AHA/ACCF Secondary Prevention and Risk Reduction Therapy For Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update

Journal of the American College of Cardiology Vol. 58, No.
23, 2011
© 2011 by the American Heart Association, Inc. ISSN 0735-1097
Published by Elsevier Inc. doi:10.1016/j.jacc.2011.10.824
PRACTICE GUIDELINE
AHA/ACCF Secondary Prevention and Risk

Reduction Therapy for Patients With Coronary and
Other Atherosclerotic Vascular Disease: 2011 Update
A Guideline From the American Heart Association and
American College of Cardiology Foundation
Endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association
Sidney C. Smith, JR, MD, FAHA, FACC, Chair; Emelia J. Benjamin, MD, ScM, FAHA, FACC;
Robert O. Bonow, MD, FAHA, FACC; Lynne T. Braun, PhD, ANP, FAHA;
Mark A. Creager, MD, FAHA, FACC; Barry A. Franklin, PhD, FAHA;
Raymond J. Gibbons, MD, FAHA, FACC; Scott M. Grundy, MD, PhD, FAHA;
Loren F. Hiratzka, MD, FAHA, FACC; Daniel W. Jones, MD, FAHA;
Donald M. Lloyd-Jones, MD, ScM, FAHA, FACC; Margo Minissian, ACNP, AACC, FAHA;
Lori Mosca, MD, PhD, MPH, FAHA; Eric D. Peterson, MD, MPH, FAHA, FACC;
Ralph L. Sacco, MD, MS, FAHA; John Spertus, MD, MPH, FAHA, FACC;
James H. Stein, MD, FAHA, FACC; Kathryn A. Taubert, PhD, FAHA
S ince the 2006 update of the American Heart Associa- outcomes, including improved survival, reduced recurrent
tion (AHA)/American College of Cardiology Founda- events, the need for revascularization procedures, and
tion (ACCF) guidelines on secondary prevention (1), improved quality of life. It is important not only that the
important evidence from clinical trials has emerged that healthcare provider implement these recommendations in
further supports and broadens the merits of intensive risk- appropriate patients but also that healthcare systems sup-
reduction therapies for patients with established coronary and port this implementation to maximize the benefit to the
other atherosclerotic vascular disease, including peripheral patient.
artery disease, atherosclerotic aortic disease, and carotid Compelling evidence-based results from recent clinical
artery disease. In reviewing this evidence and its clinical trials and revised practice guidelines provide the impetus for
impact, the writing group believed it would be more appro- this update of the 2006 recommendations with evidence-
priate to expand the title of this guideline to “Secondary based results (2–165) (Table 1). Classification of recommen-
Prevention and Risk Reduction Therapy for Patients With dations and level of evidence are expressed in ACCF/AHA
Coronary and Other Atherosclerotic Vascular Disease.” In- format, as detailed in Table 2. Recommendations made herein
deed, the growing body of evidence confirms that in patients are largely based on major practice guidelines from the
with atherosclerotic vascular disease, comprehensive risk National Institutes of Health and updated ACCF/AHA prac-
factor management reduces risk as assessed by a variety of tice guidelines, as well as on results from recent clinical trials.
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This document was approved by the American Heart Association Science Advisory and Coordinating Committee on October 5, 2011, and by the
American College of Cardiology Foundation Board of Trustees on September 29, 2011.
The American Heart Association requests that this document be cited as follows: Smith SC Jr., Benjamin EJ, Bonow RO, Braun LT, Creager MA,
Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH,
Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011
update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011: published online before
print November 3, 2011, 10.1161/CIR.0b013e318235eb4d.
Copies: This document is available on the World Wide Web sites of the American Heart Association (my.americanheart.org) and the American College
of Cardiology (www.cardiosource.org). To purchase additional reprints, call 843-216-2533 or e-mail [email protected].
Reprinted with permission from Circulation. Published online ahead of print November 3, 2011.
Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,
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JACC Vol. 58, No. 23, 2011 Smith Jr. et al. 2433
November 29, 2011:2432–46 AHA/ACCF Secondary Prevention: 2011 Update
Table 1. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular
Disease: 2011 Update: Intervention Recommendations With Class of Recommendation and Level of Evidence
Area for Intervention Recommendations

