• Kaiser Permanente Care Management Institute. Secondary prevention of coronary artery disease clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2006 Mar. 117 p. [51 references]

This is the current release of the guideline.

Recommendations are identified as either "evidence-based (A-D, I)" or "consensus-based." For definitions of the levels of recommendations see the end of the "Major Recommendations" field.

Summary

Definition of Coronary Artery Disease (CAD)

These guidelines describe secondary prevention measures for patients with a diagnosis of ischemic heart disease based upon a history of angina, myocardial infarction (MI), coronary artery bypass surgery graft (CABG), percutaneous coronary intervention (PCI), or evidence of coronary artery disease on angiography or non-invasive testing. For treatment decisions involving patients with acute coronary syndromes, cardiology consultation is recommended.

Angiotensin-Converting Enzyme (ACE) Inhibitor Therapy

For most patients with CAD,* angiotensin-converting enzyme (ACE) inhibitor therapy is recommended for long term use,** unless contraindicated.

* In the PEACE Trial, patients with stable coronary artery disease and preserved left ventricular systolic function had no benefit on the composite endpoint of cardiovascular death, MI, and coronary revascularization with the addition of an ACE-inhibitor to standard medical therapy. ACE-inhibition is, therefore, not required in such patients.

** For patients on concomitant aspirin, low-dose aspirin is recommended.

Evidence-based

Angiotensin II Receptor Blocker (ARB) Therapy

1. Angiotensin II receptor blocker (ARB) therapy is recommended for the following patients with CAD who are intolerant to ACE inhibitors:
   • Patients with CAD and diabetes with hypertension and microalbuminuria (or albuminuria)
   • Patients with CAD and left ventricular systolic dysfunction (LVSD)

2. For patients who are intolerant to ACE inhibitors, with CAD and hypertension (without either LVSD or diabetes), ARB therapy is an option equal to other antihypertensive medications.
3. For all other patients with CAD who are intolerant to ACE inhibitors, there is insufficient evidence to recommend for or against ARB therapy.

A: Consensus-based
B, C: Evidence-based

ACE Inhibitor + Aspirin

For all patients with CAD taking low-dose aspirin, ACE inhibitor therapy may be safely recommended for long term use.

Evidence-based

ACE Inhibitor Plus ARB Therapy

1. For CAD patients, the routine addition of ARB therapy to ACE inhibitor therapy is not recommended.
2. If ARBs are added to ACE inhibitors it should be done for clinical reasons, such as uncontrolled hypertension or insufficient vasodilation.
3. This recommendation applies whether or not a patient is treated with a beta blocker.

A, B, C: Consensus-based

Antiplatelet Therapy: Aspirin

1. For all patients with CAD, daily aspirin (75 to 325 mg) is recommended indefinitely, unless there is clear contraindication such as active bleeding, major coagulopathy, or true aspirin allergy.
2. For CAD patients on concomitant ACE Inhibitors, low-dose aspirin is recommended.

   (NOTE: The lowest dose commercially available acetylsalicylic acid (ASA) in the United States is 81 mg.)

A: Evidence-based
B: Consensus-based

Antiplatelet Therapy: Clopidogrel Use in Stable Patients

1. In stable CAD patients who tolerate aspirin well (and who are not post-procedure), clopidogrel is not recommended as either a substitute for or in addition to aspirin.
2. In stable CAD patients with contraindications to aspirin, clopidogrel is recommended as the antiplatelet of choice.

A, B: Consensus-based

Antiplatelet Therapy: Post-Procedure

1. Following coronary artery bare metal stent placement clopidogrel plus aspirin is recommended to be given for at least four weeks.
2. Following coronary artery drug-eluting stent placement, clopidogrel plus aspirin is recommended to be given for at least three months and up to one year post-procedure to reduce the risk of thrombotic events.
3. If there is presence of a rash after clopidogrel use, patients may be switched to ticlopidine.

