Definitions for the Levels of Evidence (1++ to 4) and Grades of Recommendation (A - C, I, and Good Practice Points [GPP]) are given at the end of the "Major Recommendations" field.
Cardiovascular Risk Assessment
Who Should Be Assessed
C: Cardiovascular risk assessments are recommended:
- from the age of 45 years for asymptomatic men without other known risk factors
- from the age of 55 years for asymptomatic women without other known risk factors.
C: Cardiovascular risk assessments are recommended 10 years earlier for Maori (from the age of 35 years for men and 45 years for women).
C: Cardiovascular risk assessments are recommended 10 years earlier for Pacific peoples and people from the Indian subcontinent (from the age of 35 years for men and 45 years for women).
C: Cardiovascular risk assessments are recommended annually from the time of diagnosis for people with diabetes.
C: Cardiovascular risk assessments are recommended:
- from the age of 35 years for men with other known cardiovascular risk factors or at high risk of developing diabetes
- from the age of 45 years for women with other known cardiovascular risk factors or at high risk of developing diabetes.
These people will have one or more of the following risk factors:
- family history of premature cardiovascular disease in a first-degree male relative (parent or sibling) under 55 years or female relative under 65 years
- family history of diabetes in a first-degree relative (parent or sibling)
- personal history of gestational diabetes
- personal history of polycystic ovary syndrome
- personal history of current or recent smoking
- prior blood pressure of more than 160/95 mm Hg*
- prior total cholesterol to high-density lipoprotein (TC:HDL) ratio of more than 7*
- known impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) (see Table 22 in the original guideline document)
- obesity (body mass index [BMI] >30*) or truncal obesity (waist circumference >100 cm* in men or >90 cm* in women)
C: All those with cardiovascular disease should have comprehensive risk factor measurements to determine the best management approach.
C: Tracing the siblings and children of index cases known to have a genetic lipid disorder is the recommended method of identifying individuals with genetic lipid disorders.
*Where risk factor thresholds are given these should be interpreted as approximate guides to clinical practice only.
Who Should Do the Assessment
C: Risk assessments should be provided at the primary care level by health practitioners with appropriate training, infrastructure support, systems for follow-up, and systems that improve quality.
Frequency of Cardiovascular Risk Assessment
C: People with a 5-year cardiovascular risk under 5% should have a further cardiovascular risk assessment in 10 years.
C: People with a 5-year cardiovascular risk between 5 and 15% should have a further cardiovascular risk assessment in 5 years.
C: Annual cardiovascular risk assessments are recommended in people with:
- a 5-year cardiovascular risk greater than 15%
- diabetes
- people receiving treatment with lipid-modifying or blood-pressure-lowering medication
C: People with diabetes or receiving medication or intensive lifestyle advice may need individual risk factor measurements taken more frequently (e.g., monitored 3 monthly until controlled, then every 6 months).
Treatment Decisions
A: All treatment decisions should be based on an individual’s 5-year absolute cardiovascular risk.
C: Everyone with risk factors should be involved in the decision-making process regarding their treatment.
C: The higher an individual’s absolute risk of a cardiovascular event, the more aggressive management should be.
A: Everyone with a history of a cardiovascular event and any risk factor above optimal levels should be considered for treatment to reduce their cardiovascular risk. Treatment should aim to lower the risk factors to optimal levels.
C: Everyone with isolated very high-risk factor levels, either a total cholesterol greater than 8 mmol/L or a TC:HDL ratio greater than 8 or blood pressure greater than 170/100 mm Hg should have drug treatment and specific lifestyle advice to lower risk factor levels.
A: Everyone with the specific genetic lipid disorders (familial hypercholesterolaemia, familial defective ApoB, or familial combined dyslipidaemia) or diabetes with overt nephropathy should be considered for treatment to reduce their cardiovascular risk. Treatment should aim to lower the risk factors to optimal levels.
A: Everyone with cardiovascular disease, a 5-year cardiovascular risk of greater than 20%, genetic lipid disorders, diabetes, or the metabolic syndrome should receive intensive lifestyle advice. Lifestyle changes that have been shown to benefit people with these risk profiles include:
- dietary change (A)
- smoking cessation (A)
- physical activity (B)
A: Intensive dietary advice should be given in individual/group sessions with a dietitian.
C: People with a 5-year cardiovascular risk greater than 20% should receive intensive lifestyle advice and drug treatment of all modifiable risk factors simultaneously.