Smoking
Goal: Complete cessation. No Class I
exposure to environmental 1. Patients should be asked about tobacco use status at every office visit (2,3,4,5,7). (Level of Evidence: B)
tobacco smoke 2. Every tobacco user should be advised at every visit to quit (4,5,7,9). (Level of Evidence: A)
3. The tobacco user’s willingness to quit should be assessed at every visit. (Level of Evidence: C)
4. Patients should be assisted by counseling and by development of a plan for quitting that may include
pharmacotherapy and/or referral to a smoking cessation program (4 –9). (Level of Evidence: A)
5. Arrangement for follow up is recommended. (Level of Evidence: C)
6. All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at
work, home, and public places (10,11). (Level of Evidence: B)
Blood pressure control Note: The writing committee did not think that the 2006 recommendations for blood pressure control
Goal: ⬍140/90 mm Hg (below) should be modified at this time. The writing committee anticipates that the recommendations
will be reviewed when the updated JNC guidelines are released.
Class I
1. All patients should be counseled regarding the need for lifestyle modification: weight control; increased
physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh
fruits, vegetables, and low-fat dairy products (12–16). (Level of Evidence: B)
2. Patients with blood pressure ⱖ140/90 mm Hg should be treated, as tolerated, with blood pressure
medication, treating initially with ␤-blockers and/or ACE inhibitors, with addition of other drugs as needed to
achieve goal blood pressure (12,17,18). (Level of Evidence: A)
Lipid management Note: The writing committee anticipates that the recommendations will be reviewed when the updated
Goal: Treatment with statin ATP guidelines are released.
therapy; use statin therapy to Class I
achieve an LDL-C of ⬍100 1. A lipid profile in all patients should be established, and for hospitalized patients, lipid-lowering therapy as
mg/dL; for very high risk* recommended below should be initiated before discharge (20). (Level of Evidence: B)
patients an LDL-C ⬍70 mg/dL 2. Lifestyle modifications including daily physical activity and weight management are strongly recommended for
is reasonable; if triglycerides all patients (19,29). (Level of Evidence: B)
are ⱖ200 mg/dL, non–HDL- 3. Dietary therapy for all patients should include reduced intake of saturated fats (to ⬍7% of total calories),
C† should be ⬍130 mg/dL, trans fatty acids (to ⬍1% of total calories), and cholesterol (to ⬍200 mg/d) (21–24,29).
whereas non–HDL-C ⬍100 (Level of Evidence: B)
mg/dL for very high risk 4. In addition to therapeutic lifestyle changes, statin therapy should be prescribed in the absence of
patients is reasonable contraindications or documented adverse effects (25–29). (Level of Evidence: A)
5. An adequate dose of statin should be used that reduces LDL-C to ⬍100 mg/dL AND achieves at least a 30%
lowering of LDL-C (25–29). (Level of Evidence: C)
6. Patients who have triglycerides ⱖ200 mg/dL should be treated with statins to lower non–HDL-C to
⬍130 mg/dL (25–27,30). (Level of Evidence: B)
7. Patients who have triglycerides ⬎500 mg/dL should be started on fibrate therapy in addition to statin therapy
to prevent acute pancreatitis. (Level of Evidence: C)
Class IIa
1. If treatment with a statin (including trials of higher-dose statins and higher-potency statins) does not achieve
the goal selected for a patient, intensification of LDL-C–lowering drug therapy with a bile acid sequestrant‡
or niacin§ is reasonable (31–33). (Level of Evidence: B)
2. For patients who do not tolerate statins, LDL-C–lowering therapy with bile acid sequestrants‡ and/or niacin§
is reasonable (35,36). (Level of Evidence: B)
3. It is reasonable to treat very high-risk* patients with statin therapy to lower LDL-C to ⬍70 mg/dL
(26 –28,37,38,166). (Level of Evidence: C)
4. In patients who are at very high risk* and who have triglycerides ⱖ200 mg/dL, a non–HDL-C goal of ⬍100
mg/dL is reasonable (25–27,30). (Level of Evidence: B)
Class IIb
1. The use of ezetimibe may be considered for patients who do not tolerate or achieve target LDL-C with
statins, bile acid sequestrants,‡ and/or niacin.§ (Level of Evidence: C)
2. For patients who continue to have an elevated non–HDL-C while on adequate statin therapy, niacin§ or
fibrate储 therapy (32,35,41) (Level of Evidence: B) or fish oil (Level of Evidence: C) may be reasonable.
3. For all patients, it may be reasonable to recommend omega-3 fatty acids from fish¶ or fish oil capsules
(1 g/d) for cardiovascular disease risk reduction (44 – 46). (Level of Evidence: B)
(Continued)
2434 Smith Jr. et al. JACC Vol. 58, No. 23, 2011
AHA/ACCF Secondary Prevention: 2011 Update November 29, 2011:2432–46
Table 1. Continued

