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| {{SI}}
| | __NOTOC__ |
| {{WikiDoc Cardiology Network Infobox}}
| | {{Chronic stable angina}} |
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| '''Associate Editor-In-Chief:''' {{CZ}} | | '''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; '''Associate Editor(s)-In-Chief:''' [[Lakshmi Gopalakrishnan, M.B.B.S.]] |
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| {{EJ}}
| | ==Overview== |
| | In patients with [[Chronic stable angina definition|chronic stable angina]], initiation of intensive risk factor modification remains an urgent and essential part of secondary prevention strategy, as they directly influence the [[Chronic stable angina prognosis|prognosis]]. Based on the 27th Bethesda Conference, [[coronary heart disease risk factors|risk factor]] modification is divided into four categories according to both the strength of evidence for causation and the evidence that risk factor modification established significant reduction in the occurrence of future coronary events.<ref name="pmid8609364">Pasternak RC, Grundy SM, Levy D, Thompson PD (1996) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8609364 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 3. Spectrum of risk factors for coronary heart disease.] ''J Am Coll Cardiol'' 27 (5):978-90. PMID: [http://pubmed.gov/8609364 8609364]</ref> ACC/AHA states that Identifying and, when present, treating [[Coronary heart disease risk factors|Category I]] risk factors can be an optimal secondary prevention strategy in patients with chronic stable angina.<ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58.[http://content.onlinejacc.org/cgi/reprint/41/1/159.pdf] PMID: [http://pubmed.gov/12515758 12515758]</ref> You can read more about general coronary heart disease secondary prevention, [[Coronary heart disease secondary prevention|here]]. |
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| | | ==Individual Topics for Secondary Prevention== |
| '''Click [[Chronic stable angina|''here'']] for the Chronic stable angina main page'''
| | You can read in greater detail about each of the risk factor modification topic below by clicking on the link for that topic: |
| | | *'''[[Chronic stable angina treatment smoking cessation|Smoking Cessation]]''' |
| ==Prevention of Chronic Stable Angina== | | *'''[[Chronic stable angina treatment weight management|Weight Management]]''' |
| | | *'''[[Chronic stable angina treatment physical activity|Physical Activity]]''' |
| Patients are increasingly and rightly demanding accessible and readily understandable information which enables them to be full partners in management decisions about their conditions.
| | *'''[[Chronic stable angina treatment lipid management|Lipid Management]]''' |
| | | *'''[[Chronic stable angina treatment blood pressure control|BP Control]]''' |
| As well as the world leading organizations such as the American Heart Association, the European Society of Cardiology, the World Heart Federation and the British Heart Foundation; the WikiDoc Foundation, a non for profit organization have produced many helpful chapters explaining heart disease, its primary and secondary prevention, treatment and rehabilitation, and for many patients this is understandable and sufficient.
| | *'''[[Chronic stable angina treatment diabetes control|Diabetes Control]]''' |
| | | *'''[[Chronic stable angina treatment psychological factors|Management of psychological factors]]''' |
| ==ACC / AHA Guidelines- Treatment of Risk Factors (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref><ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref><ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
| | *'''[[Chronic stable angina treatment alcohal consumption|Alcohal consumption]]''' |
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| | *'''[[Chronic stable angina treatment avoidance of air pollution|Avoidance of air pollution]]''' |
| ===Class IIb===
| | *'''[[Chronic stable angina treatment additional therapy to reduce risk of MI and death|Additional therapy to reduce risk of MI and death]]''' |
| 1. [[Folate therapy]] in patients with elevated [[homocysteine]] levels. ''(Level of Evidence: C)''
| | *'''[[Chronic stable angina treatment influenza vaccination|Influneza Vaccination]]''' |
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| 2. Identification and appropriate treatment of [[clinical depression]]. ''(Level of Evidence: C)''
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| 3. Intervention directed at psychosocial [[stress]] reduction. ''(Level of Evidence: C)''
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| ===Class III===
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| 1. [[Garlic]]. ''(Level of Evidence: C)''
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| 2. [[Acupuncture]]. ''(Level of Evidence: C)''
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| 3. Initiation of [[hormone replacement therapy]] ([[HRT]]) in postmenopausal women for the purpose of reducing cardiovascular risk. ''(Level of Evidence: A)''
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| 4. [[Vitamin C]] and [[Vitamin E|E]] supplementation. ''(Level of Evidence: A)''
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| 5. [[Coenzyme Q]]. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Smoking (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. [[Smoking cessation]] and avoidance of exposure to environmental [[tobacco]] smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including [[nicotine replacement]]) is recommended, as is a stepwise strategy for [[smoking cessation]] (Ask, Advise, Assess, Assist, Arrange). ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Blood Pressure Control (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. Patients should initiate and/or maintain lifestyle modifications—weight control; increased physical activity; moderation of alcohol consumption; limited sodium intake; and maintenance of a diet high in fresh fruits, vegetables, and low-fat dairy products. ''(Level of Evidence: B)''
