Smoking
Goal: complete cessation
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- Assess tobacco use.
- Strongly encourage patient and family to stop smoking and to avoid secondhand smoke. Provide counseling, pharmacological therapy (including nicotine replacement and buproprion), and formal smoking cessation programs as appropriate.
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Blood pressure control***
Goal:
<140/90 mmHg or
<130/80 mmHg if diabetes or chronic kidney disease
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- Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients with blood pressure ≥120 mmHg systolic or 80 mmHg diastolic.
- Add blood pressure medication, individualized to other patient requirements and characteristics (e.g., age, race, need for drugs with specific benefits) if blood pressure is not <140 mmHg systolic or 90 mmHg diastolic or if blood pressure is not <130 mmHg systolic or <80 mmHg diastolic for individuals with diabetes or chronic kidney disease.
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Lipid management
Primary goal: low-density lipoprotein (LDL) 100 mg/dL
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- Start dietary therapy in all patients (<7% saturated fat and <200 mg/d cholesterol), and promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids.
- Assess fasting lipid profile in all patients and within 24 hours of hospitalization for those with an acute event. If patients are hospitalized, consider adding drug therapy on discharge. Add drug therapy according to the following guide:
LDL at baseline or on treatment, mg/dL
100: Further LDL-lowering therapy not required. Consider fibrate or niacin (if low high-density lipoprotein (HDL) or high triglycerides (TG)).
100-129: Therapeutic options: Intensify LDL-lowering therapy (statin or resin*). Fibrate or niacin (if low HDL or high TG). Consider combined drug therapy (statin, fibrate, or niacin) (if low HDL or high TG).
≥130: Intensify LDL-lowering therapy (statin or resin*). Add or increase drug therapy with lifestyle therapies.
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Lipid management
Secondary goal: If TG ≥200 mg/dL, then non-HDL** should be <130 mg/dL
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- If TG ≥150 mg/dL or HDL <40 mg/dL: Emphasize weight management and physical activity. Advise smoking cessation.
- If TG 200 to 499 mg/dL: Consider fibrate or niacin after LDL-lowering therapy.*
- If TG ≥500 mg/dL: Consider fibrate or niacin before LDL-lowering therapy.*
- Consider omega-3 fatty acids as adjunct for high TG.
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Physical activity
Minimum goal: 30 minutes 3 to 4 days per week
Optimal daily
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- Assess risk, preferably with exercise test, to guide prescription.
- Encourage minimum of 30 to 60 minutes of activity, preferably daily, or at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). Advise medically supervised programs for moderate- to high-risk patients.
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Weight management
Goal: body mass index (BMI) 18.5-24.9 kg/m2
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- Calculate BMI and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy.
- Start weight management and physical activity as appropriate. Desirable BMI range is 18.5-24.9 kg/m2.
- When BMI ≥25 kg/m2, goal for waist circumference is ≤40 inches in men and ≤35 inches in women.
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Diabetes management
Goal: HbA1c <7%
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- Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c.
- Treatment of other risks (e.g., physical activity, weight management, blood pressure, and cholesterol management).
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Antiplatelet/anticoagulants |
- Start and continue indefinitely aspirin 75 to 325 mg/d if not contraindicated.
- Consider clopidogrel 75 mg/d or warfarin if aspirin contraindicated. Manage warfarin to international normalized ratio =2.0 to 3.0 in post-myocardial infarction (MI) patients when clinically indicated or for those not able to take aspirin or clopidogrel.
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Angiotensin-converting enzyme (ACE) inhibitors |
- Treat all patients indefinitely after MI; start early in stable high-risk patients (anterior MI, previous MI, Killip class II [S3 gallop, rales, radiographic congestive heart failure (CHF)]).
- Consider chronic therapy for all other patients with coronary or other vascular disease unless contraindicated.
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Beta-blockers |
- Start in all post-MI and acute ischemic syndrome patients. Continue indefinitely. Observe usual contraindications.
- Use as needed to manage angina, rhythm, or blood pressure in all other patients.
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