C: People with a 5-year cardiovascular risk of between 15 and 20% are likely to need treatment of all modifiable risk factors. Specific lifestyle advice may be given for 3 to 6 months prior to drug treatment.
C: Among people with a 5-year cardiovascular risk greater than 15%, the aim of treatment is to lower 5-year cardiovascular risk to less than 15%.
B: People with a 5-year cardiovascular risk between 10 and 20% should receive specific lifestyle advice on a healthy cardioprotective dietary pattern, physical activity, and smoking cessation from their primary health care team. This advice should be followed for 3 to 6 months prior to considering drug treatment.
C: People with a 5-year cardiovascular risk of less than 15% should receive nonpharmacological approaches to treating multiple risk factors.
B: People with a 5-year cardiovascular risk of less than 10% should receive general lifestyle advice on a healthy cardioprotective dietary pattern, physical activity, and smoking cessation.
GPP: The order in which to start interventions should take into account individual risk factor profiles, potential side effects, other concurrent illness, compliance, personal preference, and cost. It is appropriate to treat multiple risk factors simultaneously.
Intervention: Cardioprotective Dietary Patterns
A: Dietary intervention is strongly recommended as an integral component of the management of cardiovascular risk.
A: Use behavioural and motivational strategies in education and counselling to achieve and sustain dietary change.
A: Everyone with cardiovascular disease, a 5-year cardiovascular risk of greater than 20%, genetic lipid disorders, diabetes, or the metabolic syndrome should receive intensive lifestyle advice. Lifestyle changes that have been shown to benefit people with these risk profiles include:
- dietary change (A)
- smoking cessation (A)
- physical activity (B)
A: Intensive dietary advice should be given in individual/group sessions with a dietitian.
A: Everyone with a 5-year cardiovascular risk between 10 and 20% should receive specific lifestyle advice on a cardioprotective dietary pattern, physical activity, and smoking cessation from their primary health care team. This advice should be followed for 3 to 6 months prior to considering drug treatment and continued for life.
GPP: People with a 5-year cardiovascular risk of less than 10% should receive general lifestyle advice on a cardioprotective dietary pattern, physical activity, and smoking cessation.
A: Everyone should be encouraged to adopt a cardioprotective dietary pattern that includes fruit and vegetables, whole grains, fish and/or dried peas and beans or soy products, oil, margarine spreads, nuts or seeds, very low-fat milk products, and optional small servings of lean meat or skinned poultry. This dietary pattern avoids regular consumption of foods prepared with meat or dairy fats.
B: A cardioprotective diet in people with type 2 diabetes who are overweight or obese should be tailored to promote weight loss.
A: Fish oil supplements, 1 g/day eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) combined, may be offered post myocardial infarction.
A: The use of antioxidant supplements is not recommended for the prevention or treatment of cardiovascular disease.
GPP: Individualise dietary counselling and other lifestyle changes to complement prescribed risk factor modifying pharmacological agents to assist the individual in reducing their absolute risk of cardiovascular disease.
Intervention: Physical Activity
B: Everyone should aim to do a minimum of 30 minutes of moderate intensity physical activity (3 to 6 metabolic equivalents [METs]) on most days of the week.
B: For people with time constraints this physical activity may be accumulated in bouts of 8 to 10 minutes.
B: People who are already doing 30 minutes of moderate-intensity physical activity per day should be encouraged to do physical activity of higher intensity or for longer to increase the beneficial effect by further improving their cardiorespiratory fitness.
B: Physical activity is an integral part of the lifestyle advice for people with increased cardiovascular risk.
B: Individuals with a history of cardiovascular disease should consult their doctor before they undertake vigorous physical activity. Vigorous activity is generally not encouraged in people with impaired left ventricular function, severe coronary artery disease, recent myocardial infarction, significant ventricular arrhythmias, or stenotic valve disease.
C: Physical activity for people with coronary heart disease should begin at a low intensity and gradually increase over several weeks.
Intervention: Weight Management
B: Measure BMI and waist circumference as part of a comprehensive cardiovascular risk assessment.
B: The immediate priorities in weight management are to prevent weight gain, to achieve and sustain moderate weight loss (5 – 10%) where appropriate, and to increase physical fitness.
B: Encourage people with a 5-year cardiovascular risk above 15% or with diabetes and a BMI greater than 25 (especially anyone who has a BMI >30) to commence graduated lifestyle change aimed at weight reduction.
A: For significant weight loss, recommend a reduction in energy intake and an increase in physical activity.
