Chronic stable angina treatment lipid management: Difference between revisions

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{{Chronic stable angina}}
{{Chronic stable angina}}


'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan. M.B.B.S.]]
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan. M.B.B.S.]]; {{AA}}


==Overview==
==Overview==
In patients with established [[coronary artery disease]], the recommended goal for '''[[cholesterol|total cholesterol]] is 130 mg/dl''' and '''[[LDL|LDL-C]] is 100 mg/dl''', while the [[HDL|HDL-C]] and [[triglyceride]] concentrations serve as preferred markers for [[Chronic stable angina risk stratification|risk assessment]].<ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprinst/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref> In patients with [[CAD]], a '''fasting lipid-profile''' may be repeated at 5 year intervals to assess the overall risk of cardiovascular mortality and morbidity.<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref> Based on the individual’s lipid abnormalities, necessary dietary interventions and/or [[Chronic stable angina treatment anti-lipid agents|lipid-lowering agents]] are suggested to prevent the risk of future coronary events.<ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref> A '''Mediterranean diet''' consisting of fruits, vegetables, lean meat and fish has also been shown to be beneficial. '''Omega-3 fatty acid''' supplementation may be indicated in patients with [[Chronic stable angina definition|stable angina]] for secondary prevention, as it has been shown to reduce elevated [[triglycerides]] and also reduce the risk of [[sudden cardiac arrest|sudden cardiac death]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref><ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref><ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref><ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref> '''Fish consumption''' once a week has also been associated with reduced risk of mortality from [[coronary artery disease]] and, for this reason, is strongly recommended.<ref name="pmid12588785">Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12588785 Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease.] ''Arterioscler Thromb Vasc Biol'' 23 (2):e20-30. PMID: [http://pubmed.gov/12588785 12588785]</ref><ref name="pmid15184295">He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15184295 Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies.] ''Circulation'' 109 (22):2705-11. [http://dx.doi.org/10.1161/01.CIR.0000132503.19410.6B DOI:10.1161/01.CIR.0000132503.19410.6B] PMID: [http://pubmed.gov/15184295 15184295]</ref>
In patients with established [[coronary artery disease]], the recommended goal for [[cholesterol|total cholesterol]] is 130 mg/dl and [[LDL|LDL-C]] is 100 mg/dl, while the [[HDL|HDL-C]] and [[triglyceride]] concentrations serve as preferred markers for [[Chronic stable angina risk stratification|risk assessment]].<ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprints/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref> In patients with [[CAD]], a fasting lipid-profile may be repeated at 5 year intervals to assess the overall risk of cardiovascular mortality and morbidity.<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref> Based on the individual’s lipid abnormalities, necessary dietary interventions and/or [[Chronic stable angina treatment anti-lipid agents|lipid-lowering agents]] are suggested to prevent the risk of future coronary events.<ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref> A Mediterranean diet consisting of fruits, vegetables, lean meat and fish has also been shown to be beneficial. Omega-3 fatty acid supplementation may be indicated in patients with [[Chronic stable angina definition|stable angina]] for secondary prevention, as it has been shown to reduce elevated [[triglycerides]] and also reduce the risk of [[sudden cardiac arrest|sudden cardiac death]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref><ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref><ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref><ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref> Fish consumption once a week has also been associated with reduced risk of mortality from [[coronary artery disease]] and, for this reason, is strongly recommended.<ref name="pmid12588785">Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12588785 Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease.] ''Arterioscler Thromb Vasc Biol'' 23 (2):e20-30. PMID: [http://pubmed.gov/12588785 12588785]</ref><ref name="pmid15184295">He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15184295 Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies.] ''Circulation'' 109 (22):2705-11. [http://dx.doi.org/10.1161/01.CIR.0000132503.19410.6B DOI:10.1161/01.CIR.0000132503.19410.6B] PMID: [http://pubmed.gov/15184295 15184295]</ref>


==Guide to Lipid Management adapted from the European Task Force <ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref>==
==Lipid Management==
===Guide to Lipid Management Adapted from the European Task Force<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref>===
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[[Image:European task force Lipid management.JPG|650px|center]]}}
[[Image:European task force Lipid management.JPG|650px|center]]}}


==Supportive trial data==
===Supportive Trial Data===
*'''The Whitehall Study''', a cohort study of 17,718 male civil servants aged 40 through 64 years of age at enrollment with an average follow-up of 18 years of study, evaluated the relationship between plasma [[cholesterol]] concentration and mortality from major causes of death. Researchers reported a significant increase in mortality from [[coronary artery disease]] associated with increasing cholesterol concentration from the lowest levels (p < 0.01).<ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref>
*''The Whitehall Study'', a cohort study of 17,718 male civil servants aged 40 through 64 years of age at enrollment with an average follow-up of 18 years of study, evaluated the relationship between plasma [[cholesterol]] concentration and mortality from major causes of death. Researchers reported a significant increase in mortality from [[coronary artery disease]] associated with increasing cholesterol concentration from the lowest levels (p < 0.01).<ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref>