A: Evidence-based
B, C: Consensus-based

Beta Blocker Therapy

Beta blocker therapy is recommended for CAD patients unless contraindicated; specifically:

1. For post-MI patients non-intrinsic sympathomimetic activity (non-ISA) beta blocker therapy is recommended.
2. For post-MI patients non-ISA beta blocker therapy is recommended to be initiated within hours after MI and continued long term.
3. For CAD patients with unstable angina, long term non-ISA beta blocker therapy is recommended.
4. For CAD patients with chronic stable angina, long term non-ISA beta blocker therapy is recommended for treatment of symptoms.
5. For CAD patients with silent ischemia, non-ISA beta blocker therapy is recommended.
6. For patients with CAD, beta blocker therapy is recommended peri-operatively for vascular surgery or noncardiac surgery with general anesthesia.
7. For patients at risk for CAD,* beta blocker therapy is recommended peri-operatively for vascular surgery.

   * At risk for CAD is defined as having at least two of the following cardiac risk factors: age >65 years, hypertension, current smoking, serum cholesterol >240 mg/dL (6.2 mmol/L), diabetes mellitus.

   (NOTE: Drugs without ISA are atenolol, betaxolol, bisoprolol, carvedilol, labetalol, nadolol, metoprolol, propranolol, and timolol.  Drugs with ISA are acebutolol, and pindolol.)

A, D, F, G: Evidence-based
B, C, E: Consensus-based

CAD Plus Mild to Moderate Reversible Airway Disease or Chronic Obstructive Pulmonary Disease (COPD): Beta Blocker Therapy

1. For CAD patients with concomitant mild to moderate reversible airway disease or chronic obstructive pulmonary disease (COPD) cardioselective beta blockers are recommended.
2. Discuss the risks and benefits of treatment with the patient and instruct the patient to report any increase in airway symptoms.
3. Initiating beta blocker therapy is NOT recommended:
   • For patients with severe airway disease requiring frequent hospitalization or intubation
   • During acute exacerbation of airway disease
   • When airway disease is unstable or poorly controlled

A: Evidence-based
B, C: Consensus-based

CAD Plus Heart Failure: Beta Blocker Therapy

1. For CAD patients with either left ventricular systolic dysfunction (LVSD) (New York Heart Associations (NYHA) Class II-IV) or asymptomatic LVSD (NYHA Class I), beta blockers are strongly recommended.
2. For CAD patients with LVSD carvedilol, metoprolol CR/XL, or bisoprolol is the recommended choice of beta blocker therapy.
3. Metoprolol tartrate (short-acting formulation) titrated to maximum tolerated dosage, is an acceptable but less well-established alternative to carvedilol, metoprolol CR/XL, or bisoprolol.

A, B: Evidence-based
C: Consensus-based

Lipid Management

Treatment with statins is recommended for all adults with established atherosclerosis, even if baseline low density lipoprotein (LDL)-C is <100 mg/dL.

Evidence-based

Diet Therapy

For all patients with CAD a diet rich in fruits, vegetables, legumes, nuts, whole grains, and n-3- (omega-3) polyunsaturated fat is recommended.

Evidence-based

Dietary Fat Modification

For all patients with CAD consuming a usual Western diet the following modifications in dietary fat are recommended:

• Increase intake of n-3 (omega-3) polyunsaturated fatty acids to a level of approximately 1 g/day from a variety of sources (flaxseed, canola, and soybean oils, nuts, fish, and fish oil supplements).*
• Replace saturated fatty acids with polyunsaturated and monounsaturated fatty acids.
• Reduce or eliminate intake of trans-fatty acids.

* To limit the bioaccumulation of methylmercury, polychlorinated biphenyls (PCBs), dioxins, and other environmental contaminants, intake of certain fish (e.g., swordfish, tuna, and farmed salmon) is recommended not to exceed two servings per week.

Consensus-based

Dietary Supplement Therapy

1. For patients with CAD, supplemental vitamins C, E and beta carotene are not recommended for prevention of cardiovascular mortality or subsequent coronary events.
2. For CAD patients who are current or former smokers, supplemental beta carotene is not recommended due to a small but significant excess in all cause mortality reported in this group.
3. For patients with CAD supplemental folic acid, vitamin B6, and vitamin B12 are not recommended.