C: Discourage the use of weight loss programmes that promote the exclusion of food groups from the cardioprotective dietary pattern or that increase saturated fatty acid intake.
GPP: Consider referral to weight management health care practitioners for motivational counselling or specific energy balance assessment and advice when general lifestyle advice does not achieve a sustained weight loss.
GPP: Appropriate equipment is required to assess the cardiovascular risk in people who are overweight or obese.
GPP: Review the indication for use of drugs that cause weight gain. Offer weight management support to people requiring drugs that cause weight gain.
GPP: Only initiate pharmacological interventions as an adjunct to a comprehensive weight management programme that includes diet and physical activity and uses motivational and behavioural methods.
GPP: Surgery may be considered for people with a BMI greater than 40. Decisions should take into account both the absolute cardiovascular risk and other health risks and comorbidities.
Intervention: Smoking Cessation
A: All smokers should be encouraged to stop smoking. Smoking cessation has major and immediate health benefits for smokers of all ages.
GPP: The recording of current and past smoking habits is recommended as part of a comprehensive cardiovascular risk assessment.
A: Nicotine replacement therapy (NRT) is recommended as first-line pharmacotherapy for smoking cessation in New Zealand. Bupropion or nortriptyline hydrochloride are alternatives and recommended as second-line agents.
C: Use NRT cautiously (after discussion with a specialist) in the immediate post-myocardial infarction period (4 weeks) and in those with serious arrhythmias or severe or worsening angina.
C: Nortriptyline hydrochloride is contraindicated during the acute recovery period after myocardial infarction.
Intervention: Lipid Modification
Management of Lipid Abnormalities
C: The higher the calculated cardiovascular risk, the more aggressive the management of modifiable risk factors, including lipids, should be.
A: People presenting after an acute cardiac event (myocardial infarction or unstable angina) should start treatment with a statin simultaneously with intensive lifestyle advice. Treatment should aim to lower low-density lipoprotein cholesterol (LDL-C) to less than 2.5 mmol/L.* This should be given in association with other appropriate medication such as aspirin, a beta-blocker, and an angiotensin-converting enzyme (ACE)-inhibitor.
C: Lipids should ideally be measured at the time of the acute event. Since the metabolic disturbance continues for 10 to 12 weeks after a myocardial infarction, further measurements should be deferred for three months.
C: People presenting after an acute cardiac event with hypertriglyceridaemia and a low HDL-C should be considered for a fibrate or combination therapy.
A: In people with venous coronary artery bypass graft (CABG), treatment should aim to lower the total cholesterol to less than 3.5 mmol/L and LDL-C to less than 2.0 mmol/L.*
B: Most people presenting after an ischaemic stroke or transient ischaemic attack should start treatment with a statin.
C: Everyone with a total cholesterol greater than 8 mmol/L or TC:HDL ratio greater than 8* should have drug treatment and specific lifestyle advice to lower risk factor levels.
B: Within the range of total cholesterol 4 to 8 mmol/L, all decisions to treat should be based on the individual’s cardiovascular risk.
B: People with low HDL-C and elevated triglycerides with a 5-year cardiovascular risk greater than 15% should be treated with intensive lifestyle interventions and are likely to need treatment with a fibrate or combination drug therapy.
A: A cardioprotective dietary pattern is strongly recommended as an integral component of lipid management.
B: Dietary advice should be tailored to the individual’s risk factor and lipid profile.
B: Among people with a 5-year cardiovascular risk greater than 15% the aim of treatment is to lower 5-year cardiovascular risk to less than 15%.
C: LDL-C should be used as the primary indicator of optimum lipid management and should be used to monitor lipid-modifying treatment.
*Note: Where risk factor thresholds are given these should be interpreted as approximate guides to clinical practice only.
Dietary Interventions for Lipid Modification
A: Dietary intervention is strongly recommended as an integral component of the management of blood cholesterol and lipids.
A: Advise a cardioprotective dietary pattern rich in plant foods including fruits, vegetables, dried peas and beans including soy, whole grains and other appropriately processed cereals, suitable plant oils, nuts, and seeds. This eating pattern may include plant sterol or stanol-fortified spreads and regular use of oily fish.
A: Assist the individual in identifying and choosing foods which are low in saturated fatty acids, transunsaturated fat, and dietary cholesterol.
A: People who are overweight or obese should be offered appropriate weight loss interventions.
A: Identify excessive alcohol intake and advise reduction or substitution with non-alcoholic beverages.
GPP: Individualise nutritional counselling and other lifestyle changes to complement prescribed risk factor modifying pharmacological agents to reduce absolute cardiovascular risk.