*The '''GISSI-Prevenizone trial''', a multi-center interventional trial involving 11,324 participants (both male and female) with a history of recent MI who were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, evaluated the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. Researchers observed a significant reduction over 3-5 years in the n-3 PUFA treatment group in the rate of death, non-fatal [[myocardial infarction]] and stroke. No effect was cene for the vitamin E treatment group. Based on this evidence and the supporting data of similar trials such as DART, the study investigators concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the overall clinical outcome of patients with [[ischemic heart disease]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref>  
*The ''GISSI-Prevenizone trial'', a multi-center interventional trial involving 11,324 participants (both male and female) with a history of recent [[MI]] who were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, evaluated the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. Researchers observed a significant reduction over 3-5 years in the n-3 PUFA treatment group in the rate of death, non-fatal [[myocardial infarction]] and stroke. No effect was cene for the vitamin E treatment group. Based on this evidence and the supporting data of similar trials such as DART, the study investigators concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the overall clinical outcome of patients with [[ischemic heart disease]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref>  


*In a '''GISSI Prevenzione sub-study''', that assessed the time course of benefit with omega-3 polyunsaturated fatty acids, attributed the anti-arrhythmic effect of omega-3 PUFA consistent with previous experimental studies, being responsible for an early reduction in the total mortality ''(RR 0.59; 95% CI 0.36 to 0.97; P=0.037)'' and [[sudden cardiac arrest|sudden cardiac death]] ''(RR 0.47; 95% CI 0.219 to 0.995; P=0.048)''.<ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref>  
*The ''GISSI-Prevenzione sub-study'', an investigation within the ''GISSI-Prevenzione trial'' data of 11,323 patients (both, male and female) with a history of recent (<3 months) [[myocardial infarction]], assessed the time course of benefit of omega-3 polyunsaturated fatty acids. Researchers attributed the anti-arryhthmic effect of omega-3 PUFA, a finding consistent with previous randomized clinical trials, to a significant early reduction in the total mortality (RR 0.59, 95% CI 0.36,  0.97; P=0.037) and [[sudden cardiac arrest|sudden cardiac death]] (RR 0.47, 95% CI 0.219, 0.995; p=0.048).<ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref>  


*A '''meta-analysis''' that evaluated the effects of dietary and non-dietary supplementation of omega-3 polyunsaturated fatty acids on [[coronary artery disease]], reported a significant reduction in the risk of fatal [[myocardial infarction]] ''(RR 0.7; 95% CI: 0.6 to 0.8; p<0.001)'' and [[sudden cardiac arrest|sudden cardiac death]] ''(RR 0.7; 95% CI: 0.6 to 0.9; p<0.01)''. Thus, the study concluded omega-3 polyunsaturated fatty acid consumption significantly reduced the overall mortality, mortality due to [[myocardial infarction]] and [[sudden cardiac death]]; however, these benefits were confined to [[Chronic stable angina risk assessment in patients with an intermediate or high probability of coronary artery disease|high-risk]] patients.<ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref>  
*Observational studies have been inconsistent in defining the association between omega-3 polyunsaturated fatty acids and [[coronary artery disease]] risk. Therefore, researchers conducted a meta-analysis of randomized controlled trials that compared dietary and non-deitary supplementation of omega-3 polyunsaturated fatty acids on [[coronary artery disease|coronary heart disease]]. The analysis reported a significant reduction in the risk of fatal [[myocardial infarction]] (RR 0.7; 95% CI: 0.6, 0.8; p<0.001) and [[sudden cardiac death]] (RR 0.7; 95% CI: 0.6, 0.9; p<0.01). Thus, the study concluded omega-3 polyunsaturated fatty acid consumption significantly reduced the overall mortality, mortality due to myocardial infarction and sudden cardiac death; however, these benefits were confined to high-risk patients.<ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref>  


*A 2005 '''meta-analysis''' that reviewed 97 studies to assess the efficacy and safety of different [[Chronic stable angina treatment anti-lipid agents|lipid-lowering interventions]] based on mortality data, reported significant reduction in over-all cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation and hence can be used in patients with [[Chronic stable angina definition|stable angina]] for secondary prevention.<ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref>
*A 2005 meta-analysis, which reviewed 97 randomized control trials, evaluated the efficacy and safety of different [[Chronic stable angina treatment anti-lipid agents|lipid-lowering interventions]] based on mortality data. Researchers reported a significant reduction in overall cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation. It was further suggested that this therapy could be utilized in patients with [[Chronic stable defintition|stable angina]] for secondary prevention purposes.<ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref>


==ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT) <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref><ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).]''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref><ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>==
==2012 Chronic Angina ACC/AHA Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>==
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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
'''1.''' Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), transfatty acids, and cholesterol (to less than 200 mg per day). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''2.''' Daily [[Chronic stable angina treatment physical activity|physical activity]] and [[Chronic stable angina treatment weight management|weight management]] are recommended for all patients. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''3.''' Recommended lipid management includes assessment of a [[Coronary risk profile (patient information)|fasting lipid profile]].
:'''a.''' [[LDL|LDL-C]] should be less than 100 mg per dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
:'''b.''' If baseline [[LDL|LDL-C]] is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in [[LDL|LDL-C]] levels. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
:'''c.''' If on-treatment [[LDL|LDL-C]] is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
:'''d.''' If [[triglycerides|TG]] are 200 to 499 mg per dL, [[HDL|non–HDL-C]] should be less than 130 mg per dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:'''e.''' If [[triglycerides|TG]] are greater than or equal to 500 mg per dL, therapeutic options to lower the [[triglycerides|TG]] to reduce the risk of [[pancreatitis]] are fibrate or niacin; these should be initiated before [[LDL|LDL-C]] lowering therapy. The goal is to achieve [[HDL|non–HDL-C]] less than 130 mg per dL if possible. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
'''4.''' Drug combinations are beneficial for patients on lipid
lowering therapy who are unable to achieve [[LDL|LDL-C]] less
than 100 mg per dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
'''5.''' Lipid-lowering therapy in patients with documented [[CAD]] and [[LDL-LDL cholesterol]] greater than 130 mg/dL
with a target [[LDL]] of less than 100 mg/dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
 
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
'''1.''' Adding plant stanol or sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower [[LDL|LDL-C]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''2.''' Lipid-lowering therapy in patients with documented [[CAD]] and [[LDL|LDL cholesterol]] 100 to 129 mg/dL, with a target LDL of 100 mg/dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''3.''' Recommended lipid management includes assessment of a [[Coronary risk profile (patient information)|fasting lipid profile]].
:'''a.''' Reduction of [[LDL|LDL-C]] to less than 70 mg per dL or high-dose statin therapy is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''
:'''b.''' If baseline [[LDL|LDL-C]] is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:'''c.''' Further reduction of [[HDL|non–HDL-C]] to less than 100 mg per dL is reasonable, if [[triglycerides|TG]] are greater than or equal to 200 to 499 mg per dL. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''4.''' Therapeutic options to reduce [[HDL|non–HDL-C]] are:
:'''a.''' [[Niacin]] can be useful as a therapeutic option to reduce non–HDL-C (after [[LDL|LDL-C]]–lowering therapy) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:'''b.''' [[Fibrate|Fibrate therapy]] as a therapeutic option can be useful to reduce non–HDL-C (after LDL-C–lowering therapy). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''5.''' The following lipid management strategies can be beneficial:
:'''a.''' If [[LDL|LDL-C]] less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
 
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''1.''' For all patients, encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated [[triglyceride|TG]], higher doses are usually necessary for risk reduction. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}}


==Vote on and Suggest Revisions to the Current Guidelines==
===Lipid Management (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref>===
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


==Guidelines Resources==
{|class="wikitable"
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref>
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' 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). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
|}


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>
{|class="wikitable"
 
|-
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref>
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= |url=url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-angina-FT.pdf]}} </ref>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients who do not tolerate statins, low-density lipoproteincholesterol–lowering therapy with bile acid sequestrants,* niacin,† or both is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 16:46, 31 October 2016

Chronic stable angina Microchapters

Acute Coronary Syndrome Main Page

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Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan. M.B.B.S.; Aysha Anwar, M.B.B.S[3]

Overview

In patients with established coronary artery disease, the recommended goal for total cholesterol is 130 mg/dl and LDL-C is 100 mg/dl, while the HDL-C and triglyceride concentrations serve as preferred markers for risk assessment.[1] In patients with CAD, a fasting lipid-profile may be repeated at 5 year intervals to assess the overall risk of cardiovascular mortality and morbidity.[2] Based on the individual’s lipid abnormalities, necessary dietary interventions and/or lipid-lowering agents are suggested to prevent the risk of future coronary events.[3] A Mediterranean diet consisting of fruits, vegetables, lean meat and fish has also been shown to be beneficial. Omega-3 fatty acid supplementation may be indicated in patients with stable angina for secondary prevention, as it has been shown to reduce elevated triglycerides and also reduce the risk of sudden cardiac death.[4][5][6][7] Fish consumption once a week has also been associated with reduced risk of mortality from coronary artery disease and, for this reason, is strongly recommended.[8][9]

