Revised Guidelines: Secondary Prevention and Risk Reduction in Patients with Atherosclerotic Disease

New recommendations for cardiac rehabilitation and risk reduction are welcome, but updated guidance is lacking on lipid and blood pressure management.


Sponsoring Organizations: American Heart Association, American College of Cardiology

Background and Purpose: This revision updates the 2006 secondary prevention guidelines (JW Cardiol Jun 8 2006) and incorporates risk reduction into their title and purview. The guidelines continue to focus on important patient behaviors, including 30 minutes of physical activity daily, smoking cessation and avoidance of secondhand smoke, and weight management. However, the writing committee has deferred making major changes to the 2006 recommendations on blood pressure control and lipid management pending the revised versions of the National Heart, Lung, and Blood Institute's Joint National Committee guidelines (JNC) and Adult Treatment Panel report (ATP), respectively (both expected in 2012).

Key Points:

1. A new section of Class I and Class IIa recommendations highlights the importance of referring patients for cardiac rehabilitation.

2. The guideline authors have reorganized the section on lipid management to emphasize evidence-based use of statins rather than the achievement of target lipid levels. Although no new specific recommendations have been added, the lack of evidence supporting non-statin lipid-lowering agents has demoted the use of combined drug therapies from Class I to either Class IIa or IIb, depending on the agent.

3. The authors have updated recommendations regarding antiplatelet therapy, incorporating new data on prasugrel from TRITON TIMI 38 and ticagrelor from PLATO (Class I).

4. The recommendations for beta-blocker therapy have been expanded and clarified, reflecting evidence that the drugs are most efficacious in patients with recent myocardial infarction, left ventricular systolic dysfunction, or both.

5. The guidelines now identify and direct specific recommendations to populations at very high risk for poor outcomes.

6. A new section of Class IIa and Class IIb recommendations addresses screening for and management of depression.


Citation(s):

Smith SC Jr et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. A guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011 Nov 29; 124:2458.