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The Evidence for Current Cardiovascular Disease Prevention Guidelines: Introduction American College of Cardiology Best Practice Quality Initiative Subcommittee and Prevention Committee Introduction 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 Evidence Based Prevention of CV Disease • 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 Content of the Modules • 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 Modules (Continued) • 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) • 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 Classification of Recommendations and Levels of 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. Icons Representing the Classification and Evidence Levels for Recommendations I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III I IIa IIb III Cost of Cardiovascular Disease in the United States CHD=Coronary heart disease, CHF=Congestive heart failure, CVD=Cardiovascular disease, HBP=High blood pressure Go AS et al. Circulation 2003;127:e6-e245 Prevalence of Cardiovascular Disease in the United States Go AS et al. Circulation 2003;127:e6-e245 Rates of Death from Cardiovascular Disease in the United States Calendar Year (1900-2006) Go AS et al. Circulation 2003;127:e6-e245 Scope of the Problem (Continued) Prevalence of CHD associated with 3 projections of adult obesity Population prevalence of CHD Prevalence (%) Number of Excess Cases Excess prevalence of CHD Year Year Extrapolation from current data suggests that overweight adolescents will increase rates of CHD among future young and middle-aged adults CHD=Coronary heart disease Source: Bibbins-Domingo K et al. NEJM 2007;357:2371-2379 Definitions of Different Types of Prevention 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 Summary of Abbreviations A1C=Glycosylated hemoglobin ABI=Ankle brachial index ACC=American College of Cardiology ACCF=American College of Cardiology Foundation ACE=Angiotensin converting enzyme Ach=Acetylcholine ACE-I=Angiotensin converting enzyme inhibitor ACS=Acute coronary syndrome ADA=American Diabetes Association ADP=Adenosine diphosphate AF=Atrial fibrillation AGE=Advanced glycation end products AHA=American Heart Association Aldo ANT=Aldosterone antagonist APO-A1=Apolipoprotein A1 ARB=Angiotensin receptor blocker ARBS=Angiotensin receptor blocker strategy ASA=Aspirin ASVD=Atherosclerotic vascular disease ATP=Adult Treatment Panel BA=Bile acid BB=Beta-blocker BMI=Body mass index BMS=Bare metal stent BP=Blood pressure CABG=Coronary artery bypass graft CAD=Coronary artery disease CAS=Calcium antagonist strategy CCB=Calcium channel blocker CDC=Centers for Disease Control CE=Cholesterol ester CHD=Coronary heart disease CHF=Congestive heart failure CKD=Chronic kidney disease CI=Confidence Interval COX=Cyclooxygenase COX-1=Cyclooxygenase 1 COX-2=Cyclooxygenase 2 CrCl=Creatinine clearance CRP=C-reactive protein CV=Cardiovascular CVA=Cerebrovascular accident CVD=Cardiovascular disease DAP=Dual antiplatelet DBP=Diastolic blood pressure DES=Drug eluting stent DHA=Docosahexaenoic acid DM=Diabetes mellitus DSE=Diabetes support and education EAD=Established atherothrombotic disease EF=Ejection fraction EP=Electrophysiology EPA=Eicosapenteaenoic acid EPS=Electrophysiology study ESRD=End stage renal disease FC=Free cholesterol Summary of Abbreviations (Continued) FDA=Food and Drug Administration FFA=Free fatty acid FPG=Fasting plasma glucose FRS=Framingham risk score GI=Gastointestinal GFR=Glomerular filtration rate HbA1C=Glycosylated hemoglobin HF=Heart failure HR=Hazard ratio HDL=High density lipoprotein HDL-C=High density lipoprotein cholesterol HRT=Hormone replacement therapy HTN=Hypertension ICD=Implantable cardioverter defibrillator ICH=Intracranial hemorrhage IDL=Intermediate density lipoprotein IFG=Impaired fasting glucose IGT=Impaired glucose tolerance IL-6=Interleukin-6 ILI=Intensive lifestyle intervention INR=International normalized ratio LCAT=Lecithin cholesterol acyltransferase LD=Loading dose LDL=Low density lipoprotein LDL-C=Low density lipoprotein cholesterol LDL-R=Low density lipoprotein receptor LE=Life expectancy LPL=Lipoprotein lipase LV=Left ventricular LV EF=Left ventricular ejection fraction LVH=Left ventricular hypertrophy LVSD=Left ventricular systolic dysfunction MCE=Major cardiovascular events MD=Maintenance dose MetS=Metabolic syndrome MI=Myocardial infarction MS=Metabolic syndrome NA=Not applicable NCEP=National cholesterol education program NE=Norepinephrine NF=Non-fatal NH=Non-Hispanic NHANES=National Health and Nutrition Examination Survey NHLBI=National Heart Lung Blood Institute NIH=National Institute of Health NRT=Nicotine replacement therapy NS=Not significant NSAIDs=Non-steroidal antiinflammatory drugs NSTE-ACS=Non-ST-segment elevation acute coronary syndrome Summary of Abbreviations (Continued) NSTE-MI=Non-ST-segment elevation myocardial infarction NYHA=New York Heart Association OA=Oral anticoagulation OAC=Oral anticoagulant OGTT=Oral glucose tolerance test OR=Odds ratio PAD=Peripheral arterial disease PAI-1=Plasminogen activator inhibitor-1 PAR=Population attributable risk PCI=Percutaneous coronary intervention PDGF=Platelet-derived growth factor PUFA=Polyunsaturated fatty acids RAS=Renin angiotensin system RCT=Randomized controlled trial RF=Risk factor RNA=Radionuclide angiography RR=Relative risk RRR=Relative risk reduction Rx=Treatment SAA=Serum amyloid A protein SBP=Systolic blood pressure SCD=Sudden cardiac death SPECT=Single photon emission computed tomography STEMI=ST-segment elevation myocardial infarction TC=Total cholesterol TF=Tissue factor TG=Triglyceride TIA=Transient ischemic attack TLC=Therapeutic lifestyle changes tPA=Tissue plasminogen activator TX=Transplant TXA2=Thromboxane A2 UA=Unstable angina ULN=Upper limit of normal USDA=United States Department of Agriculture VLDL=Very low density lipoprotein VF=Ventricular fibrillation VT=Ventricular tachycardia