Physical activity Class I
Goal: At least 30 minutes, 1. For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such
7 days per week (minimum as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily
5 days per week) lifestyle activities (eg, walking breaks at work, gardening, household work) to improve cardiorespiratory
fitness and move patients out of the least fit, least active high-risk cohort (bottom 20%) (54,55,58).
(Level of Evidence: B)
2. For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to
guide prognosis and prescription (47–52,58). (Level of Evidence: B)
3. The clinician should counsel patients to report and be evaluated for symptoms related to exercise.
(Level of Evidence: C)
Class IIa
1. It is reasonable for the clinician to recommend complementary resistance training at least 2 days per
week (59). (Level of Evidence: C)
Weight management Class I
Goals: 1. Body mass index and/or waist circumference should be assessed at every visit, and the clinician should
Body mass index: 18.5 to consistently encourage weight maintenance/reduction through an appropriate balance of lifestyle physical
24.9 kg/m2 activity, structured exercise, caloric intake, and formal behavioral programs when indicated to
maintain/achieve a body mass index between 18.5 and 24.9 kg/m2 (60 – 62,65–70). (Level of Evidence: B)
Waist circumference:
women ⬍35 inches 2. If waist circumference (measured horizontally at the iliac crest) is ⱖ35 inches (ⱖ89 cm) in women and ⱖ40
(⬍89 cm), men inches (ⱖ102 cm) in men, therapeutic lifestyle interventions should be intensified and focused on weight
⬍40 inches (⬍102 cm) management (66 –70). (Level of Evidence: B)
3. The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from
baseline. With success, further weight loss can be attempted if indicated. (Level of Evidence: C)
Type 2 diabetes mellitus Note: Recommendations below are for prevention of cardiovascular complications.
management Class I
1. Care for diabetes should be coordinated with the patient’s primary care physician and/or endocrinologist.
(Level of Evidence: C)
2. Lifestyle modifications including daily physical activity, weight management, blood pressure control, and lipid
management are recommended for all patients with diabetes (19,22–24,29,56,58,59,62,66,74,162). (Level of
Evidence: B)
Class IIa
1. Metformin is an effective first-line pharmacotherapy and can be useful if not contraindicated (74 –76).
(Level of Evidence: A)
2. It is reasonable to individualize the intensity of blood sugar–lowering interventions based on the individual
patient’s risk of hypoglycemia during treatment. (Level of Evidence: C)
Class IIb
1. Initiation of pharmacotherapy interventions to achieve target HbA1c may be reasonable (71,72,74 – 80). (Level
of Evidence: A)
2. A target HbA1c of ⱕ7% may be considered. (Level of Evidence: C)
3. Less stringent HbA1c goals may be considered for patients with a history of severe hypoglycemia, limited life
expectancy, advanced microvascular or macrovascular complications, or extensive comorbidities, or those in
whom the goal is difficult to attain despite intensive therapeutic interventions. (Level of Evidence: C)
Antiplatelet agents/ Class I
anticoagulants 1. Aspirin 75–162 mg daily is recommended in all patients with coronary artery disease unless contraindicated
(64,81,82,116). (Level of Evidence: A)
● Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to
aspirin (117). (Level of Evidence: B)

2. A P2Y12 receptor antagonist in combination with aspirin is indicated in patients after ACS or PCI with stent
placement (83– 85). (Level of Evidence: A)
● For patients receiving a bare-metal stent or drug-eluting stent during PCI for ACS, clopidogrel 75 mg daily,
prasugrel 10 mg daily, or ticagrelor 90 mg twice daily should be given for at least 12 months
3. For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after
surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg daily for
1 year appear to be efficacious (87–90). (Level of Evidence: A)
4. In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA,
treatment with aspirin alone (75–325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin
plus extended-release dipyridamole (25 mg and 200 mg twice daily, respectively) should be started and
continued (91,104,116). (Level of Evidence: A)
(Continued)
Table 1. Continued

Antiplatelet agents/ 5. For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet
anticoagulants cont’d therapy with aspirin (75–325 mg daily) or clopidogrel (75 mg daily) should be started and continued
6. Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K
antagonists to treat patients with atherosclerosis (93,94,105,110). (Level of Evidence: A)
● If there is a compelling indication for anticoagulant therapy, such as atrial fibrillation, prosthetic heart valve,
left ventricular thrombus, or concomitant venous thromboembolic disease, warfarin should be administered
(95,99 –102). (Level of Evidence: A) (NOTE : Patients receiving low-dose aspirin for atherosclerosis should
continue to receive it.)
● For patients requiring warfarin, therapy should be administered to achieve the recommended INR for the
specific condition (81,96). (Level of Evidence: B)

● Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding
and should be monitored closely (97,98,110). (Level of Evidence: A)

