Chronic stable angina secondary prevention: Difference between revisions
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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)''}} | 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)''}} | ||
==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=== | |||
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, LDLlowering 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–HDLC (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)''}} | |||
==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>== | ==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>== | ||
Revision as of 14:40, 5 June 2009
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Prevention of Chronic Stable Angina
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ACC / AHA Guidelines- Treatment of Risk Factors (DO NOT EDIT)[1][2][3]
| “ |
Class I1. Management of diabetes. (Level of Evidence: C) 2. Exercise training program. (Level of Evidence: B) 3. Lipid-lowering therapy in patients with documented or suspected CAD and LDL >130 mg/dL, with a target LDL <100 mg/dL. (Level of Evidence: A) 4. Weight reduction in obese patients in the presence of hypertension, hyperlipidemia, or diabetes mellitus. (Level of Evidence: C) Class IIa1. In patients with documented or suspected CAD and low-density lipoprotein (LDL) cholesterol 100 to 129 mg/dL, several therapeutic options are available: (Level of Evidence: B)
Evidence: B)
2. Therapy to lower non-HDL cholesterol in patients with documented or suspected CAD and triglyceride levels greater than 200 mg/dL, with a target non-HDL cholesterol level of less than 130 mg/dL. (Level of Evidence: B) 3. Weight reduction in obese patients in the absence of hypertension, hyperlipidemia, or diabetes mellitus. (Level of Evidence: C) Class IIb1. 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 III1. Chelation therapy. (Level of Evidence: C) 2. Garlic. (Level of Evidence: C) 3. Acupuncture. (Level of Evidence: C) 4. Initiation of hormone replacement therapy (HRT) in postmenopausal women for the purpose of reducing cardiovascular risk. (Level of Evidence: A) 5. Vitamin C and E supplementation. (Level of Evidence: A) 6. Coenzyme Q. (Level of Evidence: C) |
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ACC / AHA Guidelines- Smoking (DO NOT EDIT)[3]
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Class I1. 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) |
” |
ACC / AHA Guidelines- Blood Pressure Control (DO NOT EDIT)[3]
| “ |
Class I1. 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) |
” |
ACC / AHA Guidelines- Lipid Management (DO NOT EDIT)[3]
| “ |
Recommendations1. 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)
6. The following lipid management strategies can be beneficial:
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) |
” |
ACC / AHA Guidelines- Renin-Angiotensin-Aldosterone System Blockers (DO NOT EDIT)[3]
| “ |
Class I1. 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 IIa1. 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 IIb1. 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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See Also
Sources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [2]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [3]
References
- ↑ 1.0 1.1 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
- ↑ 2.0 2.1 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
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 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