The Evidence for Current Cardiovascular
Disease Prevention Guidelines:
Introduction
American College of Cardiology
Best Practice Quality Initiative Subcommittee
and Prevention Committee
Introduction
This slide set was adapted from the 2004-13 ACC/ADA/AHA guidelines:
Evidence-Based Guidelines for CV Disease Prevention in Women
Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease
Management of Patients With ST-Elevation Myocardial Infarction
Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation MI
Preventing Heart Attack and Death in Patients with Atherosclerotic CV 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
Primary Prevention of CV Disease in People with Diabetes Mellitus
Standards of Medical Care in Diabetes
The full-text guidelines and executive summaries are also available on
ACC’s website www.acc.org
ACC=American College of Cardiology, ADA=American Diabetes Association,
AHA=American Heart Association, CV=Cardiovascular, MI=Myocardial infarction
Evidence Based Prevention of CV Disease
• Evidence based guidelines are based on rigorous expert analysis of
available data, documenting relative benefits and risks of procedures and
therapies.
• ACC/ADA/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.
• The guidelines are 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
Content of the Modules
• Introduction
• Antiplatelet and 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
• Cholesterol, Cholesterol Therapies, and Cholesterol Guidelines
Content of the Modules (Continued)
• Lifestyle Management Evidence and Guidelines
• Tobacco 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
• Prediabetic Conditions and Metabolic Syndrome
• Diabetes Mellitus
Content of the Modules (Continued)
• Other Cardiovascular Therapies and Areas with Room for
Improvement
• Influenza Vaccination Evidence and Guidelines
• Ejection Fraction Evidence and Guidelines
• Aldosterone Antagonist Evidence and Guidelines
• Digoxin Evidence and Guidelines
• ICD Evidence and Guidelines
• Room for Improvement
• Quality Improvement Initiatives
• Ineffective Therapies in Cardiovascular Disease
Classification of Recommendations
and Levels of Evidence
*Data available from clinical trials or
registries about the
usefulness/efficacy in different
subpopulations, such as gender, age,
history of diabetes, history of prior
myocardial infarction, history of heart
failure, and prior aspirin use. A
recommendation with Level of
Evidence B or C does not imply that
the recommendation is weak. Many
important clinical questions addressed
in the guidelines do not lend
themselves to clinical trials. Even
though randomized trials are not
available, there may be a very clear
clinical consensus that a particular
test or therapy is useful or effective.
†In 2003, the ACC/AHA Task Force
on Practice Guidelines developed a
list of suggested phrases to use when
writing recommendations. All
guideline recommendations have
been written in full sentences that
express a complete thought, such that
a recommendation, even if separated
and presented apart from the rest of
the document (including headings
above sets of recommendations),
would still convey the full intent of the
recommendation. It is hoped that this
will increase readers’ comprehension
of the guidelines and will allow queries
at the individual recommendation
level.
Icons Representing the Classification and Evidence
Levels for Recommendations
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
I IIa IIb III
Cost of Cardiovascular Disease
in the United States
CHD=Coronary heart disease, CHF=Congestive heart failure,
CVD=Cardiovascular disease, HBP=High blood pressure
Go AS et al. Circulation 2003;127:e6-e245
Prevalence of Cardiovascular
Disease in the United States
Go AS et al. Circulation 2003;127:e6-e245
Rates of Death from Cardiovascular
Disease in the United States
Calendar Year (1900-2006)
Go AS et al. Circulation 2003;127:e6-e245
Scope of the Problem (Continued)
Prevalence of CHD associated with 3 projections of adult obesity
Population prevalence of CHD
Prevalence (%)
Number of Excess Cases
Excess prevalence of CHD
Year
Year
Extrapolation from current data suggests that overweight adolescents will
increase rates of CHD among future young and middle-aged adults
CHD=Coronary heart disease