Class IIa
1. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by thienopyridine therapy
after stent implantation, earlier discontinuation (eg, ⬍12 months) is reasonable. (Level of Evidence: C)
(Note: the risk for serious cardiovascular events because of early discontinuation of thienopyridines is greater
for patients with drug-eluting stents than those with bare-metal stents.)
2. After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses
(84,85,118 –122). (Level of Evidence: B)
3. For patients undergoing coronary artery bypass grafting, clopidogrel (75 mg daily) is a reasonable alternative
in patients who are intolerant of or allergic to aspirin. (Level of Evidence: C)
Class IIb
1. The benefits of aspirin in patients with asymptomatic peripheral artery disease of the lower extremities are
not well established (108,109). (Level of Evidence: B)
2. Combination therapy with both aspirin 75 to 162 mg daily and clopidogrel 75 mg daily may be considered in
Renin-angiotensin- patients with stable coronary artery disease (112). (Level of Evidence: B)
aldosterone system blockers
ACE inhibitors Class I
1. ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction
ⱕ40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated (124,125).
Class IIa
1. It is reasonable to use ACE inhibitors in all other patients (126). (Level of Evidence: B)
ARBs Class I
1. The use of ARBs is recommended in patients who have heart failure or who have had a myocardial infarction
with left ventricular ejection fraction ⱕ40% and who are ACE-inhibitor intolerant (130 –132).
Class IIa
1. It is reasonable to use ARBs in other patients who are ACE-inhibitor intolerant (133). (Level of Evidence: B)
Class IIb
1. The use of ARBs in combination with an ACE inhibitor is not well established in those with systolic heart
failure (132,134). (Level of Evidence: A)
Aldosterone blockade Class I
1. Use of aldosterone blockade in post–myocardial infarction patients without significant renal dysfunction# or
hyperkalemia** is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor
and ␤-blocker, who have a left ventricular ejection fraction ⱕ40%, and who have either diabetes or heart
failure (136,137). (Level of Evidence: A)
␤-Blockers Class I
1. ␤-Blocker therapy should be used in all patients with left ventricular systolic dysfunction (ejection fraction
ⱕ40%) with heart failure or prior myocardial infarction, unless contraindicated. (Use should be limited to
carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce mortality.) (138,140,141)
2. ␤-Blocker therapy should be started and continued for 3 years in all patients with normal left ventricular
function who have had myocardial infarction or ACS (139,142,143). (Level of Evidence: B)
Class IIa
1. It is reasonable to continue ␤-blockers beyond 3 years as chronic therapy in all patients with normal left
ventricular function who have had myocardial infarction or ACS (139,142,143). (Level of Evidence: B)
2. It is reasonable to give ␤-blocker therapy in patients with left ventricular systolic dysfunction (ejection fraction
ⱕ40%) without heart failure or prior myocardial infarction. (Level of Evidence: C)
(Continued)
Table 1. Continued