Treatment Monitoring and Duration
GPP: For people prescribed intensive lifestyle therapy or lipid-lowering medication, lifelong treatment is recommended.
C: Lipid monitoring is recommended for those on lipid-lowering drug treatment every 3 months until levels are controlled, then every 6 months.
GPP: A baseline transaminase level (ALT) should be taken prior to initiating statin medication. A baseline ALT and creatinine should also be taken prior to initiating fibrate medication. A second ALT should be taken at the time of the first follow-up, and thereafter if indicated clinically.
GPP: Creatine kinase should be requested for people who have definite unexplained muscle symptoms.
C: Lipids should be measured when people present acutely at the time of a myocardial infarction. Further measurements should be deferred until 3 months.
Intervention: Blood Pressure Lowering
Management of Blood Pressure
C: The higher the calculated cardiovascular risk, the more aggressive the management of modifiable risk factors, including blood pressure, should be.
A: People presenting after an acute myocardial infarction should be considered for a beta-blocker and ACE-inhibitor regardless of blood pressure level, concurrently with intensive lifestyle advice. This should be given in association with other appropriate medication, such as aspirin and a statin.
A: People presenting after an acute ischaemic stroke or transient ischaemic attack should start blood pressure lowering medication unless the person has symptomatic hypotension. This medication should be given in addition to other appropriate medication such as aspirin, a statin, or warfarin, if indicated. Treatment should start concurrently with intensive lifestyle advice. It is usually advisable to wait 7 to 14 days before starting blood pressure lowering medication.
C: Everyone with blood pressure consistently greater than 170/100 mm Hg should have drug treatment and specific lifestyle advice to lower risk factor levels.
B: Within the blood pressure range 115/70 to 170/100 mm Hg, all decisions to treat should be based on the individual’s cardiovascular risk.
A: A cardioprotective dietary pattern is strongly recommended as an integral component of blood pressure management.
B: Dietary advice should include the limitation of both alcohol (see Table 6 in the original guideline document) and sodium consumption.
B: Among people with a 5-year cardiovascular risk greater than 15% the aim of treatment is to lower 5-year cardiovascular risk to less than 15%.
A: A low-dose thiazide diuretic is the drug of first choice in those without contraindications.
A: Intensive blood pressure management is required (with early consideration of an ACE inhibitor) in all people with diabetes due to the increased risk of renal complications.
B: More than one drug is frequently required to lower blood pressure to optimum levels.
A: Aggressive blood pressure control is indicated in people with diabetes and overt nephropathy, or diabetes and microalbuminuria, or diabetes and other renal disease.
A: People with diabetes and overt nephropathy or diabetes and confirmed microalbuminuria should be started on an ACE-inhibitor or A2 receptor-blocker (if there are no contraindications) irrespective of blood pressure levels.
A: Most of the treatment benefit is achieved by reaching the following blood pressure levels:
- 140/85 mm Hg* in people without clinical cardiovascular disease
- 130/80 mm Hg* in people with diabetes or cardiovascular disease
GPP: A blood pressure lower than 130/80 mm Hg is preferable for people with diabetes and overt nephropathy or diabetes with other renal disease.
*Note: Where risk factor thresholds are given these should be interpreted as approximate guides to clinical practice only.
Dietary Interventions for Blood Pressure Lowering
A: Dietary intervention is strongly recommended as an integral component of the management of elevated blood pressure.
A: Advise an eating plan low in total fat, saturated fatty acids, and dietary cholesterol, and rich in fruits, vegetables, and low-fat dairy products.
A: People who are overweight or obese should be offered appropriate weight loss interventions.
A: Identify excessive alcohol intake and advise reduction or substitution with non-alcoholic beverages.
A: Assist the individual to reduce sodium intake to no more than 2 g per day (6 g sodium chloride).
GPP: Individualise nutritional counselling and other lifestyle changes to complement prescribed risk factor modifying pharmacological agents to reduce cardiovascular risk.
Monitoring and Duration of Treatment
GPP: Lifelong treatment is advised for people prescribed medication or intensive lifestyle advice.
GPP: Side effects of blood pressure lowering treatment are uncommon, but the possibility of drug-specific unwanted effects should be discussed prior to treatment.
GPP: For those on drug treatment, blood pressure monitoring is recommended every 3 months until the blood pressure is controlled, then every 6 months. Ongoing monitoring of creatinine and electrolytes is advisable for people with high initial values, persistent elevated blood pressure or in those taking diuretics, ACE-inhibitors, or A2 receptor-blockers.
