Chapter 5 Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Diseasebeen incorporated into these guidelines. Specifi c
recommendations for clopidogrel in patients with
acute coronary syndromes and for those receiving
bare metal and drug eluting stents have been incor-
porated into these guidelines. The results of three
major trials involving ACE inibitors form the basis
for recommendations about the use of these thera-
pies among patients with atherosclerotic disease and
normal left ventricular function. New recommenda-
tions for the use of aldosterone blockade therapy
among patients with systolic heart failure and revised
recommendations for beta blockade therapy are
presented. For the fi rst time a recommendation
regarding infl uenza vaccine is presented with a Class
I recommendation for its use in all patients with
established atherosclerotic cardiovascular disease.
The recommendations for physical activity have
been upgrade to comply with recent NIH guidelines.
The following guideline recommendations are those
put forth in the AHA/ACC 2006 Secondary Preven-
tion Update [2] as adapted and published in the
2007 PCI Focused Update [3].
We have presented this information both in text
and table format (Table 5.1).
Comprehensive risk reduction for
patients with coronary and
other vascular disease
Smoking
Goal: Complete cessation, no exposure to
environmental tobacco smoke
1 Status of tobacco use should be asked about at
every visit. I (B)
2 Every tobacco user and family members who
smoke should be advised to quit at every visit.
I (B)
3 The tobacco user’s willingness to quit should be
assessed. I (B)
4 The tobacco user should be assisted by counseling
and developing a plan for quitting. I (B)
5 Follow-up, referral to special programs, or phar-
macotherapy (including nicotine replacement and
pharmacological treatment) should be arranged.
I (B)
6 Exposure to environmental tobacco smoke at
work and home should be avoided. I (B)
Blood pressure control
Goal: Less than 140/90 mm Hg or less than
130/80 mm Hg if patient has diabetes or chronic
kidney disease
1 For patients with blood pressure greater than or
equal to 140/90 mm Hg (or greater than or equal to
130/80 mm Hg for patients with diabetes or chronic
kidney disease), it is recommended to initiate or
maintain lifestyle modifi cation – weight control;
increased physical activity; alcohol moderation;
sodium reduction; and emphasis on increased con-
sumption of fresh fruits, vegetables, and low-fat
dairy products. I (B)
2 For patients with blood pressure greater than or
equal to 140/90 mm Hg (or greater than or equal to
130/80 mm Hg for patients with diabetes or chronic
kidney disease), it is useful as tolerated, to add blood
pressure medication, treating initially with beta
blockers and/or ACE inhibitors, with the addition of
other drugs such as thiazides as needed to achieve
goal blood pressure.* I (A)Lipid management
Goal: LDL-C substantially less than 100 mg
per dL
(If triglycerides are greater than or equal to 200 mg
per dL, non-HDL-C should be less than 130 mg
per dL†.)
1 Starting dietary therapy is recommended. Reduce
intake of saturated fats (to less than 7% of total calo-
ries), trans fatty acids, and cholesterol (to less than
200 mg per day). I (B)
2 Adding plant stanol/sterols (2 g per day) and/or
viscous fi ber (greater than 10 g per day) is reason-
able to further lower LDL-C. IIa (A)
3 Promotion of daily physical activity and weight
management is recommended. I (B)
4 It may be reasonable to encourage increased
consumption of omega-3 fatty acids in the form of* For compelling indications for individual drug classes in spe-
cifi c vascular diseases, see the Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7).
† Non-HDL-C indicates total cholesterol minus HDL-C.