␤-Blockers cont’d Class IIb
1. ␤-Blockers may be considered as chronic therapy for all other patients with coronary or other vascular
disease. (Level of Evidence: C)
Influenza vaccination Class I
1. Patients with cardiovascular disease should have an annual influenza vaccination (144 –147).
(Level of Evidence: B)
Depression Class IIa
1. For patients with recent coronary artery bypass graft surgery or myocardial infarction, it is reasonable to
screen for depression if patients have access to case management, in collaboration with their primary care
physician and a mental health specialist (148 –152). (Level of Evidence: B)
Class IIb
1. Treatment of depression has not been shown to improve cardiovascular disease outcomes but may be
reasonable for its other clinical benefits. (Level of Evidence: C)
Cardiac rehabilitation Class I
1. All eligible patients with ACS or whose status is immediately post coronary artery bypass surgery or post-PCI
should be referred to a comprehensive outpatient cardiovascular rehabilitation program either prior to hospital
discharge or during the first follow-up office visit (55,154,161,163). (Level of Evidence: A)
2. All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery or PCI (Level of Evidence: A)
(55,154,155,161), chronic angina (Level of Evidence: B) (161,163), and/or peripheral artery disease
(Level of Evidence: A) (158,164) within the past year should be referred to a comprehensive outpatient
cardiovascular rehabilitation program.
3. A home-based cardiac rehabilitation program can be substituted for a supervised, center-based program for
low-risk patients (153,159,160). (Level of Evidence: A)
Class IIa
1. A comprehensive exercise-based outpatient cardiac rehabilitation program can be safe and beneficial for
clinically stable outpatients with a history of heart failure (159,159a–159c). (Level of Evidence: B)
JNC indicates the report of the National Heart, Lung, and Blood Institute’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure guidelines; ACE, angiotensin-converting enzyme; ATP, Adult Treatment Panel; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density
lipoprotein cholesterol; HbA1c, hemoglobin A1c; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; TIA, transient ischemic attack; INR,
international normalized ratio; and ARB, angiotensin receptor blocker.
*Presence of established CVD plus 1) multiple major risk factors (especially diabetes), 2) severe and poorly controlled risk factors (especially continued cigarette
smoking), 3) multiple risk factors of the metabolic syndrome (especially high triglycerides ⱖ200 mg/dL plus non–HDL-C ⱖ130 mg/dL with low HDL-C ⬍40 mg/dL),
and 4) patients with ACSs.
†Non–HDL-C⫽total cholesterol minus HDL-C.
‡The use of bile acid sequestrants is relatively contraindicated when triglycerides are ⱖ200 mg/dL and is contraindicated when triglycerides are ⱖ500 mg/dL.
§Dietary supplement niacin must not be used as a substitute for prescription niacin.
储The combination of high-dose statin plus fibrate (especially gemfibrozil) can increase risk for severe myopathy. Statin doses should be kept relatively low with
this combination.
¶Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.
#Estimated creatinine clearance should be ⬎30 mL/min.
**Potassium should be ⬍5.0 mEq/L.
Thus, the development of the present guideline involved a human subjects and published in English. In addition, the
process of partial adaptation of other guideline statements and writing group reviewed documents related to the subject
reports and supplemental literature searches. The recommenda- matter previously published by the AHA, the ACCF, and the
tions listed in this document are, whenever possible, evidence National Institutes of Health.
based. Writing group members performed these relevant supple- With regard to lipids and dyslipidemias, the lipid reduction
mental literature searches with key search phrases including but trials published between 2002 and 2006 (18,25,166 –168)
not limited to tobacco/smoking/smoking cessation; blood pres- included ⬎50,000 patients and resulted in new optional
sure control/hypertension; cholesterol/hypercholesterolemia/lip- therapeutic targets, which were outlined in the 2004 update of
ids/lipoproteins/dyslipidemia; physical activity/exercise/exercise the National Heart, Lung, and Blood Institute’s Adult Treat-
training; weight management/overweight/obesity; type 2 diabe- ment Panel (ATP) III report (169). These changes defined
tes mellitus management; antiplatelet agents/anticoagulants; optional lower target cholesterol levels for very high-risk
renin/angiotensin/aldosterone system blockers; ␤-blockers; in- coronary heart disease (CHD) patients, especially those with
fluenza vaccination; clinical depression/depression screening; acute coronary syndromes, and expanded indications for drug
and cardiac/cardiovascular rehabilitation. Additional searches treatment. Subsequent to the 2004 update of ATP III, 2
cross-referenced these topics with the subtopics of clinical additional trials (26,27) demonstrated cardiovascular benefit
trials, secondary prevention, atherosclerosis, and coronary/ for lipid lowering significantly below current cholesterol goal
cerebral/peripheral artery disease. These searches were lim- levels for those with chronic coronary heart disease. These
ited to studies, reviews, and other evidence conducted in trials allowed for alterations in the 2006 guideline, such that
Table 2. Applying Classification of Recommendation and Level of Evidence
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines
do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is
useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior
myocardial infarction, history of heart failure, and prior aspirin use.
†
For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve
direct comparisons of the treatments or strategies being evaluated.
low-density lipoprotein cholesterol (LDL-C) should be ⬍100 with triglyceride levels ⱖ200 mg/dL, non– high-density lipo-
mg/dL for all patients with CHD and other clinical forms of protein cholesterol values should be used as a guide to
atherosclerotic disease, but in addition, it is reasonable to therapy. Although no studies have directly tested treatment to
treat to LDL-C ⬍70 mg/dL in patients at highest risk. The target strategies, the target LDL-C and non–HDL-C levels are
benefits of lipid-lowering therapy are in proportion to the derived from several randomized controlled trials where the
reduction in LDL-C, and when LDL-C is above 100 mg/dL, LDL-C levels achieved for patients showing benefit are used
an adequate dose of statin therapy should be used to achieve to suggest targets. Thus, references for the studies from which
