider in all other patients who are ACE inhibitor intolerant
  • Consider use in combination with ACE inhibitors in systolic dysfunction heart failure

Aldosterone Blockade

  • Use in post myocardial infarction patients without significant renal dysfunction or hyper-kalemia who are already receiving ACE inhibitors and beta blockers, who have left ventricular ejection fraction less than 40% and have diabetes or heart failure

Beta blockers

  • Start and continue indefinitely in patients who have had myocardial infarction, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms
  • Consider chronic therapy for all other patients

Influenza vaccinations

  • Patients with cardiovascular disease should receive influenza vaccinations

This information was derived from J Am Coll Cardiol 2006;47:2130-9. Updated information and additional resources are available online at http://content.onlinejaac.org/cgi/content/full/47/10/2130.