The Evidence for Current Cardiovascular Disease

Prevention Guidelines: Introduction

American College of Cardiology Best Practice Quality Initiative Subcommittee

and Prevention Committee

This slide set was adapted from the 2004-13 ACC/ADA/AHA guidelines:

Evidence-Based Guidelines for CV Disease Prevention in Women

Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease

Management of Patients With ST-Elevation Myocardial Infarction

Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation MI

Preventing Heart Attack and Death in Patients with Atherosclerotic CV Disease

Management of Patients with Chronic Stable Angina

Update for Coronary Artery Bypass Graft Surgery

Evaluation and Management of Chronic Heart Failure in the Adult

Primary Prevention of CV Disease in People with Diabetes Mellitus

Standards of Medical Care in Diabetes

The full-text guidelines and executive summaries are also available on

ACC’s website www.cardiosource.org

ACC=American College of Cardiology, ADA=American Diabetes Association, AHA=American Heart Association, CV=Cardiovascular,

MI=Myocardial infarction

IntroductionIntroduction

• Evidence based guidelines are based on rigorous expert analysis of available data, documenting relative benefits and risks of procedures and therapies.

• ACC/ADA/AHA practice guidelines reflect a consensus of expert opinion and are intended to assist healthcare providers in decision making by describing a range of approaches for the diagnosis, management, and prevention of CVD.

• The guidelines are intended to help improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

ACC=American College of Cardiology, AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease

Evidence Based Prevention of CV Evidence Based Prevention of CV DiseaseDisease

• Introduction

• Antiplatelet and Anticoagulant Therapy Evidence and Guidelines

• Antiplatelet Therapy Evidence and Guidelines• Anticoagulant Therapy Evidence and Guidelines

• Blood Pressure, Blood Pressure Agents, and Blood Pressure Guidelines

• Angiotensin Converting Enzyme Inhibitor Evidence and Guidelines

• Angiotensin Receptor Blocker Evidence and Guidelines

• Beta-blocker Evidence and Guidelines

• Cholesterol, Cholesterol Therapies, and Cholesterol Guidelines

Content of the ModulesContent of the Modules

• Lifestyle Management Evidence and Guidelines • Tobacco Cessation Evidence and Guidelines• Diet and Weight Management Evidence and

Guidelines• Diet, Cardiovascular Events, and Guidelines• Physical Activity Evidence and Guidelines

• Diabetes Mellitus Evidence and Guidelines • Prediabetic Conditions and Metabolic Syndrome• Diabetes Mellitus

Content of the Modules (Continued)Content of the Modules (Continued)

• Other Cardiovascular Therapies and Areas with Room for Improvement

• Influenza Vaccination Evidence and Guidelines

• Ejection Fraction Evidence and Guidelines• Aldosterone Antagonist Evidence and

Guidelines• Digoxin Evidence and Guidelines• ICD Evidence and Guidelines• Room for Improvement• Quality Improvement Initiatives

• Ineffective Therapies in Cardiovascular Disease

Content of the Modules (Continued)Content of the Modules (Continued)

Classification of Classification of Recommendations and Levels Recommendations and Levels of Evidenceof Evidence

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. 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. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

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I IIa IIb III I IIa IIb III

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Icons Representing the Classification and Icons Representing the Classification and Evidence Levels for RecommendationsEvidence Levels for Recommendations

Go AS et al. Circulation 2003;127:e6-e245

CHD=Coronary heart disease, CHF=Congestive heart failure, CVD=Cardiovascular disease, HBP=High blood pressure

Cost of Cardiovascular DiseaseCost of Cardiovascular Diseasein the United Statesin the United States

Prevalence of CardiovascularPrevalence of CardiovascularDisease in the United StatesDisease in the United States

Go AS et al. Circulation 2003;127:e6-e245

Calendar Year (1900-2006)

Go AS et al. Circulation 2003;127:e6-e245

Rates of Death from CardiovascularRates of Death from CardiovascularDisease in the United StatesDisease in the United States

Source: Bibbins-Domingo K et al. NEJM 2007;357:2371-2379

Prevalence of CHD associated with 3 projections of adult obesity

Num

ber

of E

xces

s C

ases

Pre

vale

nce

(%)

Excess prevalence of CHD

Year Year

Population prevalence of CHD

Extrapolation from current data suggests that overweight adolescents will increase rates of CHD among future young and

middle-aged adults

Scope of the Problem (Continued)Scope of the Problem (Continued)

CHD=Coronary heart disease

Primordial Prevention: Prevention of coronary heart disease risk factors

Primary Prevention: Modification of risk factors in order to prevent or delay the onset of coronary heart disease

Secondary Prevention: Initiation of therapy to reduce recurrent coronary heart disease events and decrease cardiac mortality in patients with established coronary heart disease

Definitions of Different Types of Definitions of Different Types of PreventionPrevention

