Coronary Artery Disease Clinical Practice Guidelines Guidelines are systematically developed statements to assist patients and providers in choosing appropriate healthcare for specific clinical conditions. This guideline is not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by practitioners, considering each patient s needs on an individual basis. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. BP indicates blood pressure CHD indicates coronary heart disease LDL-C indicates low-density lipoprotein cholesterol HDL-C indicates high-density lipoprotein cholesterol INR indicates international normalized ratio Arteriosclerotic Heart Disease is the presence of atherosclerosis with any of the following: Angina Myocardial infarction Intravascular intervention Coronary artery bypass graft (CABG) Evidence of coronary atherosclerosis by invasive angiography or noninvasive imaging Framingham risk evaluation tool is available Within this guideline Online at National Institutes of Health, Publication No. 01-3305 As an online calculator for providers and patients at http://cvdrisk.nhlbi.nih.gov/calculator.asp The Framingham CVD risk tool approximates the absolute risk of symptomatic cardiovascular disease, including angina, fatal and non-fatal MI, fatal and non-fatal stroke, TIA, peripheral vascular disease (PVD), or heart failure in the next five to 10 years. Providers should update risk calculation every five years or if a new risk factor develops. Limitations: The Framingham risk assessment tool estimates CVD risk inpatients aged 35-74 without known CVD. The tool is not for use in patients with a history of coronary artery disease or stroke. Other factors: Although Framingham CVD Risk Assessment does not include family history, family history of premature coronary artery disease (CAD) is a known risk factor and should be taken into account increasing absolute risk by up to five percent over five years on average. Family history of CAD is defined as CAD before the age of 55 in a first-degree male relative or before the age of 60 in a first-degree female relative. The degree of risk added from diabetes depends on the duration of the disease and the level of glycemic control. Uncontrolled hypertension, with or without treatment, is a more significant risk factor than treated and controlled blood pressure. PPC051510 1 of 8
Smoking: Goal: Complete cessation, no exposure to environmental smoke. Blood Pressure Control Goal: <140/90 mm Hg Lipid Management Goal: Treatment with statin therapy; Use statin therapy to achieve and LDL-C of <100 mg/dl; for very high-risk patients an LDL-C <70 mg/dl is reasonable. If triglycerides are 200 mm/dl, non-hdl-c 1 should be 130mg/dL; non-hdl-c <100 mg/dl for very high-risk patients is reasonable. If triglycerides are >500 mg/dl start fibrate therapy in addition to statin therapy to prevent pancreatitis. 2 Ask about tobacco use status at every visit. I (B) Every tobacco user should be advised to quit at every visit. I (B) Assess the tobacco user s willingness to quit at every visit. I (B) Assist with cessation by counseling, developing a quit plan that may include pharmacotherapy (including nicotine replacement, Bupropion, and varenicline) and referral to a cessation program. I (B) Arrange for follow-up with provider or cessation service. I (B) Advise patients to avoid exposure to environmental tobacco smoke at work, home, and public places. I (B) Counsel regarding life style modification: weight control; increase physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables and low fat dairy products. I (B) Patients with blood pressure 140/90 mm Hg should be treated, as tolerated, with β-blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve goal blood pressure. I (A) Lipid profile in all patients should be established, and for hospitalized patients, lipid-lowering therapy as recommended below should be initiated before discharge. I (A) Lifestyle modifications including daily physical activity and weight management are strongly recommended for all patients. I (B) Counsel to reduce intake of saturated fats to <7% of total calories, trans fatty acids to <1% of total calories, and cholesterol to <200 mg/d. I (B) Statin therapy should be prescribed in the absence of contraindications or documented adverse effects. I (A) 1 Non-HDL-C = total cholesterol minus HDL-C 2 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. PPC051510 2 of 8
Dietary Intake: Goal: An overall healthy eating pattern. Physical Activity: Goal: At least 30 minutes of moderate intensity activity at least 5 days per week. An adequate dose of statin should be used to reduce LDL-C to <100 mg/dl. Patients who have triglycerides 200 mg/dl should be treated with statins to lower non-hdl-c to <130 mm/dl I (C) If treatment with a statin, including higher dose statins and high-potency statins does not achieve goal, addition of a bile acid sequestrant or niacin or a fibrate is reasonable. I (B) 3 For patients who do not tolerate statins, LDL-Clowering therapy with bile acid sequestrants and/or niacin is reasonable. I (B) 4 Ezetimibe may be considered for patients who do not tolerate or achieve target LDL-C with statins, bile acid sequestrants, and or niacin. II (B) Assist patients to identify their level of activity and to balance food intake with physical activity. I (B) Advocate for increased consumption of fruits, vegetables, and low fat or nonfat dairy, fish, 5 legumes, poultry, and lean meats. I (B) Dietary therapy for all patient should include reduced intake of saturated fats to <7% of total calories, trans fatty acids to <1% of total calories, and cholesterol to <200 mg/d. I (B) For all patients, it may be reasonable to recommend omega-3 fatty acids from fish or fish oil capsules (1g/d) for cardiovascular disease risk reduction. I (B) Limit salt intake to 2.3g/d. I (B) Limit alcohol to 2 drinks/day in men, 1 drinks / day in women among those who drink. I (B) Risk assessment with physical activity history and/or an exercise test is recommended to guide activity recommendations. I (B) Counsel patients to report and have evaluated exercise induced symptoms. I (C) 3 The use of bile acid sequestrants is relatively contraindicated when triglycerides are 200 mg/dl and is contraindicated when triglycerides are 500 mg/dl. 4 Dietary supplement niacin must not be used as a substitute for prescription niacin. 5 Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury. PPC051510 3 of 8
