The Evidence for Current Cardiovascular Prevention Guidelines: A Practical ‘ABC’ Approach

1. 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

2. 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 Introduction ACC=American College of Cardiology, AHA=American Heart Association

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

4. 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 Content of Modules

5. 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 Content of Modules

6. 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 Content of Modules

7. Applying Classification of Recommendations and Level of Evidence Alternative Phrasing:

8. Applying Classification of Recommendations and Level of Evidence Level of Evidence:

9. 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 CVD=Cardiovascular disease *2004 estimates †Totals do not add up because of rounding and overlap NHLBI. www.nhlbi.nih.gov

10. 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 2000;35:1067-81

11. 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 CHD=Coronary heart disease

12. Summary of Abbreviations ACC=American College of Cardiology ACE=Angiotensin converting enzyme ACE-I=Angiotensin converting enzyme inhibitors ACS=Acute coronary syndrome ADP=Adenosine diphosphate AGE=Advanced glycation end products AHA=American Heart Association Aldo ANT=Aldosterone antagonist APO-A1=Apolipoprotein A1 ARB=Angiotensin receptor blockers ARBS=Angiotensin receptor blocker strategy ASA=Aspirin ASVD=Atherosclerotic vascular disease ATP=Adult Treatment Panel BA=Bild acid BB=b-blocker BMI=Body mass index BP=Blood pressure CABG=Coronary artery bypass graft surgery 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 CRP=C-reactive protein CV=Cardiovascular CVA=Cerebrovascular accident CVD=Cardiovascular disease DAP=Dual antiplatelet therapy DBP=Diastolic blood pressure DM=Diabetes mellitus EF=Ejection fractionEPS=Electrophysiology study FC=Free cholesterol FDA=Food and Drug Administration FRS=Framingham risk score HbA1C=Glycosylated hemoglobin HF=Heart failure HR=Hazard ratio HDL-C=High density lipoprotein cholesterol HTN=Hypertension ICD=Implantable cardioverter defibrillator IDL=Intermediate density lipoprotein cholesterol IFG=Impaired fasting glucose IGT=Impaired glucose tolerance IL-6=Interleukin-6 LCAT=Lecithin cholesterol acyltransferase LDL-C=Low density lipoprotein cholesterol LPL=Lipoprotein lipase LVH=Left ventricular hypertrophy

13. Summary of Abbreviations (Continued) LVSD=Left ventricular systolic dysfunction MI=Myocardial infarction MS=Metabolic syndrome NA=Not applicable NE=Norepinephrine NCEP=National cholesterol education program NIH=National Institute of Health NHANES=National Health and Nutrition Examination Survey NHLBI=National Heart Lung Blood Institute NRT=Nicotine replacement therapy NS=Not significant NSAIDS=Non-steroidal anti- inflammatory drugs NSTE-ACS=Non-ST-segment elevation acute coronary syndrome NSTE-MI=Non-ST segment elevation myocardial infarction NYHA=New York Heart Association OA=Oral anticoagulation OR=Odds ratio PAD=Peripheral arterial disease PAI-1=Plasminogen activator inhibitor-1 PCI=Percuanteous coronary intervention PDGF=Platelet-derived growth factor RAS=Renin angiotensin system RCT=Randomized controlled trial RF=Risk factor RR=Relative risk RRR=Relative risk reduction Rx=Treatment SAA=Serum amyloid A protein SBP=Systolic blood pressure SCD=Sudden cardiac death STEMI=ST-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 ULN=Upper limit of normal USDA=United States Department of Agriculture VLDL=Very low density lipoprotein cholesterol VF=Ventricular fibrillation VT=Ventricular tachycardia