A1C=Glycosylated hemoglobinABI=Ankle brachial indexACC=American College of CardiologyACCF=American College of Cardiology FoundationACE=Angiotensin converting enzymeAch=AcetylcholineACE-I=Angiotensin converting enzyme inhibitorACS=Acute coronary syndromeADA=American Diabetes AssociationADP=Adenosine diphosphateAF=Atrial fibrillationAGE=Advanced glycation end productsAHA=American Heart AssociationAldo ANT=Aldosterone antagonistAPO-A1=Apolipoprotein A1ARB=Angiotensin receptor blocker

ARBS=Angiotensin receptor blocker strategyASA=AspirinASVD=Atherosclerotic vascular diseaseATP=Adult Treatment PanelBA=Bile acidBB=Beta-blockerBMI=Body mass indexBMS=Bare metal stentBP=Blood pressure CABG=Coronary artery bypass graftCAD=Coronary artery diseaseCAS=Calcium antagonist strategyCCB=Calcium channel blockerCDC=Centers for Disease ControlCE=Cholesterol esterCHD=Coronary heart diseaseCHF=Congestive heart failureCKD=Chronic kidney diseaseCI=Confidence IntervalCOX=Cyclooxygenase

COX-1=Cyclooxygenase 1COX-2=Cyclooxygenase 2CrCl=Creatinine clearanceCRP=C-reactive proteinCV=CardiovascularCVA=Cerebrovascular accidentCVD=Cardiovascular diseaseDAP=Dual antiplateletDBP=Diastolic blood pressureDES=Drug eluting stentDHA=Docosahexaenoic acidDM=Diabetes mellitusDSE=Diabetes support and educationEAD=Established atherothrombotic diseaseEF=Ejection fractionEP=ElectrophysiologyEPA=Eicosapenteaenoic acidEPS=Electrophysiology studyESRD=End stage renal diseaseFC=Free cholesterol

Summary of AbbreviationsSummary of Abbreviations

FDA=Food and Drug AdministrationFFA=Free fatty acidFPG=Fasting plasma glucoseFRS=Framingham risk scoreGI=GastointestinalGFR=Glomerular filtration rateHbA1C=Glycosylated hemoglobinHF=Heart failureHR=Hazard ratioHDL=High density lipoproteinHDL-C=High density lipoprotein cholesterolHRT=Hormone replacement therapyHTN=HypertensionICD=Implantable cardioverter defibrillatorICH=Intracranial hemorrhageIDL=Intermediate density lipoproteinIFG=Impaired fasting glucoseIGT=Impaired glucose tolerance

IL-6=Interleukin-6ILI=Intensive lifestyle interventionINR=International normalized ratioLCAT=Lecithin cholesterol acyltransferaseLD=Loading doseLDL=Low density lipoproteinLDL-C=Low density lipoprotein cholesterolLDL-R=Low density lipoprotein receptorLE=Life expectancyLPL=Lipoprotein lipaseLV=Left ventricularLV EF=Left ventricular ejection fractionLVH=Left ventricular hypertrophyLVSD=Left ventricular systolic dysfunctionMCE=Major cardiovascular eventsMD=Maintenance dose

MetS=Metabolic syndromeMI=Myocardial infarctionMS=Metabolic syndromeNA=Not applicable NCEP=National cholesterol education programNE=NorepinephrineNF=Non-fatalNH=Non-HispanicNHANES=National Health and Nutrition Examination SurveyNHLBI=National Heart Lung Blood InstituteNIH=National Institute of HealthNRT=Nicotine replacement therapy NS=Not significantNSAIDs=Non-steroidal anti- inflammatory drugsNSTE-ACS=Non-ST-segment elevation acute coronary syndrome

Summary of Abbreviations Summary of Abbreviations (Continued)(Continued)

NSTE-MI=Non-ST-segment elevation myocardial infarctionNYHA=New York Heart AssociationOA=Oral anticoagulationOAC=Oral anticoagulantOGTT=Oral glucose tolerance testOR=Odds ratioPAD=Peripheral arterial diseasePAI-1=Plasminogen activator inhibitor-1PAR=Population attributable riskPCI=Percutaneous coronary interventionPDGF=Platelet-derived growth factorPUFA=Polyunsaturated fatty acidsRAS=Renin angiotensin systemRCT=Randomized controlled trialRF=Risk factor

Summary of Abbreviations Summary of Abbreviations (Continued)(Continued) RNA=Radionuclide

angiographyRR=Relative riskRRR=Relative risk reductionRx=TreatmentSAA=Serum amyloid A proteinSBP=Systolic blood pressureSCD=Sudden cardiac deathSPECT=Single photon emission computed tomographySTEMI=ST-segment elevation myocardial infarctionTC=Total cholesterolTF=Tissue factorTG=TriglycerideTIA=Transient ischemic attackTLC=Therapeutic lifestyle changestPA=Tissue plasminogen activatorTX=TransplantTXA2=Thromboxane A2

UA=Unstable anginaULN=Upper limit of normal

USDA=United States Department of AgricultureVLDL=Very low density lipoproteinVF=Ventricular fibrillationVT=Ventricular tachycardia