Lipid Management

Guide to Lipid Management Adapted from the European Task Force[2]

“
”

Supportive Trial Data

  • The Whitehall Study, a cohort study of 17,718 male civil servants aged 40 through 64 years of age at enrollment with an average follow-up of 18 years of study, evaluated the relationship between plasma cholesterol concentration and mortality from major causes of death. Researchers reported a significant increase in mortality from coronary artery disease associated with increasing cholesterol concentration from the lowest levels (p < 0.01).[3]
  • The GISSI-Prevenizone trial, a multi-center interventional trial involving 11,324 participants (both male and female) with a history of recent MI who were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, evaluated the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. Researchers observed a significant reduction over 3-5 years in the n-3 PUFA treatment group in the rate of death, non-fatal myocardial infarction and stroke. No effect was cene for the vitamin E treatment group. Based on this evidence and the supporting data of similar trials such as DART, the study investigators concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the overall clinical outcome of patients with ischemic heart disease.[4]
  • The GISSI-Prevenzione sub-study, an investigation within the GISSI-Prevenzione trial data of 11,323 patients (both, male and female) with a history of recent (<3 months) myocardial infarction, assessed the time course of benefit of omega-3 polyunsaturated fatty acids. Researchers attributed the anti-arryhthmic effect of omega-3 PUFA, a finding consistent with previous randomized clinical trials, to a significant early reduction in the total mortality (RR 0.59, 95% CI 0.36, 0.97; P=0.037) and sudden cardiac death (RR 0.47, 95% CI 0.219, 0.995; p=0.048).[5]
  • Observational studies have been inconsistent in defining the association between omega-3 polyunsaturated fatty acids and coronary artery disease risk. Therefore, researchers conducted a meta-analysis of randomized controlled trials that compared dietary and non-deitary supplementation of omega-3 polyunsaturated fatty acids on coronary heart disease. The analysis reported a significant reduction in the risk of fatal myocardial infarction (RR 0.7; 95% CI: 0.6, 0.8; p<0.001) and sudden cardiac death (RR 0.7; 95% CI: 0.6, 0.9; p<0.01). Thus, the study concluded omega-3 polyunsaturated fatty acid consumption significantly reduced the overall mortality, mortality due to myocardial infarction and sudden cardiac death; however, these benefits were confined to high-risk patients.[6]
  • A 2005 meta-analysis, which reviewed 97 randomized control trials, evaluated the efficacy and safety of different lipid-lowering interventions based on mortality data. Researchers reported a significant reduction in overall cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation. It was further suggested that this therapy could be utilized in patients with stable angina for secondary prevention purposes.[7]

2012 Chronic Angina ACC/AHA Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[10]

Lipid Management (DO NOT EDIT)[10]

Class I
"1. Lifestyle modifications, including daily physical activity and weight management, are strongly recommended for all patients with SIHD. (Level of Evidence: B) "
"2. 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) "
"3. In addition to therapeutic lifestyle changes, a moderate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects.(Level of Evidence: A) "
Class IIa
"1. For patients who do not tolerate statins, low-density lipoproteincholesterol–lowering therapy with bile acid sequestrants,* niacin,† or both is reasonable. (Level of Evidence: B) "

References

  1. ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[1] PMID: 17998462
  2. ↑ 2.0 2.1 De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 24 (17):1601-10. PMID: 12964575
  3. ↑ 3.0 3.1 Smith GD, Shipley MJ, Marmot MG, Rose G (1992) Plasma cholesterol concentration and mortality. The Whitehall Study. JAMA 267 (1):70-6. PMID: 1727199
  4. ↑ 4.0 4.1 (1999) Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. Lancet 354 (9177):447-55. PMID: 10465168
  5. ↑ 5.0 5.1 Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione. Circulation 105 (16):1897-903. PMID: 11997274
  6. ↑ 6.0 6.1 Bucher HC, Hengstler P, Schindler C, Meier G (2002) N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med 112 (4):298-304. PMID: 11893369
  7. ↑ 7.0 7.1 Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) Effect of different antilipidemic agents and diets on mortality: a systematic review. Arch Intern Med 165 (7):725-30. DOI:10.1001/archinte.165.7.725 PMID: 15824290
  8. ↑ Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Arterioscler Thromb Vasc Biol 23 (2):e20-30. PMID: 12588785
  9. ↑ He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies. Circulation 109 (22):2705-11. DOI:10.1161/01.CIR.0000132503.19410.6B PMID: 15184295
  10. ↑ 10.0 10.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.


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