GPP: People with diabetes who are receiving medication should have their blood pressure monitored every 3 months until adequate control is achieved, then every 6 months.
Intervention: Antiplatelet Therapy
Antiplatelet Therapy for People without Clinical Cardiovascular Disease
A: Everyone with a 5-year cardiovascular risk greater than 15% should be started on low-dose aspirin (75–150 mg/day) if there are no contraindications.
A: Aspirin is contraindicated in people with aspirin allergies or intolerance, active peptic ulceration, and uncontrolled blood pressure and in people with other major bleeding risks.
Intervention: Complementary and Alternative Therapies
GPP: Clinicians should enquire about the use of alternative and complementary medicines when assessing cardiovascular risk or prescribing medication.
I: There is insufficient evidence to recommend the following complementary and alternative therapies for the treatment or prevention of cardiovascular disease:
- herbal medicines, botanicals (Lin et al., 2001)
- garlic (Banerjee & Maulik, 2002; Beaglehole, 1996; Neil et al., 1996)/ginkgo biloba/rosemary/horse-chestnut seeds/xin bao
- acupuncture (Lin et al., 2001)
- chelation (Villarruz, Dans, & Tan, 2002)
- oriental medicine
- aromatherapy
- homeopathy
- hypnosis
- meditation
- yoga/tai chi
- intercessory prayer (Aviles et al., 2001)
- Strauss heart drops
C: Feverfew, garlic, ginkgo biloba, ginger, and ginseng may alter bleeding time and should not be used concomitantly with warfarin (Miller, 1998).
C: St John’s Wort reduces serum digoxin levels and can enhance the metabolism of warfarin (Ernst, 1999).
C: Herbs (e.g., karela and ginseng) may affect blood glucose levels and should not be used in people with diabetes mellitus (Miller, 1998).
Management of People with Diabetes, Hyperglycaemic States, or the Metabolic Syndrome
Reducing Cardiovascular Risk
C: The higher the calculated cardiovascular risk, the more aggressive the management of modifiable risk factors, including diabetes, should be.
C: Everyone with diabetes should be offered risk factor treatment to lower their 5-year cardiovascular risk to less than 15%. Where possible treatment should aim to achieve optimal levels: LDL-C less than 2.5 mmol/L, blood pressure less than 130/80 mm Hg, glycated hemoglobin (HbA1c) less than 7%.
A: Everyone with diabetes or the metabolic syndrome should receive intensive lifestyle advice. Lifestyle changes that have been shown to benefit people with these risk profiles include:
- dietary change (A)
- smoking cessation (A)
- physical activity (B)
A: Intensive dietary advice should be given in individual/group sessions with a dietitian.
A: A cardioprotective dietary pattern is strongly recommended as an integral component of diabetes management.
B: The optimal level of HbA1c is as close to physiological levels as possible, preferably less than 7% for most people.
A: Due to the increased risk of renal complications, intensive blood pressure management is required (with early consideration of an ACE-inhibitor) in all people with diabetes.
B: More than one drug is frequently required to lower blood pressure to optimum levels.
A: Aggressive blood pressure control is indicated in people with diabetes and overt nephropathy, diabetes and confirmed microalbuminuria, or diabetes with other renal disease.
A: People with diabetes and overt nephropathy or diabetes with confirmed microalbuminuria should be started on an ACE-inhibitor or A2 receptor-blocker (if there are no contraindications) irrespective of blood pressure levels.
A: Most of the treatment benefit is achieved by reaching the following blood pressure levels:
- 140/85 mm Hg in people without clinical cardiovascular disease
- 130/80 mm Hg in people with diabetes or cardiovascular disease.
A: A blood pressure lower than 130/80 mm Hg is preferable for people with diabetes and overt nephropathy or other renal disease.
Diagnostic Criteria for Type 2 Diabetes, IGT and IFG
C: Two fasting venous plasma glucose results greater than or equal to 7 mmol/L on two different days are diagnostic of diabetes and do not require an oral glucose tolerance test (OGTT).
C: A random venous plasma glucose result of greater than 11 mmol/L on two different days is diagnostic of diabetes.
C: A fasting venous plasma glucose of 6.1 to 6.9 mmol/L indicates impaired fasting glycaemia and an OGTT is recommended to look for diabetes or IGT.
C: Some people with a fasting venous plasma glucose of 5.5 to 6.0 mmol/L show diabetes or IGT with an OGTT.