Source: Bibbins-Domingo K et al. NEJM 2007;357:2371-2379
Definitions of Different Types of Prevention
Primordial Prevention: Prevention of coronary heart disease risk factors
Primary Prevention: Modification of risk factors in order to prevent or
delay the onset of coronary heart disease
Secondary Prevention: Initiation of therapy to reduce recurrent coronary
heart disease events and decrease cardiac mortality in patients with
established coronary heart disease
Summary of Abbreviations
A1C=Glycosylated hemoglobin
ABI=Ankle brachial index
ACC=American College of
Cardiology
ACCF=American College of
Cardiology Foundation
ACE=Angiotensin converting
enzyme
Ach=Acetylcholine
ACE-I=Angiotensin converting
enzyme inhibitor
ACS=Acute coronary syndrome
ADA=American Diabetes
Association
ADP=Adenosine diphosphate
AF=Atrial fibrillation
AGE=Advanced glycation end
products
AHA=American Heart Association
Aldo ANT=Aldosterone antagonist
APO-A1=Apolipoprotein A1
ARB=Angiotensin receptor
blocker
ARBS=Angiotensin receptor
blocker strategy
ASA=Aspirin
ASVD=Atherosclerotic vascular
disease
ATP=Adult Treatment Panel
BA=Bile acid
BB=Beta-blocker
BMI=Body mass index
BMS=Bare metal stent
BP=Blood pressure
CABG=Coronary artery bypass
graft
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
COX-1=Cyclooxygenase 1
COX-2=Cyclooxygenase 2
CrCl=Creatinine clearance
CRP=C-reactive protein
CV=Cardiovascular
CVA=Cerebrovascular accident
CVD=Cardiovascular disease
DAP=Dual antiplatelet
DBP=Diastolic blood pressure
DES=Drug eluting stent
DHA=Docosahexaenoic acid
DM=Diabetes mellitus
DSE=Diabetes support and
education
EAD=Established
atherothrombotic disease
EF=Ejection fraction
EP=Electrophysiology
EPA=Eicosapenteaenoic acid
EPS=Electrophysiology study
ESRD=End stage renal disease
FC=Free cholesterol
Summary of Abbreviations (Continued)
FDA=Food and Drug
Administration
FFA=Free fatty acid
FPG=Fasting plasma glucose
FRS=Framingham risk score
GI=Gastointestinal
GFR=Glomerular filtration rate
HbA1C=Glycosylated hemoglobin
HF=Heart failure
HR=Hazard ratio
HDL=High density lipoprotein
HDL-C=High density lipoprotein
cholesterol
HRT=Hormone replacement
therapy
HTN=Hypertension
ICD=Implantable cardioverter
defibrillator
ICH=Intracranial hemorrhage
IDL=Intermediate density
lipoprotein
IFG=Impaired fasting glucose
IGT=Impaired glucose tolerance
IL-6=Interleukin-6
ILI=Intensive lifestyle
intervention
INR=International normalized
ratio
LCAT=Lecithin cholesterol
acyltransferase
LD=Loading dose
LDL=Low density lipoprotein
LDL-C=Low density lipoprotein
cholesterol
LDL-R=Low density lipoprotein
receptor
LE=Life expectancy
LPL=Lipoprotein lipase
LV=Left ventricular
LV EF=Left ventricular ejection
fraction
LVH=Left ventricular hypertrophy
LVSD=Left ventricular systolic
dysfunction
MCE=Major cardiovascular
events
MD=Maintenance dose
MetS=Metabolic syndrome
MI=Myocardial infarction
MS=Metabolic syndrome
NA=Not applicable
NCEP=National cholesterol
education program
NE=Norepinephrine
NF=Non-fatal
NH=Non-Hispanic
NHANES=National Health and
Nutrition Examination Survey
NHLBI=National Heart Lung
Blood
Institute
NIH=National Institute of Health
NRT=Nicotine replacement
therapy NS=Not significant
NSAIDs=Non-steroidal antiinflammatory drugs
NSTE-ACS=Non-ST-segment
elevation acute coronary
syndrome
Summary of Abbreviations (Continued)
NSTE-MI=Non-ST-segment
elevation myocardial infarction
NYHA=New York Heart
Association
OA=Oral anticoagulation
OAC=Oral anticoagulant
OGTT=Oral glucose tolerance
test
OR=Odds ratio
PAD=Peripheral arterial disease
PAI-1=Plasminogen activator
inhibitor-1
PAR=Population attributable
risk
PCI=Percutaneous coronary
intervention
PDGF=Platelet-derived growth
factor
PUFA=Polyunsaturated fatty
acids
RAS=Renin angiotensin system
RCT=Randomized controlled
trial
RF=Risk factor
RNA=Radionuclide angiography
RR=Relative risk
RRR=Relative risk reduction
Rx=Treatment
SAA=Serum amyloid A protein
SBP=Systolic blood pressure
SCD=Sudden cardiac death
SPECT=Single photon emission
computed tomography
STEMI=ST-segment 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
UA=Unstable angina
ULN=Upper limit of normal
USDA=United States Department
of Agriculture
VLDL=Very low density lipoprotein
VF=Ventricular fibrillation
VT=Ventricular tachycardia