at least a 30% lowering of LDL-C. When the ⬍70 mg/dL targets are derived are listed and targets are considered as
target is chosen, it may be prudent to increase statin therapy level of evidence C. Importantly, this guideline statement for
in a graded fashion to determine a patient’s response and patients with atherosclerotic disease does not modify the
tolerance. Furthermore, if it is not possible to attain LDL-C recommendations of the 2004 ATP III update for patients
⬍70 mg/dL because of a high baseline LDL-C, it generally is without atherosclerotic disease who have diabetes mellitus or
possible to achieve LDL-C reductions of ⬎50% with either multiple risk factors and a 10-year risk level for CHD ⬎20%.
statins or LDL-C–lowering drug combinations. For patients In the latter 2 types of high-risk patients, the recommended
LDL-C goal of ⬍100 mg/dL has not changed. Finally, to tionally, the writing group added new sections on depression
avoid any misunderstanding about cholesterol management in and on cardiovascular rehabilitation.
general, it must be emphasized that a reasonable cholesterol The writing group continues to emphasize the importance
level of ⬍70 mg/dL does not apply to other types of of giving consideration to the use of cardiovascular medica-
lower-risk individuals who do not have CHD or other forms tions that have been proven in randomized clinical trials to be
of atherosclerotic disease; in such cases, recommendations of benefit. This strengthens the evidence-based foundation for
contained in the 2004 ATP III update still pertain. The writing therapeutic application of these guidelines. The committee
group agreed that no further changes be made in the recom- acknowledges that ethnic minorities, women, and the elderly
mendations for treatment of dyslipidemia pending the ex- are underrepresented in many trials and urges physician and
pected publication of the National Heart, Lung, and Blood patient participation in trials that will provide additional
Institute’s updated ATP guidelines in 2012. Similar recom- evidence with regard to therapeutic strategies for these groups
mendations were made for the treatment of hypertension by of patients.
the writing group pending the publication of the updated In the 15 years since these guidelines were first published,
report of the National Heart, Lung, and Blood Institute’s Joint 2 other developments have made them even more important
National Committee on Prevention, Detection, Evaluation, in clinical care. First, the aging of the population continues to
and Treatment of High Blood Pressure guidelines, expected expand the number of patients living with a diagnosis of
in the spring of 2012. cardiovascular disease (now estimated at 16.3 million for
Trials involving other secondary prevention therapies also CHD alone) (170) who might benefit from these therapies.
have influenced major practice guidelines used to formulate Second, multiple studies of the use of these recommended
the recommendations in the present update. Thus, specific therapies in appropriate patients, although showing slow
recommendations for clopidogrel use in post–acute coronary
improvement, continue to support the discouraging conclu-
syndrome or post–percutaneous coronary intervention stented
sion that many patients in whom therapies are indicated are
patients were included in the 2006 update, and recommenda-
not receiving them in actual clinical practice. The AHA and
tions regarding prasugrel and ticagrelor are added to this
ACCF recommend the use of programs such as the AHA’s
guideline on the basis of the results of the TRITON–TIMI 38
Get With The Guidelines (171), the American Cancer Soci-
trial (Trial to Assess Improvement in Therapeutic Outcomes
ety/American Diabetes Association/AHA’s Guideline Ad-
by Optimizing Platelet Inhibition With Prasugrel–Throm-
vantage Program (172), and the ACC’s PINNACLE (Practice
bolysis in Myocardial Infarction) and PLATO (Study of
INNovation And CLinical Excellence) program (173) to
Platelet Inhibition and Patient Outcomes). The present update
continues to recommend lower-dose aspirin for chronic ther- identify appropriate patients for therapy, provide practitioners
apy. The results of additional studies have further confirmed with useful reminders based on the guidelines, and continu-
the benefit of aldosterone antagonist therapy among patients ally assess the success achieved in providing these therapies
with impaired left ventricular function. The results of several to the patients who can benefit from them. In this regard, it is
trials involving angiotensin-converting enzyme inhibitor ther- important that the healthcare provider not only implement the
apy among patients at relatively low risk with stable coronary therapies according to their class of recommendation but also
disease and normal left ventricular function influenced the assess for and assist with patient compliance with these
current recommendations (32). Finally, the recommendations therapies in each patient encounter. Discussion of the litera-
for ␤-blocker therapy have been clarified to reflect the fact ture and supporting references for many of the recommenda-
that evidence supporting their efficacy is greatest among tions summarized in the present guideline can be found in
patients with recent myocardial infarction (⬍3 years) and/or greater detail in the upcoming ACCF/AHA guideline for
left ventricular systolic dysfunction (left ventricular ejection management of patients undergoing PCI (174), ACCF/AHA
fraction ⱕ40%). For those patients without these Class I guideline for management of patients with peripheral artery
indications, ␤-blocker therapy is optional (Class IIa or IIb). disease (175,176), the AHA effectiveness-based guidelines
The writing group confirms the recommendation intro- for cardiovascular disease prevention in women (46), and in
duced in 2006 for this guideline with regard to influenza the AHA/American Stroke Association guidelines for the
vaccination. According to the US Centers for Disease Control prevention of stroke in patients with stroke or transient
and Prevention, vaccination with inactivated influenza vac- ischemic attack (123).
cine is recommended for individuals who have chronic Finally, the practitioner should exercise judgment in initi-
disorders of the cardiovascular system because they are at ating the various recommendations if the patient has recently
increased risk for complications from influenza (147). Addi- experienced an acute event.
Disclosures
Writing Group Disclosures
Writing Group Other Research Speaker’s Bureau/ Expert Ownership Consultant/

