Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Estimating Cardiovascular Risk
D - Individuals with symptoms of cardiovascular disease or who are over the age of 40 years and have diabetes (type 1 or 2) or familial hypercholesterolaemia should be considered at high risk (>20% risk over ten years) of cardiovascular events.
D - Cardiovascular risk should be estimated at least once every five years in adults over the age of 40 years with no history of cardiovascular disease, familial hypercholesterolaemia or diabetes and who are not being treated for blood pressure or lipid reduction.
D - Asymptomatic individuals should be considered at high risk if they are assessed as having >20% risk of a first cardiovascular event over ten years.
D - Individuals at high cardiovascular risk warrant intervention with lifestyle changes and consideration for drug therapy, to reduce their absolute risk.
Diet
A - Diets low in total and saturated fats should be recommended to all for the reduction of cardiovascular risk.
A - People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure.
C - Increased fruit and vegetable consumption is recommended to reduce cardiovascular risk for the entire population.
A - Antioxidant vitamin supplementation is not recommended for the prevention or treatment of coronary heart disease.
B - Patients, and individuals at risk of cardiovascular disease, who are overweight, should be targeted with interventions designed to reduce weight, and to maintain this reduction.
Physical Activity
B - Physical activity of at least moderate intensity (e.g., makes person slightly out of breath) is recommended for the whole population (unless contraindicated by condition).
B - Physical activity should include occupational and/or leisure time activity and incorporate accumulated bouts of moderate intensity activities such as brisk walking.
B - Those who are moderately active and are able to increase their activity should be encouraged to do so. Activity can be increased through a combination of changes to intensity, duration or frequency.
Smoking
B - All people who smoke should be advised to stop and offered support to help facilitate this in order to minimise cardiovascular and general health risks.
B - Exposure to passive smoking increases cardiovascular risk and should be minimised.
A - Nicotine replacement therapies or bupropion should be used as part of a smoking cessation programme to augment professional advice and increase long term abstinence rates.
B - Smokers with coronary heart disease and comorbid clinical depression should have their depression treated both for alleviation of depressive symptoms and to increase the likelihood of stopping smoking.
Alcohol
B - Patients with no evidence of coronary heart disease may be advised that light to moderate alcohol consumption may be protective against the development of coronary heart disease.
C - Patients with established coronary heart disease may be advised that light to moderate alcohol consumption may be protective against further coronary events.
A - Brief multi-contact interventions should be used to encourage patients to reduce their levels of drinking if their current intake is hazardous to their health.
Antiplatelet Therapy
A - Individuals with established atherosclerotic disease should be treated with 75 mg aspirin daily.
A - Individuals with a history of stroke or transient ischaemic attack and who are in sinus rhythm should be considered for low dose aspirin (75 to 300 mg daily) and dipyridamole (200 mg twice daily) to prevent stroke recurrence and other vascular events. If aspirin is contraindicated, or there are side effects, clopidogrel 75 mg daily is an alternative.
A - Asymptomatic individuals without established atherosclerotic disease but with a calculated cardiovascular risk of >20% over ten years should be considered for treatment with aspirin 75 mg daily.
Lipid Lowering
A - All adults over the age of 40 years who are assessed as having a ten year risk of having a first cardiovascular event >20% should be considered for treatment with simvastatin 40 mg/day following an informed discussion of risks and benefits between the individual and responsible clinician.
B - All patients with established symptomatic atherosclerotic cardiovascular disease should be considered for more intensive statin therapy following an informed discussion of risks and benefits between the individual and responsible clinician.
A - Individuals with hypertriglyceridaemia (>1.7 mmol/l) and/or low high density lipoprotein cholesterol level (<1 mmol/l in men, or <1.2 mmol/l in women) should be considered for treatment with a fibrate or niconitic acid.
A - Statins are the drugs of choice in the management of diabetic subjects with mixed dyslipidaemia and elevated low density lipoprotein cholesterol.
Blood Pressure Lowering
A - Individuals with sustained systolic blood pressures >140 mm Hg systolic and/or diastolic blood pressures >90 mm Hg and clinical evidence of cardiovascular disease should be considered for blood pressure lowering drug therapy.
A - Individuals with established cardiovascular disease, who also have chronic renal disease or diabetes with complications, or target organ damage may be considered for treatment at the lower threshold of systolic >130 mm Hg and/or diastolic >80 mm Hg.
B - Individuals with blood pressure greater than 160/100 mm Hg should have drug treatment and specific lifestyle advice to lower their blood pressure and risk of cardiovascular disease.
Psychological Issues
B - Depression and social isolation or lack of quality social support are risk factors for the development of and prognosis with coronary heart disease and should be taken into account when assessing individual risk.
A - Stress management training is not recommended as a technique to reduce coronary heart disease mortality or morbidity or conventional risk factors. It may have a role in improving patients' mood, including depressed mood.
A - Cognitive behaviour therapy should be considered for increasing physical function and improving mood in patients with coronary heart disease.
A - Use of the stages of change model alone is not recommended as a method for changing the health behaviour of individuals with coronary heart disease.
B - Motivational interviewing should be considered in patients with cardiovascular disease who require to change health behaviours including diet, exercise, alcohol and compliance with treatment.
Definitions:
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
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
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