C: An OGTT is recommended in people with a fasting glucose of 5.5 to 6.0 mmol/L who are not of European ethnicity or who have a family history of diabetes, a past history of gestational diabetes, or the other features of the metabolic syndrome.
C: A fasting venous plasma glucose result of less than 5.5 mmol/L is normal.
GPP: HbA1c should not be used for the diagnosis of diabetes.
Cardiovascular Risk Assessment in People with Diabetes or at High Risk of Diabetes
C: All people with diabetes should be offered annual comprehensive cardiovascular risk assessments from the time of diagnosis.
C: Maori, Pacific peoples, and people from the Indian subcontinent should be offered cardiovascular risk assessment from 35 years for men and 45 years for women.
C: Men and women at higher risk of diabetes should be offered cardiovascular risk assessment from 35 years for men and 45 years for women. These people are those with one or more of the following risk factors:
- a family history of diabetes in a first-degree relative (parent or sibling)
- a personal history of gestational diabetes
- a personal history of polycystic ovary syndrome
- known IGT or IFG (see Table 21)
- obesity (BMI >30*) or truncal obesity (waist circumference >100 cm* in men or >90 cm* in women)
B: People with diabetes and overt diabetic nephropathy (albumin:creatinine ratio greater than 30 mg/mmol) or diabetes with other renal disease are classified clinically at very high risk (5-year cardiovascular risk >20%) without a cardiovascular risk calculation.
B: All other people with diabetes should have their 5-year cardiovascular risk calculated using the risk tables.
C: Certain people with diabetes or the metabolic syndrome are at increased cardiovascular risk and should be moved up one risk category as part of the cardiovascular risk assessment. These include:
- people with diabetes and microalbuminuria
- people with type 2 diabetes 10 years after diagnosis
- people with HbA1c results consistently above 8%
- people who meet the definition of the metabolic syndrome
C: Everyone with diabetes should have uric acid levels as well as renal and liver-function tests performed at the time of a cardiovascular risk assessment.
*Note: Where risk factor thresholds are given these should be interpreted as approximate guides to clinical practice only.
Dietary Interventions for People with Hyperglycaemic
A: People who are at risk of type 2 diabetes should avoid weight gain. Offer weight loss advice to people who are overweight or obese.
A: Everyone with IGT or IFG should receive intensive dietary advice. Intensive dietary advice should ideally be given in individual/group sessions with a dietitian. Physical activity should also be encouraged.
B: Encourage adults at risk of type 2 diabetes to adopt a cardioprotective dietary pattern, reduce saturated fatty acids and increase dietary fibre.
Dietary Interventions for People with Type 2 Diabetes or the Metabolic Syndrome
A: Recommend a reduction in energy intake with weight loss as the primary objective for people with diabetes or the metabolic syndrome who are overweight or obese.
A: Everyone with type 2 diabetes or the metabolic syndrome should receive intensive dietary advice. Intensive dietary advice should be given in individual/group sessions with a dietitian. Physical activity should also be encouraged.
A: Encourage people with type 2 diabetes or the metabolic syndrome to gradually adopt a cardioprotective dietary pattern. Advise a reduction in the intake of foods rich in saturated fatty acids or added sugars, and white flour bakery products.
Encourage a progressive replacement of these foods with vegetables, fruit, whole grain, high-fibre products, and dried peas and beans (legumes). Recommend an increase in the consumption of fish and include a source of polyunsaturated fat (see Table 5 in the original guideline document).
A: Interventions that are known to reduce risk factors in people without diabetes are also recommended for people with diabetes. Assess salt and alcohol consumption and provide guidance for limited use. Consider adding plant sterols/stanols to the diet.
A: For the optimal improvement of all risk factors, especially body weight and glycaemic control, employ intensive dietary interventions that include continuous education, behaviour modification, goal setting, and intensive monitoring.
C: Identify and recommend qualitative dietary changes based on the habitual dietary pattern, and then progress to quantitative advice to promote the development of a structured eating plan.
A: Specific dietary advice for people with diabetes and the metabolic syndrome includes advice about the saturated fatty acid content of foods and the quality of carbohydrate choices to encourage a high-fibre intake of more than 40 g daily (see Table 4 in the original guideline document).
A: To control postprandial hyperglycaemia the following advice is recommended:
- include high-fibre foods with a low to moderate glycaemic index at each meal
- distribute carbohydrate foods evenly throughout the day
- avoid a large volume of carbohydrate-rich foods at any one meal.
