Chronic stable angina secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

ACC / AHA Guidelines- Treatment of Risk Factors (DO NOT EDIT)

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Class IIb 1. Folate therapy in patients with elevated homocysteine levels. (Level of Evidence: C) 2. Identification and appropriate treatment of clinical depression. (Level of Evidence: C) 3. Intervention directed at psychosocial stress reduction. (Level of Evidence: C) Class III 1. Garlic. (Level of Evidence: C) 2. Acupuncture. (Level of Evidence: C) 3. Initiation of hormone replacement therapy (HRT) in postmenopausal women for the purpose of reducing cardiovascular risk. (Level of Evidence: A) 4. Vitamin C and E supplementation. (Level of Evidence: A) 5. Coenzyme Q. (Level of Evidence: C)

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ACC / AHA Guidelines- Smoking (DO NOT EDIT)

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Class I 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)

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Class I 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) 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) 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)

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Recommendations 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) 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) 3. Daily physical activity and weight management are recommended for all patients. (Class I Recommendation; Level of Evidence: B) 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) 5. Recommended lipid management includes assessment of a fasting lipid profile. (Class I Recommendation; Level of Evidence: A) a. LDL-C should be less than 100 mg per dL and (Class I Recommendation; Level of Evidence: A) 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) 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) 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) 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) 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) 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) h. Therapeutic options to reduce non–HDL-C are: Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy) or 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) 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) 6. The following lipid management strategies can be beneficial: 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 statins or LDL-C–lowering drug combinations. (Class IIa Recommendation; Level of Evidence: C) 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)

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Class I 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) 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) 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) Class IIb 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)

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Class I 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) 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 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) 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)

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Class I 1. Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA1c. (Level of Evidence: B) 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)

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Class I 1. Aspirin should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated. (Level of Evidence: A) 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)

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Class I 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) 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) 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) 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) Class IIa 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) Class IIb 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)

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Class I 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)

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Class I 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)

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Class III 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

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

References

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