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| 2. [[Blood pressure]] control according to Joint National Conference VII guidelines is recommended (i.e., [[blood pressure]] less than 140/90 mm Hg or less than 130/80 mm Hg for patients with [[diabetes]] or chronic [[kidney disease]]). ''(Level of Evidence: A)''
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| 3. For [[hypertensive]] patients with well established [[coronary artery disease]], it is useful to add [[blood pressure]] medication as tolerated, treating initially with [[beta blockers]] and/or [[ACE inhibitors]], with addition of other drugs as needed to achieve target [[blood pressure]]. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Lipid Management (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Recommendations===
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| 1. Dietary therapy for all patients should include reduced intake of [[saturated fats]] (to less than 7% of total calories), [[trans-fatty acids]], and [[cholesterol]] (to less than 200 mg per day). ''(Class I Recommendation; Level of Evidence: B)''
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| 2. Adding plant [[stanol]]/[[sterols]] (2 g per day) and/or viscous [[fiber]] (greater than 10 g per day) is reasonable to further lower [[LDL-C]]. ''(Class IIa Recommendation; Level of Evidence: A)''
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| 3. Daily physical activity and weight management are recommended for all patients. ''(Class I Recommendation; Level of Evidence: B)''
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| 4. For all patients, encouraging consumption of [[omega-3 fatty acids]] in the form of fish or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated [[TG]], higher doses are usually necessary for risk reduction. ''(Class IIb Recommendation; Level of Evidence: B)''
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| 5. Recommended [[lipid]] management includes assessment of a fasting lipid profile. ''(Class I Recommendation; Level of Evidence: A)''
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| :a. [[LDL-C]] should be less than 100 mg per dL and (Class I Recommendation; Level of Evidence: A)
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| :b. Reduction of [[LDL-C]] to less than 70 mg per dL or high-dose [[statin therapy]] is reasonable. (Class IIa Recommendation; Level of Evidence: A)''
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| :c. If baseline [[LDL-C]] is greater than or equal to 100 mg per dL, [[LDL]]-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When [[LDL]]-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in [[LDL-C]] levels. ''(Class I Recommendation; Level of Evidence: A)''
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| :d. If on-treatment [[LDL-C]] is greater than or equal to 100 mg per dL, [[LDL]]-lowering drug therapy should be intensified. ''(Class I Recommendation; Level of Evidence: A)''
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| :e. If baseline [[LDL-C]] is 70 to 100 mg per dL, it is reasonable to treat [[LDL-C]] to less than 70 mg per dL. ''(Class IIa Recommendation; Level of Evidence: B)''
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| :f. If [[TG]] are 200 to 499 mg per dL, non–[[HDL-C]] should be less than 130 mg per dL and ''(Class I Recommendation; Level of Evidence: B)''
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| :g. Further reduction of non–[[HDL-C]] to less than 100 mg per dL is reasonable, if [[TG]] are greater than or equal to 200 to 499 mg per dL. (Class IIa Recommendation; Level of Evidence: B)''
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| :h. Therapeutic options to reduce non–[[HDL-C]] are:
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| ::* [[Niacin]] can be useful as a therapeutic option to reduce non–[[HDL-C]] (after LDL-C–lowering therapy) or
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| ::* [[Fibrate therapy]] as a therapeutic option can be useful to reduce non–[[HDL-C]] (after [[LDL-C]]–lowering therapy). ''(Class IIa Recommendation; Level of Evidence: B)''
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| :i. If [[TG]] are greater than or equal to 500 mg per dL, therapeutic options to lower the [[TG]] to reduce the risk of [[pancreatitis]] are [[fibrate]] or [[niacin]]; these should be initiated before [[LDL-C]] lowering therapy. The goal is to achieve non–[[HDL-C]] less than 130 mg per dL if possible. ''(Class I Recommendation; Level of Evidence: C)''
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| 6. The following [[lipid]] management strategies can be beneficial:
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| :a. If [[LDL-C]] less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When [[LDL-C]] less than 70 mg per dL is not achievable because of high baseline [[LDL-C]] levels, it generally is possible to achieve reductions of greater than 50% in [[LDL-C]] levels by either [[statin]]s or [[LDL-C]]–lowering drug combinations. ''(Class IIa Recommendation; Level of Evidence: C)''
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| 7. Drug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve [[LDL-C]] less than 100 mg per dL. (Class I Recommendation; Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Physical Activity (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. Physical activity of 30 to 60 minutes, 7 days per week (minimum 5 days per week) is recommended. All patients should be encouraged to obtain 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work). ''(Level of Evidence: B)''
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| 2. The patient’s risk should be assessed with a physical activity history. Where appropriate, an exercise test is useful to guide the exercise prescription. ''(Level of Evidence: B)''
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| 3. Medically supervised programs ([[cardiac rehabilitation]]) are recommended for at-risk patients (e.g., recent [[acute coronary syndrome]] or [[revascularization]], [[heart failure]]). ''(Level of Evidence: B)''
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| ===Class IIb===
