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2002 Chronic Angina Recommendations 2007 Chronic Angina Recommendations 2007 COR and LOE Comments Smoking Assess tobacco use. Strongly encourage patient and family to stop smoking and to avoid second-hand smoke. Provide counseling, pharmacological therapy (including nicotine replacement and buproprion), and formal cessation programs as appropriate. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement) is recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange). I (B) Modified recommendation (changed text and COR LOE added) Blood Pressure Control Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients with blood pressure greater than or equal to 130 mm Hg systolic or 80 mm Hg diastolic. Add blood pressure medication, individualized to other patient requirements and characteristics (i.e., age, race, need for drugs with specific benefits) if blood pressure is not less than 140 mm Hg systolic or 90 mm Hg diastolic, or if blood pressure is not less than 130 mm Hg systolic or 85 mm Hg diastolic for individuals with heart failure or renal insufficiency (less than 80 mm Hg diastolic for individuals with diabetes). Patients should initiate and/or maintain lifestyle modifications—weight control; increased physical activity; moderation of alcohol consumption; limited sodium intake; and maintenance of a diet high in fresh fruits, vegetables, and low-fat dairy products. Blood pressure control according to Joint National Conference VII guidelines is recommended (i.e., blood pressure less than 140/90 mm Hg or less than 130/80 mm Hg for patients with diabetes or chronic kidney disease) (11). For hypertensive patients with well established coronary artery disease, it is useful to add blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve target blood pressure. I (B) I (A) I (C) Modified recommendation (changed text and COR LOE added) New recommendation New recommendation Lipid Management Start dietary therapy in all patients (less than 7% saturated fat and less than 200 mg per dL cholesterol) and promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids. Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), trans-fatty acids, and cholesterol (to less than 200 mg per day). Adding plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. Daily physical activity and weight management are recommended for all patients. I (B) IIa (A) I (B) Modified recommendation (changed text and COR LOE added) New recommendation New recommendation Consider omega-3 fatty acids as adjunct for high TG. For all patients, encouraging consumption of omega-3 fatty acids in the form of fish* or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated TG, higher doses are usually necessary for risk reduction. IIb (B) Modified recommendation (changed text and COR LOE added) Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event. If patients are hospitalized, consider adding drug therapy on discharge. Add drug therapy according to the following guide: Recommended lipid management includes assessment of a fasting lipid profile. I (A) Modified recommendation (changed text and COR LOE added) LDL less than 100 mg per dL (baseline or on-treatment). Further LDL-lowering therapy not required. Consider fibrate or niacin (if low HDL or high TG). a. LDL-C should be less than 100 mg per dL and b. Reduction of LDL-C to less than 70 mg per dL or high-dose statin therapy is reasonable. I (A) IIa (A) Modified recommendation (changed text and COR LOE added) New recommendation LDL 100 to 129 mg per dL (baseline or on-treatment) Therapeutic options: Intensify LDL-lowering therapy (statin or resin). Fibrate or niacin (if low HDL or high TG). Consider combined drug therapy (statin + fibrate or niacin) (if low HDL or high TG). c. If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels. I (A) Modified recommendation (changed text and COR LOE added) LDL greater than or equal to 130 mg per dL (baseline or on-treatment). Intensify LDL-lowering therapy (statin or resin). Add or increase drug therapy with lifestyle therapies. d. If on-treatment LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified. e. If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. I (A) IIa (B) Modified recommendation (changed text and COR LOE added) New recommendation If TG 200 to 499 mg per dL: Consider fibrate or niacin after LDL-lowering therapy. f. If TG are 200 to 499 mg per dL, non–HDL-C should be less than 130 mg per dL and I (B) Modified recommendation (changed text and COR LOE added) g. Further reduction of non–HDL-C to less than 100 mg per dL is reasonable, if TG are greater than or equal to 200 to 499 mg per dL. IIa (B) New recommendation h. Therapeutic options to reduce non–HDL-C are: • Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy) or • Fibrate therapy as a therapeutic option can be useful to reduce non–HDL-C (after LDL-C–lowering therapy). IIa (B) New recommendation If TG greater than or equal to 500 mg per dL: Consider fibrate or niacin before LDL-lowering therapy.* i. If TG are greater than or equal to 500 mg per dL, therapeutic options to lower the TG to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-C lowering therapy. The goal is to achieve non–HDL-C less than 130 mg per dL if possible. I (C) Modified recommendation (changed text and COR LOE added) The following lipid management strategies can be beneficial: IIa (C) a. If LDL-C less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. (12) If TG greater than or equal to 150 mg per dL or HDL less than 40 mg per dL: Emphasize weight management and physical activity. Advise smoking cessation. Deleted recommendation Drug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve LDL-C less than 100 mg per dL. I (C) New recommendation Physical Activity Assess risk, preferably with exercise test, to guide prescription. Encourage minimum of 30 to 60 minutes of activity, preferably daily, or at least 3 or 4 times weekly (walking, jogging, cycling, or other aerobic activity) supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). Physical activity of 30 to 60 minutes, 7 days per week (minimum 5 days per week) is recommended. All patients should be encouraged to obtain 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work). I (B) Modified recommendation (changed text and COR LOE added) The patient’s risk should be assessed with a physical activity history. Where appropriate, an exercise test is useful to guide the exercise prescription (see Exercise Testing Guideline) (10). I (B) New recommendation Advise medically supervised programs for moderate- to high-risk patients. Medically supervised programs (cardiac rehabilitation) are recommended for at-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure). I (B) Modified recommendation (changed text and COR LOE added) Expanding physical activity to include resistance training on 2 days per week may be reasonable. IIb (C) New recommendation Weight Management Calculate BMI and measure waist circumferences as part of evaluation. Monitor response of BMI and waist circumference to therapy. Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2. BMI and waist circumference should be assessed regularly. On each patient visit, it is useful to consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to achieve and maintain a BMI between 18.5 and 24.9 kg/m2. I (B) Modified recommendation (changed text and COR LOE added) When BMI greater than or equal to 25 kg/m2, goal for waist circumference is less than or equal to 40 inches (102 cm) in men and less than or equal to 35 inches (89 cm) in women. If waist circumference is greater than or equal to 35 inches (89 cm) in women or greater than or equal to 40 inches (102 cm) in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.g., 37 to 40 inches [94 to 102 cm]). Such persons may have a strong genetic contribution to insulin resistance. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference. I (B) Modified recommendation (changed text and COR LOE added) Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2. The initial goal of weight loss therapy should be to gradually reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. I (B) Modified recommendation (changed text and COR LOE added) Diabetes Management Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c. Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA1c. I (B) Modified recommendation (changed text and COR LOE added) Treatment of other risks (e.g., physical activity, weight management, blood pressure, and cholesterol management). Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management) as recommended should be initiated and maintained. I (B) Modified recommendation (changed text and COR LOE added) Antiplatelet Agents/Anticoagulants Start and continue indefinitely aspirin 75 to 325 mg per day if not contraindicated. Consider clopidogrel as an alternative if aspirin contraindicated. Aspirin should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated. I (A) Modified recommendation (changed text and COR LOE added) Manage warfarin to international normalized ratio = 2.0 to 3.0 in post-MI patients when clinically indicated or for those not able to take aspirin or clopidogrel. Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. I (B) Modified recommendation (changed text and COR LOE added) Renin-Angiotensin-Aldosterone System Blockers ACE Inhibitors Treat all patients indefinitely post-MI; start early in stable high-risk patients (anterior MI, previous MI, Killip class II [S3, gallop, rales, radiographic CHF]). Consider chronic therapy for all other patients with coronary or other vascular disease unless contraindicated. ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction less than or equal to 40% and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated. I (A) Modified recommendation (changed text and COR LOE added) Use as needed to manage blood pressure or symptoms in all other patients. ACE inhibitors should be started and continued indefinitely in patients who are not lower risk (lower risk defined as those with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. I (B) Modified recommendation (changed text and COR LOE added) It is reasonable to use ACE inhibitors among lower-risk patients with mildly reduced or normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed. IIa (B) New recommendation Renin-Angiotensin-Aldosterone System Blockers (Continued) Angiotensin receptor blockers are recommended for patients who have hypertension, have indications for but are intolerant of ACE inhibitors, have heart failure, or have had a myocardial infarction with left ventricular ejection fraction less than or equal to 40%. I (A) New recommendation Angiotensin receptor blockers may be considered in combination with ACE inhibitors for heart failure due to left ventricular systolic dysfunction. IIb (B) New recommendation Aldosterone blockade is recommended for use in post-MI patients without significant renal dysfunction¶ or hyperkalemia|| who are already receiving therapeutic doses of an ACE inhibitor and a beta blocker, have a left ventricular ejection fraction less than or equal to 40%, and have either diabetes or heart failure. I (A) New recommendation Beta Blockers Start in all post-MI and acute patients (arrhythmia, LV dysfunction, inducible ischemia) at 5 to 28 days. Continue 6 months minimum. Observe usual contraindications. Use as needed to manage angina, rhythm, or blood pressure in all other patients. It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated. I (A) Modified recommendation (changed text and COR LOE added) Influenza Vaccination An annual influenza vaccination is recommended for patients with cardiovascular disease. I (B) New recommendation Chelation Therapy Chelation therapy (intravenous infusions of ethylenediamine tetraacetic acid or EDTA) is not recommended for the treatment of chronic angina or arteriosclerotic cardiovascular disease and may be harmful because of its potential to cause hypocalcemia. III (C) New recommendation * Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury. The use of resin is relatively contraindicated when TG are lower than 200 mg per dL. Non–HDL cholesterol = total cholesterol minus HDL cholesterol. The combination of high-dose statin and fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination. Dietary supplement niacin must not be used as a substitute for prescription niacin. ¶ Creatinine should be less than 2.5 mg per dL in men and less than 2.0 mg per dL in women. || Potassium should be less than 5.0 mEq per L.

ACE indicates angiotensin-converting enzyme; BMI, body mass index; CHF, congestive heart failure; COR, classification of recommendation; HbA_1c, hemoglobin A_1c; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein; LDL-C = low-density lipoprotein cholesterol; LOE, level of evidence; MI = myocardial infarction; and TG, triglycerides.

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