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Guidelines: Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease

Revised recommendations from the American Heart Association and the American College of Cardiology

Sponsoring Organizations: American Heart Association, American College of Cardiology Foundation (endorsed by the National Heart, Lung, and Blood Institute)

Background and Purpose: Since 2001, when these guidelines were last updated, clinical trials have taught us more about how to prevent adverse events in patients with coronary and other atherosclerotic vascular disease. The new evidence has influenced several sets of practice guidelines (in lipid management, PCI, etc.); those guidelines have informed the revision of these 2006 secondary-prevention recommendations. Class I recommendations reflect consistent evidence and/or consensus opinion; class IIa recommendations reflect some conflict among evidence or opinion, with the weight in favor of usefulness or efficacy.

Key Points:
1. Consistent with NCEP ATP III guidelines, these guidelines recommend intensive lipid lowering in all patients with CAD and other vascular disease, including lipid-lowering drugs at discharge after an acute coronary event. The basic LDL-cholesterol goal is <100 mg/dL (class I), but the authors call it "reasonable" to lower LDL levels to <70 mg/dL in high-risk coronary patients (class IIa).

2. Moderate-intensity aerobic activity is recommended for 30 to 60 minutes daily (class I). Waist-circumference recommendations are <40 inches in men and <35 inches in women (class I).

3. Complete smoking cessation and avoidance of passive smoke are recommended for all patients (class I).

4. The basic class-I recommendation for chronic aspirin therapy is a range of 75 mg/day to 162 mg/day (down from 75 to 325 mg/day). The exception is in CABG patients, for whom the guideline authors say, "dosing regimens ranging from 100 mg/day to 325 mg/day appear to be efficacious."

5. After PCI with stent placement, the guidelines make a class-I recommendation for an initial aspirin dose of 325 mg/day (for 1 month in bare-metal stent recipients, 3 months in sirolimus-eluting stent recipients, and 6 months in paclitaxel-eluting stent recipients). Subsequently, the basic recommendation for aspirin dosing should be used (see key point 4); clopidogrel (75 mg/day) is recommended as adjunctive therapy for up to 12 months. The guidelines do not address clopidogrel dosing outside the context of PCI.

6. Secondary prevention with ACE inhibitors is now recommended for all patients without contraindications who have LV ejection fractions 40% (class I). ACE inhibitors are called "optional" for patients with normal LVEFs and well-controlled risk factors after revascularization (class IIa).

7. The guidelines recommend that all patients with cardiovascular disease receive influenza vaccinations (class I).

Comment: These guidelines are now consistent with other national guidelines in recommending aggressive lipid-lowering in a wide range of patients with vascular disease. They also emphasize weight reduction, smoking cessation, physical activity, and influenza vaccination in secondary prevention. The clarifications about aspirin dosing and about expanded use of ACE inhibitors have implications for large numbers of patients with existing disease. The guidelines, available at http://content.onlinejacc.org/cgi/content/full/47/10/2130, include a useful summary table of the secondary-prevention recommendations.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology June 8, 2006

Citation(s):

Smith SC Jr et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol 2006 May 16; 47:2130-9.

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