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| 1. Expanding physical activity to include resistance training on 2 days per week may be reasonable. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Weight Management (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. [[BMI]] and waist circumference should be assessed regularly. On each patient visit, it is useful to consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to achieve and maintain a [[BMI]] between 18.5 and 24.9 kg/m2. ''(Level of Evidence: B)''
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| 2. If waist circumference is greater than or equal to 35 inches (89 cm) in women or greater than or equal to 40 inches (102 cm) in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for [[metabolic syndrome]] as indicated. Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.g., 37 to 40
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| inches [94 to 102 cm]). Such persons may have a strong genetic contribution to [[insulin resistance]]. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference. ''(Level of Evidence: B)''
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| 3. The initial goal of weight loss therapy should be to gradually reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Diabetes Management (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. [[Diabetes]] management should include lifestyle and pharmacotherapy measures to achieve a near-normal [[HbA1c]]. ''(Level of Evidence: B)''
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| 2. Vigorous modification of other risk factors (e.g., physical activity, weight management, [[blood pressure]] control, and [[cholesterol]] management) as recommended should be initiated and maintained. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Antiplatelet Agents/Anticoagulants (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. [[Aspirin]] should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated. ''(Level of Evidence: A)''
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| 2. Use of [[warfarin]] in conjunction with [[aspirin]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and should be monitored closely. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Renin-Angiotensin-Aldosterone System Blockers (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. [[ACE inhibitors]] should be started and continued indefinitely in all patients with [[left ventricular ejection fraction]] less than or equal to 40% and in those with [[hypertension]], [[diabetes]], or chronic [[kidney disease]] unless contraindicated. ''(Level of Evidence: A)''
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| 2. [[ACE inhibitors]] should be started and continued indefinitely in patients who are not lower risk (lower risk defined as those with normal [[left ventricular ejection fraction]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed), unless contraindicated. ''(Level of Evidence: B)''
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| 3. [[Angiotensin receptor blockers]] are recommended for patients who have [[hypertension]], have indications for but are intolerant of [[ACE inhibitors]], have [[heart failure]], or have had a [[myocardial infarction]] with [[left ventricular ejection fraction]] less than or equal to 40%. ''(Level of Evidence: A)''
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| 4. [[Aldosterone]] blockade is recommended for use in post-[[MI]] patients without significant [[renal dysfunction]] or [[hyperkalemia]] who are already receiving therapeutic doses of an [[ACE inhibitor]] and a [[beta blocker]], have a [[left ventricular ejection fraction]] less than or equal to 40%, and have either [[diabetes]] or [[heart failure]]. ''(Level of Evidence: A)''
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| ===Class IIa===
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| 1. It is reasonable to use [[ACE inhibitors]] among lower-risk patients with mildly reduced or normal [[left ventricular ejection fraction]] in whom cardiovascular risk factors are well controlled and [[revascularization]] has been performed. ''(Level of Evidence: B)''
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| ===Class IIb===
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| 1. [[Angiotensin receptor blockers]] may be considered in combination with [[ACE inhibitors]] for [[heart failure]] due to [[left ventricular systolic dysfunction]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Beta Blockers (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. It is beneficial to start and continue [[beta-blocker therapy]] indefinitely in all patients who have had [[MI]], [[acute coronary syndrome]], or [[left ventricular dysfunction]] with or without [[heart failure]] symptoms, unless contraindicated. ''(Level of Evidence: A)''}}
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| ==ACC / AHA Guidelines- Influenza Vaccination (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| ===Class I===
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| 1. An annual [[influenza vaccination]] is recommended for patients with [[cardiovascular disease]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Chelation Therapy (DO NOT EDIT)<ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>==
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| {{cquote|
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| ===Class III===
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| 1. [[Chelation therapy]] (intravenous infusions of [[ethylenediamine tetraacetic acid]] or [[EDTA]]) is not recommended for the treatment of [[chronic angina]] or [[arteriosclerotic cardiovascular disease]] and may be harmful because of its potential to cause [[hypocalcemia]]. ''(Level of Evidence: C)''}}
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| ==See Also==
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| *[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
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| ==Sources==
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| *The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref>
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| *TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>
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| *The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>
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