Table 7.
Selected recommendations from the ACC/AHA updated guidelines on risk reduction in patients with angina
| Risk factor | Recommendations | COR/LOEa | Comments (not part of the guidelines) |
|---|---|---|---|
| Smoking | Smoking must be stopped immediately, and second-hand smoke should be avoided. Pharmacotherapy with nicotine and other approved agents should be used along with referral to special programs. Use a stepwise strategy: Ask, Advise, Assess, Assist, and Arrange. | I (B) | Smoking is a potent and pernicious risk factor. Cessation may lower risk by 60% in 3 y, with half of that manifested within the first 3–6 months. |
| Hypertension | BP should be kept <140/90 mmHg, or <130/90 mmHg in DM or CKD. | I (A) | Evidence at the ACC 2010 sessions raised doubts about the wisdom of tight BP control in DM.205,206 |
| Lifestyle modifications: weight control, physical activity, low alcohol, sodium intake, high consumption of fresh fruits and vegetables and low-fat dairy products – an improved “DASH diet” is advised. | I (B) | New Joint National Conference 8 Guidelines for hypertension are expected late in 2011. | |
| For patients with established CHD, use β blockers or ACE inhibitors first, then other agents. | I (C) | When a prior AMI has not occurred, ACE/ARB use is quite discretionary – see below. | |
| Dyslipidemia | When baseline LDL ≥ 100 mg/dL, begin drugs with lifestyle measures. | I (A) | Intensify therapy to reach 30%–40% reduction in high-risk patients, or <70 mg/dL. |
| Daily exercise, weight control, low-saturated fat diet <7%, reduce dietary TFA, and cholesterol intake <200 mg/d. | I (B) | The less dietary TFA, the better. | |
| If TG = 200–499 mg/dL, non-HDL should be <130 mg/dL. | |||
| Add plant stanols 2 g/d and/or soluble fiber >10 g/d. | IIa (A) | A somewhat greater intake may improve results, with maximum reduction of about 9% from each maneuver. | |
| Lowering LDL < 70 mg/dL or using high-dose statins is reasonable. | IIa (A) | Aggressive LDL lowering is being favored in many different clinical situations, but still leaves unacceptable residual risk. | |
| If baseline LDL is 70–100 mg/dL, lowering LDL to < 70 mg/dL is reasonable. | IIa (B) | ||
| When TG are 200–499 mg/dL, lowering non-HDL < 100 mg/dL is reasonable. | IIa (B) | Although LDL remains the official primary target, non-HDL better incorporates the atherogenicity of other particles. | |
| Niacin or fibrates can be used to lower non-HDL after LDL therapy is begun. | IIa (B) | ||
| Omega-3 fish oil, 1 g/d is reasonable. Greater amounts (>2.5/d) are needed for elevated TG levels. | IIb (B) | 1g fish oil means the sum of EPA + DHA, not total marine oil. Most people consume too little, even from supplements. More usually offers better protection against SCD. Omega-3 fats are pleiotropic. | |
| TG > 500 mg/dL should be addressed first to avoid pancreatitis with fibrates or niacin. | I (C) | ||
| Weight control | Keep BMI between 18.5–24.0 kg/m2. Aim for a 10% reduction first. Be persistent and measure waist circumference. If it is ≥40″ (102 cm) in men or 35″ (89 cm) in women, consider MetS, especially in men with waists 37–40″ (94–102 cm) with genetic insulin resistance. | I (B) | Sustained weight control, since there is no truly effective pharmacologic therapy, is most difficult to achieve without surgery, but it is fundamental to risk reduction. |
| Physical activity | Recommend 30–60 min of moderate-intensity aerobic activity, 7 d/wk, a minimum of 5 d/wk, supplemented by an increase in daily activities. An activity history should be recorded, and an exercise test is performed to guide the exercise prescription. CR programs should be recommended for at-risk patients such as recent ACS or revascularization, or HF. | I (B) | |
| Resistance training 2 d/wk may be reasonable. | IIb (C) | 3 days of strength training 45–60 min each session is usually the eventual goal if medically appropriate. | |
| Diabetes | Keep HbA1c levels “near normal” | I (B) | ACCORD and other studies have recently modified views on the merits of very tight control.39,207,208 HbA1c guidelines from the ADA remain intact presently. |
| Reduction of other risk factors (weight, physical activity, dyslipidemia, and BP should be vigorously pursued as recommended). | |||
| β blockers | Begin and continue indefinitely in all patients with prior AMI, ACS, or LV dysfunction with or without HF symptoms unless contraindicated. | I (A) | See discussion above concerning β blockers. |
| Antiplatelet agents | 72–162 mg aspirin should be used in all patients and be continued indefinitely unless contraindicated. | I (A) | Use in primary prevention is controversial. |
| Use with warfarin, and clopidogrel may increase bleeding and should be monitored. | I (B) | Genetic variation in responsiveness is now of clinical importance. Use of PPIs with clopidogrel is debated, and there is an FDA warning. | |
| RAA system blockers | ACEI should be used in all patients with LVEF ≤ 40% in all patients and in those with HTN, DM, or CKD. | I (A) | |
| ARB should be used for those with HTN with indications but who cannot tolerate ACEI, have HF, or are post-MI with LVEF ≤ 40%. | |||
| Aldosterone blockers should be used in post-MI patients without creatinine >2.5 mg/dL in men, >2 mg/dL in women, or K+ > 5 mEq/L, who are receiving adequate doses of an ACEI and a β-blocker, have LVEF ≤ 40%, and have either DM or HF. | |||
| ACEI for patients who are not low risk, ie, normal LVEF and in whom risk factors are controlled and revascularization has been performed. | I (B) | For patients who have not sustained an AMI, use of ACEI or ARB in angina patients is not established. | |
| Vaccination | Influenza vaccination-recommended annually. | I (B) |
Notes: There are 5 treatments that are considered class I (A), ie, should be done in all patients. There are no lifestyle recommendations that are I (A), and specific diet changes are not addressed. Currently available data concerning diet and lifestyle do not permit such classifications, but are potent therapies.
COR, classifications of recommendations is as follows: class I, benefit ⋙ risk, and treatment should be done; class IIa, benefit ≫ risk, and it is reasonable; class IIb, benefit ≥ risk, and it may be considered; class II, risk ≥ benefit, and the treatment should not be done since it is not helpful and may harm. Class III items have been omitted. LOE, level of evidence, an estimate of certainty of treatment effect, is as follows: level A, useful in different subpopulations, with general consistency of direction and magnitude of effect; level B, only 2 to 3 subpopulations or risk strata have been evaluated; level C, limited, with 1 to 2 subpopulations evaluated. Classification as levels B or C does not imply ineffectiveness or weakness of the recommendation, simply that clinical trials have not been performed.
Abbreviations: ACC, American College of Cardiology; AHA, American Heart Association; COR, classifications of recommendations; LOE, level of evidence; BP, blood pressure; DM, diabetes mellitus; CKD, chronic renal disease; CHD, coronary heart disease; ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; LDL, low-density lipoprotein; TFA, trans fatty acids; TG, triglycerides; HDL, high-density lipoprotein; BMI, body mass index; SCD, sudden cardiac death; CR, supervised cardiac rehabilitation programs; ACS, acute coronary syndrome; HF, heart failure; ADA, American Diabetes Association; AMI, acute myocardial infarction; PPIs, proton pump inhibitors; FDA, Food and Drug Administration; RAA, renin-angiotensin-aldosterone; ACEI, angiotensin-converting enzyme inhibitor; LVEF, left ventricular ejection fraction; HTN, hypertension; MI, myocardial infarction; K+, serum potassium level.