Transcript VBWG05CoreCAD-S5 (8 slides

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Appendix:
Clinical Guidelines
Updated guidelines: Classes of
Recommendations and levels of evidence
Classes
I Intervention is useful
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Levels of evidence
A
Data derived from
multiple randomized
clinical trials
B
Data derived from
a single RCT or
nonrandomized
studies
C
Consensus opinion
of experts
and effective
IIA Evidence conflicts /
opinions differ, but leans
toward efficacy
IIB Evidence conflicts /
opinions differ, but leans
against efficacy
III Intervention is not useful
or effective and may be
harmful
Gibbons RJ et al. J Am Coll Cardiol. 2003;41:159-68.
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ACC/AHA: Update for management of
chronic stable angina—asymptomatic patients
Class I interventions
Level of
evidence
A
Aspirin in patients with prior MI
B
Beta-blockers in patients with prior MI
A
Lipid-lowering therapy in patients with CAD
and LDL-C >130 mg/dL with target LDL
<100 mg/dL
A
ACEI in patients with CAD who have diabetes
and/or systolic dysfunction
Gibbons RJ et al. J Am Coll Cardiol. 2003;41:159-68.
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ACC/AHA guidelines: Discharge therapy after
unstable angina/NSTEMI–Class I interventions
Level of
evidence
A
ACEI for patients with CHF, LV dysfunction
(EF <40%), hypertension, or diabetes
A
C
Lipid-lowering agents + diet if LDL >130 mg/dL,
Lipid-lowering agents if LDL-C after diet is
>100 mg/dL
B
Beta-blockade for all patients
A
Aspirin 75–325 mg/d
Clopidogrel 75 mg/d if aspirin is contraindicated
B
Braunwald E et al. J Am Coll Cardiol. 2002;40:1366-74.
ACC/AHA: Discharge medical therapy
after STEMI–Class I interventions
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Level of
evidence
RAAS modulation
A
B
A
ACEI for all patients
ARB for ACEI-intolerant patients with HF
or LVEF <40%
Aldosterone blocker for patients on ACEI with
LVEF <40% and HF or diabetes
Lipid lowering
A
B
Statins in patients with LDL-C >100 mg/dL
LDL-C <100 mg/dL
Beta-blockade
A
Beta-blockers for all patients except those
with normal/near-normal ventricular
function, successful reperfusion, absence
of ventricular arrhythmias
Antiplatelet
A
Aspirin 75–162 mg for all patients
Antman EM et al. Circulation. 2004;110:588-636.
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RALES and EPHESUS: Aldosterone blockade
in HF and post-MI LV dysfunction
RALES
• N = 1633 with NYHA class III/IV HF
• Randomized to placebo or spironolactone 25 mg
• Treatment in addition to ACE inhibitor and loop diuretic;
most patients also received digoxin
EPHESUS
• N = 6632 with post-MI LV dysfunction and HF
• Randomized to placebo or eplerenone 50 mg
• Treatment in addition to ACEI or ARB, -blockers,
diuretics, aspirin
RALES = Randomized ALdactone Evaluation Study
EPHESUS = Eplerenone Post-Acute Myocardial
Infarction Heart Failure Efficacy and SUrvival Study
Pitt B et al. N Engl J Med. 1999;341:709-17.
Pitt B et al. N Engl J Med. 2003;348:1309-21.
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Aldosterone blockade and AT1 receptor
blockade: Trials in post-MI LV dysfunction
and HF
RALES
30% Risk reduction
RR 0.70 (0.60–0.82)
P < 0.001
1.00
0.90
Probability 0.75
of survival
0.60
0.45
0.00
0
6
12
EPHESUS
22
18
Spironolactone
Cumulative 14
25 mg
incidence 10
(%)
6
Placebo
2
0
18
24 30
36
0
Months
15% Risk reduction
RR 0.85 (0.75–0.96)
P = 0.008
Placebo
Eplerenone
50 mg
6
12
18
24
30
36
Months
Pitt B et al. N Eng J Med. 1999;341:709-17.
Pitt B et al. N Eng J Med. 2003;348:1309-21.
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ESC Guidelines: ACEI in secondary
prevention and to prevent sudden death
Setting/indication
Class
Level
1
A
Patients with heart failure
1
A
Patients with previous MI
1
A
Patients with dilated cardiomyopathy
1
B
Secondary prevention
High-risk patients
(CVD or diabetes + 1 other risk factor)
Sudden death
López-Sendón J et al. Eur Heart J. 2004;25:1454-70.