A, B: Evidence-based
C: Evidence-based (D)*

* Please note that only recommendations approved since the adoption in 2006 of evidence grading will use letters (A, B, C, etc.) to specify the grade of the evidence. Recommendations approved prior to 2006 will not include a letter grade following the statement "evidence-based."

Definitions:

Recommendations are classified as either "evidence-based (A-D, I)" or "consensus." Refer to the table below for full definitions.

• Evidence-based: sufficient number of high-quality studies from which to draw a conclusion, and the recommended practice is consistent with the findings of the evidence. A recommendation can also be considered "evidence-based" if there is insufficient evidence and no practice is recommended.
• Consensus: insufficient evidence and a practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

Label and Language of Recommendations*

^[a] All statements specify the population for which the recommendation is intended.

* Recommendations should be labeled and given an evidence grade. The evidence grade should appear in the rationale. Evidence is graded with respect to the degree it supports the specific clinical recommendation. For example, there may be good evidence that Drugs 1 and 2 are effective for Condition A, but no evidence that Drug 1 is more effective than Drug 2. If the recommendation is to use either Drug 1 or 2, the evidence is good. If the recommendation is to use Drug 1 in preference to Drug 2, the evidence is insufficient.

An algorithm on Statin Management in Secondary Prevention is provided in the original guideline document.

The type of supporting evidence is not specifically stated for each recommendation, but the evidence underlying the recommendations are drawn from randomized controlled trials, meta-analyses, and existing systematic reviews. In cases where the data was inconclusive, inconsistent, or non-existent, recommendations were based on the consensus opinion of the group.

• Kaiser Permanente Care Management Institute. Secondary prevention of coronary artery disease clinical practice guideline. Oakland (CA): Kaiser Permanente Care Management Institute; 2006 Mar. 117 p. [51 references]

Not applicable: The guideline was not adapted from another source.

2006 Mar

Kaiser Permanente Care Management Institute - Managed Care Organization

Kaiser Permanente Care Management Institute

Kaiser Permanente CAD Guidelines Project Management Team
Kaiser Permanente CAD Guidelines Development Team

Kaiser Permanente CAD Guidelines Project Management Team Members: John Golden, MD, Clinical Lead, Care Management Institute; Donna M. Schaffer, RD, MPH, Project Manager, Care Management Institute; Paul Barrett, MD, Evidence-Based Medicine Methodologist, Care Management Institute; Tabitha Pousson, Staff Assistant, Care Management Institute

Kaiser Permanente CAD Guidelines Development Team Members: John H. Merenich, MD, Cardiology, KP Colorado; George Kawamura, MD, Cardiology, KP Georgia; Alan Golston, MD, Cardiology, Group Health Cooperative; Art Resnick, MD, Cardiology, Group Health Cooperative; Steven Hong, MD, Internal Medicine, KP Hawaii; Patricia E. Casey, MSN, RN, Chronic Disease Management, KP Mid-Atlantic States; John Golden, MD, Cardiology, KP Mid-Atlantic States; Gerald Bourne, MD, Cardiology, KP Northern California; Carlos Iribarren, MD, CVD Research, KP Northern California; Marc Jaffe, MD, Endocrinology, KP Northern California; Eleanor Levin, MD, Cardiology, KP Northern California; Anita Strohmeier, Chronic Disease Management, KP Northern California; Wiley V. Chan, MD, Internal Medicine, KP Northwest; Alison Fulmer, MD, Cardiology, KP Northwest; Shobana Rajagopal, MD, Family Practice, KP Northwest; Maan Fares, MD, Cardiology, KP Ohio; Carol Bartolotto, MPH, RD, Health Education, KP Southern California; Victor M. Benson, MD, Internal Medicine, KP Southern California; Gary M Besinque, PharmD, Pharmacy, KP Southern California; Kathleen Ryman, MD, Cardiology, KP Southern California

Not stated

This is the current release of the guideline.

Electronic copies: None available

Print copies: Available from the Kaiser Permanente Care Management Institute, One Kaiser Plaza, 16L, Oakland, CA 94612

None available

This NGC summary was completed by ECRI on November 17, 2006. The information was verified by the guideline developer on December 19, 2006.