Member Employment Research Grant Support Honoraria Witness Interest Advisory Board Other
Sidney C. Smith, University of North None None None None None None None
Jr Carolina
Emelia J. Boston University None None None None None None None
Benjamin School of Medicine
Robert O. Bonow Northwestern None None None None None None None
University
Lynne T. Braun Rush University NIH-Coinvestigator, None None None None None None
Medical Center Reducing Health
Disparity in African
American Women:
Adherence to Physical
Activity*
Mark A. Creager Brigham and Women’s Merck†; Sanofi None None None None Pfizer*; Sanofi None
Hospital Aventis† Aventis*; Merck (via
TIMI group)*;
AstraZeneca*
Barry A. Franklin William Beaumont None None I receive honoraria None None Smart Balance None
Hospital throughout the year Scientific Advisory
for talks to hospitals Board*
(ie, medical grand
rounds) and cardiac
rehabilitation state
associations*
Raymond J. Mayo Clinic King Pharmaceuticals†; None None None None Cardiovascular Clinical None
Gibbons TherOx†; VeloMedix† Studies*; Medscape
(heart.org)*; Molecular
Insight
Pharmaceuticals*;
TherOx*; Lantheus
Medical Imaging*
Scott M. Grundy UT Southwestern Sankyo† Perot Foundation† None None None AstraZeneca*; Merck*; None
Medical Center Merck/Schering-Plough*;
Pfizer* (Relationships
ended 3 years ago)
Loren F. Hiratzka Cardiovascular and None None None None None None None
Thoracic
Surgeons/Tri-Health
Inc
Daniel W. Jones University of None None None None None None None
Mississippi
Donald M. Northwestern None None None None None None None
Lloyd-Jones
Margo Minissian Cedars Sinai Medical RWise Study, Co- None None None None None None
Center Investigator, Gilead
Sciences†
Lori Mosca Columbia University NIH* None None None None Advise & Consent, None
Inc.*; Gilead Science*;
Rowpar
Pharmaceuticals,
Inc.†; Sanofi-Aventis*
Eric D. Peterson Duke University Bristol-Myers Squibb/ None None None None None None
Medical Center Sanofi†; Eli Lilly†;
Merck/Schering-Plough†;
Johnson & Johnson†
Ralph L. Sacco University of Miami NINDS–Northern None None None None Boehringer Ingelheim* None
Manhattan Study* (ended March 2009);
GlaxoSmithKline
(ended March 2009)*;
Sanofi Aventis*
(ended March 2009);
DSMB (Atrial
Fibrillation
Trial–institutionally
sponsored by
Population Health
Research Institute at
McMaster University,
Hamilton, Ontario)*
(Continued)
Writing Group Disclosures, Continued
Writing Group Other Research Speaker’s Bureau/ Expert Ownership Consultant/

