The Evidence for CurrentCardiovascular 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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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/Non–ST-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

IntroductionIntroduction

ACC=American College of Cardiology, AHA=American Heart Association

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Evidence Based Prevention of CV DiseaseEvidence 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

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

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Content of Modules

• Introduction

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

• Antiplatelet Therapy Evidence and GuidelinesAntiplatelet Therapy Evidence and Guidelines• Anticoagulant Therapy Evidence and GuidelinesAnticoagulant Therapy Evidence and Guidelines

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

• Angiotensin Converting Enzyme Inhibitor Evidence and Angiotensin Converting Enzyme Inhibitor Evidence and GuidelinesGuidelines

• Angiotensin Receptor Blocker Evidence and GuidelinesAngiotensin Receptor Blocker Evidence and Guidelines• Beta Blocker Evidence and GuidelinesBeta Blocker Evidence and Guidelines

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Content of Modules

• Cholesterol, Cholesterol Therapies, and Cholesterol, Cholesterol Therapies, and Cholesterol GuidelinesCholesterol Guidelines

• Lifestyle Management Evidence and Guidelines Lifestyle Management Evidence and Guidelines • Cigarette Smoking Cessation Evidence and GuidelinesCigarette Smoking Cessation Evidence and Guidelines• Diet and Weight Management Evidence and GuidelinesDiet and Weight Management Evidence and Guidelines• Diet, Cardiovascular Events, and GuidelinesDiet, Cardiovascular Events, and Guidelines• Physical Activity Evidence and GuidelinesPhysical Activity Evidence and Guidelines

• Diabetes Mellitus Evidence and GuidelinesDiabetes Mellitus Evidence and Guidelines

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Content of Modules

• Other Risk Reducing Therapies, Guidelines, and Other Risk Reducing Therapies, Guidelines, and Areas for ImprovementAreas for Improvement

• Influenza Vaccination Evidence and GuidelinesInfluenza Vaccination Evidence and Guidelines• Ejection Fraction Evidence and GuidelinesEjection Fraction Evidence and Guidelines• Aldosterone Antagonist Evidence and GuidelinesAldosterone Antagonist Evidence and Guidelines• Digitalis Evidence and GuidelinesDigitalis Evidence and Guidelines• ICD Evidence and GuidelinesICD Evidence and Guidelines• Room for ImprovementRoom for Improvement• Quality Improvement InitiativesQuality Improvement Initiatives

• Therapies Not IndicatedTherapies Not Indicated

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Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Recommendations and Level of Evidence

Alternative Phrasing:

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Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A: Data derived from multiple randomized clinical trials or meta-analyses

Multiple populations evaluated;

Level B: Data derived from a single randomized trial or nonrandomized studies Limited populations evaluated

Level C: Only consensus of experts opinion, case studies, or standard of care

Very limited populations evaluated

Applying Classification of Recommendations and Level of Evidence

Level of Evidence:

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*2004 estimates †Totals do not add up because of rounding and overlap

NHLBI. www.nhlbi.nih.gov

Cost of Cardiovascular Disease in the United States*Cost of Cardiovascular Disease in the United States*

$54

$56

$133

$239

$368

$29

0 50 100 150 200 250 300 350 400

Billions of dollars

Congestive heartfailure

Stroke

Hypertension

Coronaryheart disease

Heart disease

Total CVD†

CVD=Cardiovascular disease

10

0

5

10

15

20

25

30

1970 1980 1990 2000 2010 2020 2030 2040 2050

Foot DK et al. JACC 2000;35:1067-81

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24.6

Scope of the ProblemScope of the Problem

Prevalence of U.S. Heart DiseaseP

atie

nts

(Mill

ions

)

Year

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DefinitionDefinition

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

CHD=Coronary heart disease

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Summary of AbbreviationsSummary of Abbreviations

ACC=American College of CardiologyACE=Angiotensin converting enzymeACE-I=Angiotensin converting enzyme inhibitorsACS=Acute coronary syndromeADP=Adenosine diphosphateAGE=Advanced glycation end productsAHA=American Heart AssociationAldo ANT=Aldosterone antagonistAPO-A1=Apolipoprotein A1 ARB=Angiotensin receptor blockersARBS=Angiotensin receptor blocker strategyASA=AspirinASVD=Atherosclerotic vascular diseaseATP=Adult Treatment PanelBA=Bild acidBB=-blockerBMI=Body mass indexBP=Blood pressure

CABG=Coronary artery bypass graft surgeryCAD=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=CyclooxygenaseCRP=C-reactive proteinCV=CardiovascularCVA=Cerebrovascular accidentCVD=Cardiovascular diseaseDAP=Dual antiplatelet therapyDBP=Diastolic blood pressureDM=Diabetes mellitusEF=Ejection fractionEPS=Electrophysiology studyFC=Free cholesterol

FDA=Food and Drug AdministrationFRS=Framingham risk scoreHbA1C=Glycosylated hemoglobinHF=Heart failureHR=Hazard ratioHDL-C=High density lipoprotein cholesterolHTN=HypertensionICD=Implantable cardioverter defibrillatorIDL=Intermediate density lipoprotein cholesterolIFG=Impaired fasting glucoseIGT=Impaired glucose toleranceIL-6=Interleukin-6LCAT=Lecithin cholesterol acyltransferaseLDL-C=Low density lipoprotein cholesterolLPL=Lipoprotein lipaseLVH=Left ventricular hypertrophy

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

LVSD=Left ventricular systolic dysfunctionMI=Myocardial infarctionMS=Metabolic syndromeNA=Not applicableNE=NorepinephrineNCEP=National cholesterol education programNIH=National Institute of HealthNHANES=National Health and Nutrition Examination SurveyNHLBI=National Heart Lung Blood InstituteNRT=Nicotine replacement therapy NS=Not significantNSAIDS=Non-steroidal anti- inflammatory drugsNSTE-ACS=Non-ST-segment elevation acute coronary syndrome NSTE-MI=Non-ST segment elevation myocardial infarctionNYHA=New York Heart AssociationOA=Oral anticoagulation

OR=Odds ratioPAD=Peripheral arterial diseasePAI-1=Plasminogen activator inhibitor-1PCI=Percuanteous coronary interventionPDGF=Platelet-derived growth factorRAS=Renin angiotensin systemRCT=Randomized controlled trialRF=Risk factorRR=Relative riskRRR=Relative risk reductionRx=TreatmentSAA=Serum amyloid A proteinSBP=Systolic blood pressureSCD=Sudden cardiac deathSTEMI=ST-elevation myocardial infarctionTC=Total cholesterolTF=Tissue factorTG=Triglyceride

TIA=Transient ischemic attackTLC=Therapeutic lifestyle changestPA=Tissue plasminogen activatorTX=TransplantTXA2=Thromboxane A2ULN=Upper limit of normalUSDA=United States Department of AgricultureVLDL=Very low density lipoprotein cholesterolVF=Ventricular fibrillationVT=Ventricular tachycardia