Weight Management: Goal: Body Mass Index 18.5-24.9 kg/m2 Waist circumference: women < 35 inches (<89cm), men < 40 inches (<102cm) Type 2 Diabetes Mellitus Management Goal: Normal fasting plasma glucose (<110mg/dL) and near normal HbA1c (<7%). Encourage 30 to 60 minutes of moderate-intensity aerobic activity such as brisk walking at least 5 days and preferably 7 days per week. Moderate intensity activity is activity at 40-60% of maximum capacity and is equivalent to a brisk walk at 15-20 minutes per mile. I (B) Encourage resistance training at moderate intensity 2d/week. II (A) Assess Body Mass Index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to achieve goal body mass index between 18.5-24.9kg/m2. I (B) If waist circumference (measured horizontally at the iliac crest) is 35 inches in women and 40 inches in men, therapeutic lifestyle interventions should be intensified and focused on weight management. I (B) The initial goal of weight loss therapy should be to reduce body weight by approximately 5% - 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. I (C) Coordinated care with Primary Care Physician and/or endocrinologist. I (C) Initiate appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose or as indicated by near-normal HbA1c. I (B) Lifestyle modifications including daily physical activity, weight management, blood pressure control, and lipid management are recommended for all patients with diabetes. I (B) Metformin is an effective first-line pharmacotherapy and can be useful if not contraindicated. II (C) It is reasonable to individualize the intensity of blood sugar-lowering interventions based on the individual patient s risk of hypoglycemia during treatment. II (C) PPC051510 4 of 8
Antiplatelet Agents/Anticoagulants Goal: To achieve a safe and therapeutic anticoagulation state. Aspirin 75-160 mg daily is recommended in all patients with coronary artery disease unless contraindicated. I (A) Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin. I (B) 2A P2Y12 receptor antagonist is combination with aspirin is indicated in patients after ACS or PCI with stent placement. I (A) For patients receiving a bare-metal stent or drugeluting 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. I (A) 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 100-325 mg daily for 1 year appears to be efficacious. I (A) 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. I (A) For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity antiplatelet therapy with aspirin (75-325 mg daily) or clopidogrel (75 mg daily) should be started and continued. I (A) Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis. I (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. (NOTE: Patients receiving low-dose aspirin for atherosclerosis should continue to receive it.) I (A) For patients requiring warfarin, therapy should be administered to achieve the recommended INR for the PPC051510 5 of 8
Renin-Angiotensin-Aldosterone System Blockers specific condition. I (B) Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. I (A) If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by thienopyridine therapy after stent implantation, earlier discontinuation is reasonable. II (C) After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses. II (B) 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. II (C) The benefits of aspirin in patients with asymptomatic peripheral artery disease of the lower extremities are not well established. II (B) Combination therapy with both aspirin 75 to 162 mg daily and clopidogrel 75 mg daily may be considered in patients with stable coronary artery disease. II (B) ACE Inhibitors Inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction 40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. I (A) It is reasonable to use ACE inhibitors in all other patients. II (B) Angiotensin Receptor Blockers The use of ARBs is recommended in patients who have heart failure or who have had a myocardial infarction with left ventricular ejection fraction 40% and who are ACE-inhibitor intolerant. I (A) It is reasonable to use ARBs in other patients who are ACE-inhibitor intolerant. I (A) The use of ARBs in combination with an ACE inhibitor is not well established in those with systolic heart failure. II (A) PPC051510 6 of 8 Aldosterone Blockade
Use of aldosterone blockade in post-myocardial infarction patients without significant renal dysfunction 6 or hyperkalemia 7 is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and β-blocker, who have a left ventricular ejection fraction 40% and who have either diabetes of heart failure. I (A) β -Blockers β-blocker therapy should be used in all patients with left ventricular systolic dysfunction (ejection fraction 40%) 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.) I (A) β-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. I (B) It is reasonable to continue β-blockers beyond 3 years as chronic therapy in all patients with normal left ventricular function who have had myocardial infarction or ACS. II (C) It is reasonable to give β-blocker therapy in patients with left ventricular systolic dysfunction without heart failure or prior myocardial infarction. II (B) β-blockers may be considered as chronic therapy for all other patients with coronary or other vascular disease. II (C) Influenza vaccination Patients with cardiovascular disease should have an annual influenza vaccination. I (B) 6 Estimated creatinine clearance should be >30 ml/min 7 Potassium should be <5.0 meq/l PPC051510 7 of 8
This guideline is based upon recommendations of the American Heart Association (AHA)/American College of Cardiology(ACC): 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. Full documentation is available at http://circ.ahajournals.org/content/124/22/2458.full 2015 Corrections available at http://circ.ahajournals.org/content/131/15/e408 Originally adopted 10/23/02; Reviewed/revised; 7/23/03; 4/28/04; 3/23/05; 2/22/06; 08/24/11; 9/25/13; 5/18/15; 5/18/17 Clinical Practice guidelines are reviewed at least every two years. Websites of nationally recognized sources from which guidelines have been adopted are reviewed regularly for changes/updates. PPC051510 8 of 8