Member Employment Research Grant Support Honoraria Witness Interest Advisory Board Other
John Spertus Mid America Heart ACCF†; AHA†; Atherotech†; Roche None None Holds copyright to St. Jude Medical*; None
Institute Amgen†; Bristol-Myers Diagnostics† Kansas City United HealthCare*;
Squibb/Sanofi†; Cardiomyopathy Amgen*
Cordis†; Eli Lilly†; NIH† Questionnaire†;
holds copyright to
Peripheral Artery
Questionnaire*;
holds copyright to
Seattle Angina
Questionnaire†
James H. Stein University of Wisconsin Sanofi-Aventis† (ended None Abbott* and Takeda* None None Abbott,* Lilly,* and Takeda* (training grant
School of Medicine July 2009); Siemens (no permanent Takeda* (research to institution ended
and Public Health Medical Solutions† remuneration; all trial DSMBs) June 2009); Wisconsin
(ended July 2009); money to charity. Alumni Research
SonoSite† (ended Both were Foundation* (royalties
September 2009) terminated related to carotid
December 2008) ultrasound and
cardiovascular disease
risk prediction)
Kathryn A. World Heart Federation None None None None None None None
Taubert
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if 1) the person
receives $10,000 or more during any 12-month period, or 5% or more of the person’s gross income; or 2) the person owns 5% or more of the voting stock or share
of the entity, or owns $10,000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the
preceding definition.
*Modest.
†Significant.
Reviewer Disclosures
Other
Research Speaker’s Bureau/ Expert Ownership Consultant/
Reviewer Employment Research Grant Support Honoraria Witness Interest Advisory Board Other
Elliott M. Antman Brigham & Women’s None None None None None None None
Hospital
Jeffrey L. Intermountain Medical None None None None None AstraZeneca* None
Anderson Center
Gary J. Balady Boston Medical Center None None None None None None None
Eric R. Bates University of Michigan None None None None None AstraZeneca*; Daiichi None
Sankyo*; Eli Lilly*; Merck*;
Sanofi Aventis*
Vera Bittner University of Alabama at Clinical site PI for multicenter None None None None Roche/Genentech*; None
Birmingham trials funded by: Amarin*; Pfizer*
Roche/Genentech†; Gilead;
GSK†; NIH/Abbott†; NIH/Yale†
Ann F. Bolger University of California, None None None None None None None
San Francisco
Victor A. Ferrari University of None None None None None Board of Trustees, Society None
Pennsylvania for Cardiovascular
Magnetic Resonance (no
monetary value)*; Editorial
Board, Journal of
Cardiovascular Magnetic
Resonance (no monetary
value)*
Stephan Fihn Department of Veterans None None None None None None None
Affairs and University of
Washington
Gregg Fonarow UCLA NHLBI†; AHRQ† None None None None Novartis†; Medtronic* None
Federico Gentile Centro Medico None None None None None None None
diagnostic, Naples-Italy
(Continued)
Reviewer Disclosures, Continued
Other
Research Speaker’s Bureau/ Expert Ownership Consultant/
Reviewer Employment Research Grant Support Honoraria Witness Interest Advisory Board Other
Larry B. Duke University None None None None None None None
Goldstein
Jonathan Mount Sinai Medical None None None None None Boehringer Ingelheim†; None
Halperin Center Astellas Pharma, US*;
Bristol-Myers Squibb*;
Daiichi Sankyo*; Johnson
& Johnson*; Pfizer, Inc*;
Sanofi-Aventis*
Courtney Jordan University of Minnesota None None None None None None None
Noel Bairey Merz Cedars-Sinai Medical Gilead† NHLBI† Mayo Foundation*; SCS None Medtronic† UCSF*; Society for None
Center Healthcare†; Practice Point Women’s Health
Communications*; Inst for Research*; Interquest*;
Professional Education*; Dannemiller*; Navvis &
Medical Education Speakers Co*; Springer SBM LLC*;
Network*; Minneapolis Heart Duke*; NHLBI*; Italian
Institute*; Catholic Healthcare National Institutes of
West*; Novant Health*; Health*; Gilead*
HealthScience Media Inc*;
Huntsworth Health*;
WomenHeart Coalition*; Los
Robles Medical Center*;
Monterrey Community Hospital
(honorarium, donated to ACC)*;
Los Angeles OB-GYN Society*;
Pri-Med*; North American
Menopause Society*
L. Kristin Newby Duke University None None None None None None None
Patrick O’Gara Brigham & Women’s None None None None None Lantheus Medical None
Hospital Imaging*
Thomas W. Mayo Clinic None None None None None Merck–Adjudication None
Rooke (Event) Committee*
Vincent Sorrell University of Arizona None None Lantheus Medical Imaging† None None None None
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure
Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if 1) the person receives $10,000 or more
during any 12-month period, or 5% or more of the person’s gross income; or 2) the person owns 5% or more of the voting stock or share of the entity, or owns
$10,000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
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AHA/ACCF Secondary Prevention and Risk Reduction Therapy For Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update

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Journal of the American College of Cardiology Vol. 58, No.

AHA/ACCF Secondary Prevention and Risk

Area for Intervention Recommendations

Area for Intervention Recommendations

aspirin (117). (Level of Evidence: B)

Area for Intervention Recommendations

specific condition (81,96). (Level of Evidence: B)

and should be monitored closely (97,98,110). (Level of Evidence: A)

Area for Intervention Recommendations

Table 2. Applying Classification of Recommendation and Level of Evidence

Writing Group Other Research Speaker’s Bureau/ Expert Ownership Consultant/

Writing Group Disclosures, Continued

Writing Group Other Research Speaker’s Bureau/ Expert Ownership Consultant/

Reviewer Disclosures, Continued

References smoking cessation intervention on 14.5-year mortality: a randomized

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