GPP: All people with diabetes should be referred to a dietitian.
Treatment Monitoring and Duration
GPP: Lifelong treatment is advised for people with diabetes.
GPP: People with diabetes receiving medication should have their lipids and blood pressure, glycaemic control, diet, and activity level monitored every 3 months until adequate control is achieved, then every 6 months.
GPP: Referral to a specialist for an opinion or specialist management should be considered for people with type 2 diabetes if:
- serum creatinine is greater than or equal to 0.15 mmol/L
- calculated glomerular filtration rate (GFR) is less than 60 ml/min/1.73m2
- there is a rapid increase in level of microalbuminuria or proteinuria
- there is a difficulty in achieving blood pressure targets
- in situations where non-diabetic renal disease may be present or may co-exist with diabetic renal disease:
- there is absence of diabetic retinopathy in a person with renal disease
- there are urinary abnormalities such as haematuria or casts (once infection has been excluded as the cause)
Medication for Cardiovascular Disease
Aspirin Use After Myocardial Infarction and Stroke
After Myocardial Infarction
A: Aspirin 75 to 150 mg/day should be given routinely and continued for life. These doses are at least as effective as higher doses.
After Stroke
A: Aspirin 75 to 150 mg/day should be given routinely after ischaemic stroke or transient ischaemic attack, unless there is an indication for anticoagulation with warfarin. These doses are at least as effective as higher doses.
C: Computed tomography (CT) scan should be obtained prior to aspirin therapy to exclude intracranial haemorrhage.
Clopidogrel Use After Myocardial Infarction and Stroke
After Myocardial Infarction
A: Clopidogrel (75 mg/day) is an effective alternative to aspirin for people with contraindications to aspirin or those who are intolerant of aspirin.
After Stroke
A: Clopidogrel (75 mg/day) can be used as a safe and effective alternative to aspirin after stroke.
Dipyridamole Use After Stroke
After Stroke
I: There is insufficient evidence to recommend dipyridamole as a first-line treatment for the secondary prevention of vascular events, either as monotherapy or in combination with aspirin.
B: Combination treatment with modified-release dipyridamole and aspirin can be used for prevention of non-fatal stroke for people at high risk of cerebral ischaemic events, including those who have symptomatic cerebral ischaemia while treated with aspirin alone.
B: Monotherapy with modified-release dipyridamole is recommended for prevention of non-fatal stroke if aspirin is contraindicated and clopidogrel is unavailable.
Warfarin Use After Myocardial Infarction and Stroke
After Myocardial Infarction
A: Warfarin should be prescribed for high-risk survivors of myocardial infarction including those with:
- atrial fibrillation or paroxysmal atrial fibrillation
- a large left ventricular aneurysm
- thrombus demonstrated in the left ventricle at the infarction site by echocardiography
- systemic embolism.
A: Warfarin should be considered for people who cannot be given antiplatelet agents after myocardial infarction.
After Stroke
A: Warfarin should not be prescribed for people with transient ischaemic attack or minor strokes unless cardiac embolism is suspected.
A: Warfarin should be considered for people after stroke associated with atrial fibrillation unless contraindicated.
C: Warfarin should be considered for people after ischaemic stroke associated with mitral valve disease, prosthetic heart valves, or within 30 days of myocardial infarction.
C: Warfarin should ideally be started in hospital. For minor stroke, it can be started after the first 48 hours or later if haemorrhage has been excluded by brain imaging. Delay for 7 to 14 days may be preferable for people after a major stroke.
After Myocardial Infarction or Stroke
A: The target international normalized ratio (INR) should be 2.5 (range 2 – 3), for most people prescribed warfarin after myocardial infarction or after ischaemic stroke associated with atrial fibrillation or mitral valve disease.
Beta-Blocker Use After Myocardial Infarction
After Myocardial Infarction
A: Beta-blockers should be considered for everyone following myocardial infarction unless there are contraindications.
A: Beta-blockers are also recommended in those with left ventricular dysfunction and heart failure.
GPP: The initial dose of beta-blockers should be low and the dose should be titrated upwards slowly.
GPP: Everyone should receive an explanation of the benefits and risks of treatment.
GPP: Beta-blockers given at night may reduce the risks of postural hypotension and alleviate symptoms of tiredness and lethargy.
GPP: Before discontinuing beta-blockers because of side effects, a lower dose or alternative beta-blocker should be tried.
GPP: If full doses of a beta-blocker and ACE-inhibitor are not tolerated, moderate doses of both are preferable to a high dose of a single agent.
