The Evidence for Current

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The Evidence for Current Cardiovascular
Prevention Guidelines A Practical ABC
Approach Ty J. Gluckman, Andrew P. DeFilippis,
James Mudd, Catherine Campbell, Vera Bittner,
Suzanne Hughes, Gregg Fonarow, Roger S.
Blumenthal
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Introduction

• This slide set was adapted from the following
  2004-7 ACC/AHA guidelines
• Evidence-Based Guidelines for Cardiovascular
  Disease Prevention in Women 2007 Update
• Treatment of Hypertension in the Prevention and
  Management of Ischemic Heart Disease 2007
• Management of Patients With ST-Elevation
  Myocardial Infarction
• 2007 Guidelines for the Management of Patients
  With Unstable Angina/NonST-Elevation Myocardial
  Infarction
• Preventing Heart Attack and Death in Patients
  with Atherosclerotic Cardiovascular 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
• The full-text guidelines and executive summaries
  are also available on the
• ACC websites at www.acc.org

ACCAmerican College of Cardiology, AHAAmerican
Heart Association
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Evidence Based Prevention of CV Disease

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

ACCAmerican College of Cardiology, AHAAmerican
Heart Association, CVCardiovascular,
CVDCardiovascular disease
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Content of Modules

• Introduction
• Antiplatelet / 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

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Content of Modules

• Cholesterol, Cholesterol Therapies, and
  Cholesterol Guidelines
• Lifestyle Management Evidence and Guidelines
• Cigarette Smoking 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

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Content of Modules

• Other Risk Reducing Therapies, Guidelines, and
  Areas for Improvement
• Influenza Vaccination Evidence and Guidelines
• Ejection Fraction Evidence and Guidelines
• Aldosterone Antagonist Evidence and Guidelines
• Digitalis Evidence and Guidelines
• ICD Evidence and Guidelines
• Room for Improvement
• Quality Improvement Initiatives
• Therapies Not Indicated

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Applying Classification of Recommendations and
Level of Evidence
Alternative Phrasing
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Applying Classification of Recommendations and
Level of Evidence
Level of Evidence
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Cost of Cardiovascular Disease in the United
States
Total CVD
368
Heart disease
239
Coronaryheart disease
133
Hypertension
56
Stroke
54
Congestive heartfailure
29
0
50
100
150
200
250
300
350
400
Billions of dollars
CVDCardiovascular disease
2004 estimates Totals do not add up because of
rounding and overlap
NHLBI. www.nhlbi.nih.gov
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Scope of the Problem
Prevalence of U.S. Heart Disease
30
24.6
25
20
Patients (Millions)
12.4
15
10
5
0
1970
1980
1990
2000
2010
2020
2030
2040
2050
Year
Foot DK et al. JACC 2000351067-81
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Definition
Primordial Prevention Prevention of CHD risk
factors Primary Prevention Modification of risk
factors in order to prevent or delay the onset of
CHD Secondary Prevention Initiation of therapy
to reduce recurrent CHD events and decrease
cardiac mortality in patients with established CHD
CHDCoronary heart disease
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Summary of Abbreviations
ACCAmerican College of Cardiology ACEAngiote
nsin converting enzyme ACE-IAngiotensin
converting enzyme inhibitors ACSAcute
coronary syndrome ADPAdenosine
diphosphate AGEAdvanced glycation end
products AHAAmerican Heart Association Aldo
ANTAldosterone antagonist APO-A1Apolipoprotein
A1 ARBAngiotensin receptor
blockers ARBSAngiotensin receptor blocker
strategy ASAAspirin ASVDAtherosclerotic
vascular disease ATPAdult Treatment
Panel BABild acid BBb-blocker BMIBody mass
index BPBlood pressure
CABGCoronary artery bypass graft
surgery CADCoronary artery disease CASCalcium
antagonist strategy CCBCalcium channel
blocker CDCCenters for Disease
Control CECholesterol ester CHDCoronary heart
disease CHFCongestive heart failure CKDChronic
kidney disease CIConfidence Interval COXCyclooxy
genase CRPC-reactive protein CVCardiovascular CV
ACerebrovascular accident CVDCardiovascular
disease DAPDual antiplatelet therapy DBPDiastoli
c blood pressure DMDiabetes mellitus EFEjection
fractionEPSElectrophysiology study FCFree
cholesterol
FDAFood and Drug Administration FRSFramingha
m risk score HbA1CGlycosylated
hemoglobin HFHeart failure HRHazard
ratio HDL-CHigh density lipoprotein
cholesterol HTNHypertension ICDImplantable
cardioverter defibrillator IDLIntermediate
density lipoprotein cholesterol IFGImpaired
fasting glucose IGTImpaired glucose
tolerance IL-6Interleukin-6 LCATLecithin
cholesterol acyltransferase LDL-CLow density
lipoprotein cholesterol LPLLipoprotein
lipase LVHLeft ventricular hypertrophy
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Summary of Abbreviations (Continued)
LVSDLeft ventricular systolic
dysfunction MIMyocardial infarction MSMetabolic
syndrome NANot applicable NENorepinephrine NCEP
National cholesterol education
program NIHNational Institute of
Health NHANESNational Health and Nutrition
Examination Survey NHLBINational Heart Lung
Blood Institute NRTNicotine replacement
therapy NSNot significant NSAIDSNon-steroidal
anti- inflammatory drugs NSTE-ACSNon-ST-segmen
t elevation acute coronary syndrome
NSTE-MINon-ST segment elevation myocardial
infarction NYHANew York Heart
Association OAOral anticoagulation
OROdds ratio PADPeripheral arterial
disease PAI-1Plasminogen activator
inhibitor-1 PCIPercuanteous coronary
intervention PDGFPlatelet-derived growth
factor RASRenin angiotensin system RCTRandomized
controlled trial RFRisk factor RRRelative
risk RRRRelative risk reduction RxTreatment SAA
Serum amyloid A protein SBPSystolic blood
pressure SCDSudden cardiac death STEMIST-elevati
on myocardial infarction TCTotal
cholesterol TFTissue factor TGTriglyceride
TIATransient ischemic attack TLCTherapeutic
lifestyle changes tPATissue plasminogen
activator TXTransplant TXA2Thromboxane
A2 ULNUpper limit of normal USDAUnited States
Department of Agriculture VLDLVery low
density lipoprotein cholesterol VFVentricular
fibrillation VTVentricular tachycardia