This is the current release of the guideline.

• Coronary artery disease
• Peripheral arterial disease
• Atherosclerotic aortic disease
• Carotid artery disease
• Other atherosclerotic vascular disease

Counseling
Management
Prevention
Risk Assessment
Treatment

Cardiology
Family Practice
Internal Medicine
Physical Medicine and Rehabilitation
Preventive Medicine

Health Care Providers
Physicians

To provide an evidence-based guideline for aggressive secondary prevention, risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease

Patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease

1. Advice and assistance in smoking cessation
2. Avoidance of second-hand smoke
3. Blood pressure control
   • Lifestyle modification
   • Drug therapy (beta-blockers, thiazides, angiotensin-converting enzyme [ACE] inhibitors)
4. Lipid management
   • Diet therapy
   • Addition of plant sterol/stanol
   • Physical activity and weight management
   • Consumption of omega-3 fatty acids
   • Assessment of fasting lipid profile
   • Lipid-lowering drug therapy
5. Encouragement and counseling on physical activity
6. Weight management
   • Assessment of body mass index and waist circumference
   • Encouragement of weight maintenance/reduction
   • Weight loss therapy
7. Diabetes management
   • Lifestyle and pharmacotherapy
   • Risk factor modification
8. Use of antiplatelet agents (aspirin, clopidogrel) and anticoagulants (warfarin)
9. Use of ACE inhibitors, angiotensin receptor blockers, and aldosterone blockers
10. Use of beta-blockers
11. Influenza vaccination

Not stated

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The guideline recommendations are based largely on major practice guidelines from the National Institutes of Health and American College of Cardiology/American Heart Association (ACC/AHA). In many cases, these practice guidelines were supplemented by research findings published after the publication of the primary reference(s). References and supplemental search criteria used to support each recommendation and level of evidence are provided in the Appendix of the original guideline document.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.

Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies.

Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

The development of the present statement involved a process of partial adaptation of other guideline statements and reports and supplemental literature searches.

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

This document was approved by the American Heart Association Science Advisory and Coordinating Committee on November 11, 2005, and by the American College of Cardiology Foundation Board of Trustees on November 10, 2005.

Definitions for the weight of the evidence (A-C) and classes of recommendations (I-III) are provided at the end of the "Major Recommendations" field.

American Heart Association/American College of Cardiology (AHA/ACC) Secondary Prevention for Patients With Coronary and Other Vascular Disease*: 2006 Update

Notes:

*Patients covered by these guidelines include those with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. Treatment of patients whose only manifestation of cardiovascular risk is diabetes will be the topic of a separate American Heart Association (AHA) scientific statement.

^a Non-HDL-C =total cholesterol minus HDL-C.

^b Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.

^c When LDL-lowering medications are used, obtain at least a 30% to 40% reduction in LDL-C levels. If LDL-C <70 mg/dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C <70 mg/dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of >50% in LDL-C levels by either statins or LDL-C–lowering drug combinations.

^d Standard dose of statin with ezetimibe, bile acid sequestrant, or niacin.

^e The combination of high-dose statin + fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination. Dietary supplement niacin must not be used as a substitute for prescription niacin.

^f Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrant is relatively contraindicated when triglycerides are >200 mg/dL.

^g Creatinine should be <2.5 mg/dL in men and <2.0 mg/dL in women.

^h Potassium should be <5.0 mEq/L.

Definitions:

Levels of Evidence

Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.

Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies.

Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.

Strength of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

• Improved survival
• Reduced recurrent events
• Decreased need for intervention procedures
• Improved quality of life

• Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely.
• The combination of high-dose statin + fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination.
• Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.

The use of bile acid sequestrant is relatively contraindicated when triglycerides are > 200 mg/dL.

• The findings from additional lipid reduction trials allow for alterations in these guidelines, such that low-density lipoprotein cholesterol (LDL-C) should be < 100 mg/dL for all patients with coronary heart disease (CHD) and other clinical forms of atherosclerotic disease, but in addition, it is reasonable to treat to LDL-C < 70 mg/dL in such patients. When the < 70 mg/dL target is chosen, it may be prudent to increase statin therapy in a graded fashion to determine a patient's response and tolerance. Furthermore, if it is not possible to attain LDL-C < 70 mg/dL because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of > 50% with either statins or LDL-C–lowering drug combinations. Moreover, this guideline for patients with atherosclerotic disease does not modify the recommendations of the 2004 Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATP III) update for patients without atherosclerotic disease who have diabetes or multiple risk factors and a 10-year risk level for CHD > 20%. In the latter 2 types of high-risk patients, the recommended LDL-C goal of < 100 mg/dL has not changed. Finally, to avoid any misunderstanding about cholesterol management in general, it must be emphasized that a reasonable cholesterol level of < 70 mg/dL does not apply to other types of lower-risk individuals who do not have CHD or other forms of atherosclerotic disease; in such cases, recommendations contained in the 2004 ATP III update still pertain.
• The writing group emphasizes the importance of giving consideration to the use of cardiovascular medications that have been proved in randomized clinical trials to be of benefit. This strengthens the evidence-based foundation for therapeutic application of these guidelines. The committee acknowledges that ethnic minorities, women, and the elderly are underrepresented in many trials and urges physician and patient participation in trials that will provide additional evidence with regard to therapeutic strategies for these groups of patients.

An implementation strategy was not provided.

Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

The guideline recommendations are partially adapted from major practice guidelines from the National Institutes of Health and the American College of Cardiology/American Heart Association (ACC/AHA).

2006 May 16

American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association

The American College of Cardiology Foundation and the American Heart Association

Writing Committee

Writing Committee Members: Sidney C. Smith, Jr, MD; Jerilyn Allen, RN, ScD; Steven N. Blair, PED; Robert O. Bonow, MD; Lawrence M. Brass, MD; Gregg C. Fonarow, MD; Scott M. Grundy, MD, PhD; Loren Hiratzka, MD; Daniel Jones, MD; Harlan M. Krumholz, MD; Lori Mosca, MD, PhD, MPH; Richard C. Pasternak, MD*; Thomas Pearson, MD, MPH, PhD; Marc A. Pfeffer, MD, PhD; Kathryn A. Taubert, PhD

The American Heart Association and American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationships with industry for writing committee members, as well as peer reviewers of the document, are located before the references.

Table: Writing Group Disclosures

*Modest

**Significant

Note: This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "Significant" if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person's gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be "Modest" if it is less than "Significant" under the preceding definition.

Table: Reviewers' Disclosures

Note: This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.

National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.]

This is the current release of the guideline.

None available

This summary was completed by ECRI on August 3, 2006. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.