ACE-Inhibitor Use After Myocardial Infarction and Stroke
After Myocardial Infarction
A: An ACE-inhibitor should be prescribed for everyone after myocardial infarction, regardless of left ventricular function. Treatment should be started early and continued long-term especially in those with anterior infarction, left ventricular dysfunction, or heart failure. Long-term ACE-inhibitor therapy should be prescribed for all people with coronary heart disease.
After Stroke
A: Blood pressure lowering medication or increased doses of current agents should be started for people presenting after an acute ischaemic stroke or transient ischaemic attack unless they have symptomatic hypotension. An ACE-inhibitor in conjunction with a thiazide diuretic is an appropriate combination.
GPP: Blood pressure targets after a stroke should take into account the number and dose of medications prescribed as well as comorbidities and general frailty.
GPP: It is advisable to wait 7 to 14 days after an acute stroke to start blood pressure lowering medication.
After Myocardial Infarction or Stroke
GPP: In general, low-dose combination therapies are good choices. Periodic monitoring of electrolytes and renal function is recommended.
Use of Lipid-Modifying Agents After Myocardial Infarction and Stroke
After Myocardial Infarction
A: A statin equivalent to simvastatin 40 mg/day should be prescribed to everyone after myocardial infarction. Statin therapy should preferably be started in hospital.
After Stroke
B: Treatment with a statin is recommended for most people following ischaemic stroke or transient ischaemic attack. Statin therapy should preferably be started in hospital.
Use of Antiarrhythmic Agents After Myocardial Infarctions
A: Antiarrhythmic therapy, apart from beta-blockers, is not recommended for routine use after myocardial infarction.
Hormone Replacement Therapy After Myocardial Infarction and Stroke
A: Combined Hormone Replacement Therapy should not be used for the prevention of coronary heart disease/stroke or after a cardiovascular event.
Calcium Channel Blocker Use After Myocardial Infarction
A: Rate-limiting non-dihydropyridine calcium channel blockers may be considered for people with normal ventricular function where beta-blockers are contraindicated and treatment is required for concurrent angina or hypertension.
Nitrate Use After Myocardial Infarction
A: Nitrates can be used after myocardial infarction for controlling symptoms of angina and heart failure, but are not indicated for reducing the risk of further events.
When to Start Therapy After Myocardial Infarction and Stroke
After Myocardial Infarction
PP: Most therapies will have been started in hospital. Some people, on review in primary care, will require initiation or dose adjustment.
After Stroke
GPP: Aspirin should be started as soon as possible after ischaemic stroke. Warfarin and statins should be started in hospital. Blood pressure lowering therapy with ACE-inhibitor and thiazide treatment should be started after 7 to 14 days.
Cardiovascular Health of Pacific People
GPP: Consider that difficult socioeconomic circumstances present significant barriers to Pacific people’s access to quality health care.
GPP: Be cognisant of the diversity and heterogeneity of the Pacific population – made up of different Pacific ethnic groups each with a distinct language and culture.
GPP: Be aware that the English language may be a barrier. Pacific ethnic-specific translators should be made available within services that provide for Pacific people.
GPP: Absolute cardiovascular risk determines treatment decisions and benefits. Within this guideline, cardiovascular risk assessment is recommended 10 years earlier for Pacific people.
GPP: Recognise the importance of the family to Pacific people. Involve family members in the management of the person’s illness and suggested dietary and lifestyle changes.
GPP: Invest in the development of Pacific ethnic-specific cardiovascular workforce and resources.
GPP: Collect quality Pacific health information (including Pacific ethnic specific data).
GPP: Support and partner with Pacific providers and Pacific communities to promote cardiovascular health for Pacific people.
Definitions:
Levels of Evidence
1++
High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2E
An economic evaluation that has used local data (in this case from New Zealand) with level 1 evidence on effectiveness of interventions from well conducted meta-analyses or RCTs
2++
High quality systematic reviews of case-control or cohort studies
High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+
Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-
Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3
Non-analytic studies (e.g., case reports, case series)
4
Expert opinion
Rating Scheme for the Strength of the Recommendations
A
The recommendation is supported by good evidence.
B
The recommendation is supported by fair evidence.
C
The recommendation is supported by non-analytic studies or consistent expert opinion.
I
The evidence is insufficient, evidence is lacking, of poor quality or opinions conflicting, the balance of benefits and harms cannot be determined.
Good Practice Point (GPP)
Recommended practice based on the clinical experience of the Guideline Development Team
