Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2011 AHA/ACC Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease

Smoking

Class I

"1. Patients should be asked about tobacco use status at every office visit (Level of Evidence: B)"

"2. Every tobacco user should be advised at every visit to quit (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 (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 (Level of Evidence: B)"

Blood pressure control

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 (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 -blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve goal blood pressure (Level of Evidence: A)"

Lipid management

Goal: 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–HDLC† should be <130 mg/dL, whereas non–HDL-C <100 mg/dL for very high risk patients is reasonable

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 (Level of Evidence: B)"

"2. Lifestyle modifications including daily physical activity and weight management are strongly recommended for all patients (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) (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 (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 (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 (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 (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 (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 (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 <100mg/dL is reasonable (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 (Level of Evidence: C)"

"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 (Level of Evidence: B)"

Physical activity

Goal: At least 30 minutes, 7 days per week (minimum 5 days per week)

Class I

"1. 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 (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. (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. (Level of Evidence: C)"

Weight management

Goals: Body mass index: 18.5 to 24.9 kg/m2 Waist circumference: women <35 inches (<89 cm), men <40 inches (<102 cm)

Class I

"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 (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 (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)"