Skip to main content

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute

AHA/ACC Guideline

J Am Coll Cardiol, 47 (10) 2130–2139
Sections

Introduction

Since the 2001 update of the American Heart Association (AHA)/American College of Cardiology (ACC) consensus statement on secondary prevention (1), important evidence from clinical trials has emerged that further supports and broadens the merits of aggressive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. This growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves quality of life for these patients.

Compelling evidence from recent clinical trials and revised practice guidelines provided the impetus for this update of the 2001 recommendations with evidence-based results (Table 1).Classification of Recommendations and Level of Evidence are expressed in ACC/AHA format, as detailed in Tables 2 and 3.Recommendations made herein are based largely on major practice guidelines from the National Institutes of Health and ACC/AHA. In many cases, these practice guidelines were supplemented by research findings published after the publication of the primary reference(s). Thus, the development of the present statement involved a process of partial adaptation of other guideline statements and reports and supplemental literature searches 2–32). (For specific search criteria, see the Appendix.) The findings from additional lipid reduction trials (33–37) involving more than 50 000 patients resulted in new optional therapeutic targets, which were outlined in the 2004 update of the National Heart, Lung, and Blood Institute’s Adult Treatment Panel (ATP) III report (6). These changes defined optional lower target cholesterol levels for very high-risk coronary heart disease (CHD) patients, especially those with acute coronary syndromes, and expanded indications for drug treatment. Subsequent to the 2004 update of ATP III, 2 additional trials (8,9) demonstrated cardiovascular benefit for lipid lowering significantly below current cholesterol goal levels for those with chronic CHD. These new trials allow for alterations in guidelines, such that low-density lipoprotein cholesterol (LDL-C) should be <100 mg/dL for all patients with CHD and other clinical forms of atherosclerotic disease, but in addition, it is reasonable to treat to LDL-C <70 mg/dL in such patients. When the <70-mg/dL target is chosen, it may be prudent to increase statin therapy in a graded fashion to determine a patient’s response and tolerance. Furthermore, if it is not possible to attain LDL-C <70 mg/dL because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of >50% with either statins or LDL-C–lowering drug combinations. Moreover, this guideline for patients with atherosclerotic disease does not modify the recommendations of the 2004 ATP III update for patients without atherosclerotic disease who have diabetes or multiple risk factors and a 10-year risk level for CHD >20%. In the latter 2 types of high-risk patients, the recommended LDL-C goal of <100 mg/dL has not changed. Finally, to avoid any misunderstanding about cholesterol management in general, it must be emphasized that a reasonable cholesterol level of <70 mg/dL does not apply to other types of lower-risk individuals who do not have CHD or other forms of atherosclerotic disease; in such cases, recommendations contained in the 2004 ATP III update still pertain.

TABLE 1. AHA/ACC Secondary Prevention for Patients With Coronary and Other Vascular Disease: 2006 Update

Intervention Recommendations With Class of Recommendation and Level of Evidence
SMOKING:

Ask about tobacco use status at every visit. I (B)

Advise every tobacco user to quit. I (B)

Assess the tobacco user’s willingness to quit. I (B)

Assist by counseling and developing a plan for quitting. I (B)

Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion). I (B)

Urge avoidance of exposure to environmental tobacco smoke at work and home. I (B)

Goal
Complete cessation. No exposure to environmental tobacco smoke.
BLOOD PRESSURE CONTROL:For all patients:
Goal

Initiate or maintain lifestyle modification—weight control; increased physical activity; alcohol moderation; sodium reduction; and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. I (B)

<140/90 mm Hg
or
<130/80 mm Hg if patient has diabetes or chronic kidney disease
For patients with blood pressure ≥140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes):

As tolerated, add blood pressure medication, treating initially with β-blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve goal blood pressure. I (A)

[For compelling indications for individual drug classes in specific vascular diseases, see Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).]4
LIPID MANAGEMENT:For all patients:

Start dietary therapy. Reduce intake of saturated fats (to <7% of total calories), trans-fatty acids, and cholesterol (to <200 mg/d). I (B)

Adding plant stanol/sterols (2 g/d) and viscous fiber (>10 g/d) will further lower LDL-C.

Promote daily physical activity and weight management. I (B)

Encourage increased consumption of omega-3 fatty acids in the form of fishor in capsule form (1 g/d) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. IIb (B)

Goal
LDL-C <100 mg/dL
If triglycerides are ≥200 mg/dL, non-HDL-C should be <130 mg/dL
For lipid management:
Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiate lipid-lowering medication as recommended below before discharge according to the following schedule:

LDL-C should be <100 mg/dL I (A), and

Further reduction of LDL-C to <70 mg/dL is reasonable. IIa (A)

If baseline LDL-C is ≥100 mg/dL, initiate LDL-lowering drug therapy.§I (A)

If on-treatment LDL-C is ≥100 mg/dL, intensify LDL-lowering drug therapy (may require LDL-lowering drug combination). I (A)

If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. IIa (B)

If triglycerides are 200 to 499 mg/dL, non-HDL-C should be <130 mg/dL. I (B), and

Further reduction of non-HDL-C to <100 mg/dL is reasonable. IIa (B)

Therapeutic options to reduce non-HDL-C are:

More intense LDL-C–lowering therapy I (B), or

Niacin(after LDL-C–lowering therapy) IIa (B), or

Fibrate therapy## (after LDL-C–lowering therapy) IIa (B)

If triglycerides are ≥500 mg/dL#, therapeutic options to prevent pancreatitis are fibrateor niacinbefore LDL-lowering therapy; and treat LDL-C to goal after triglyceride-lowering therapy. Achieve non-HDL-C <130 mg/dL if possible. I (C)

PHYSICAL ACTIVITY:

For all patients, assess risk with a physical activity history and/or an exercise test, to guide prescription. I (B)

For all patients, encourage 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 lifestyle activities (eg, walking breaks at work, gardening, household work). I (B)

Encourage resistance training 2 days per week. IIb (C)

Advise medically supervised programs for high-risk patients (eg, recent acute coronary syndrome or revascularization, heart failure). I (B)

Goal
30 minutes, 7 days per week (minimum 5 days per week)
WEIGHT MANAGEMENT:

Assess body mass index and/or waist circumference on each visit and consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2. I (B)

If waist circumference (measured horizontally at the iliac crest) is ≥35 inches in women and ≥40 inches in men, initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. I (B)

The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. I (B)

Goal
Body mass index: 18.5 to 24.9 kg/m2
Waist circumference: men <40 inches, women <35 inches
DIABETES MANAGEMENT:

Initiate lifestyle and pharmacotherapy to achieve near-normal HbA1c. I (B)

Begin vigorous modification of other risk factors (eg, physical activity, weight management, blood pressure control, and cholesterol management as recommended above). I (B)

Coordinate diabetic care with patient’s primary care physician or endocrinologist. I (C)

Goal
HbA1c<7%
ANTIPLATELET AGENTS/ ANTICOAGULANTS:

Start aspirin 75 to 162 mg/d and continue indefinitely in all patients unless contraindicated. I (A)

For patients undergoing coronary artery bypass grafting, aspirin should be started within 48 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg/d appear to be efficacious. Doses higher than 162 mg/d can be continued for up to 1 year. I (B)

Start and continue clopidogrel 75 mg/d in combination with aspirin for up to 12 months in patients after acute coronary syndrome or percutaneous coronary intervention with stent placement (≥1 month for bare metal stent, ≥3 months for sirolimus-eluting stent, and ≥6 months for paclitaxel-eluting stent). I (B)

Patients who have undergone percutaneous coronary intervention with stent placement should initially receive higher-dose aspirin at 325 mg/d for 1 month for bare metal stent, 3 months for sirolimus-eluting stent, and 6 months for paclitaxel-eluting stent. I (B)

Manage warfarin to international normalized ratio=2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in post–myocardial infarction patients when clinically indicated (eg, atrial fibrillation, left ventricular thrombus). I (A)

Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely. I (B)

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM BLOCKERS:ACE inhibitors:

Start and continue indefinitely in all patients with left ventricular ejection fraction ≤40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. I (A)

Consider for all other patients. I (B)

Among lower-risk patients with normal left ventricular ejection fraction in whom cardiovascular risk factors are well controlled and revascularization has been performed, use of ACE inhibitors may be considered optional. IIa (B)

Angiotensin receptor blockers:

Use in patients who are intolerant of ACE inhibitors and have heart failure or have had a myocardial infarction with left ventricular ejection fraction ≤40%. I (A)

Consider in other patients who are ACE inhibitor intolerant. I (B)

Consider use in combination with ACE inhibitors in systolic-dysfunction heart failure. IIb (B)

Aldosterone blockade:

Use in post–myocardial infarction patients, without significant renal dysfunction⁎⁎or hyperkalemia††, who are already receiving therapeutic doses of an ACE inhibitor and β-blocker, have a left ventricular ejection fraction ≤40%, and have either diabetes or heart failure. I (A)

β-BLOCKERS:

Start and continue indefinitely in all patients who have had myocardial infarction, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated. I (A)

Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated. IIa (C)
INFLUENZA VACCINATION:Patients with cardiovascular disease should have an influenza vaccination. I (B)

⁎ Patients covered by these guidelines include those with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. Treatment of patients whose only manifestation of cardiovascular risk is diabetes will be the topic of a separate AHA scientific statement. ACE indicates angiotensin-converting enzyme.

† Non-HDL-C=total cholesterol minus HDL-C.

‡ Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.

§ When LDL-lowering medications are used, obtain at least a 30% to 40% reduction in LDL-C levels. If LDL-C <70 mg/dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C <70 mg/dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of >50% in LDL-C levels by either statins or LDL-C–lowering drug combinations.

∥ Standard dose of statin with ezetimibe, bile acid sequestrant, or niacin.

¶ The combination of high-dose statin+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.

# Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrant is relatively contraindicated when triglycerides are >200 mg/dL.

⁎⁎ Creatinine should be <2.5 mg/dL in men and <2.0 mg/dL in women.

†† Potassium should be <5.0 mEq/L.

TABLE 2. Classification of Recommendations and Level of Evidence

Classification of Recommendations
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.
Level of Evidence
Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies.
Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.

⁎ Classification of Recommendations and Level of Evidence are expressed in the ACC/AHA format and described in more detail in Table 3.

TABLE 3. Applying Classification of Recommendations and Level of Evidence

TABLE 3.

Trials involving other secondary prevention therapies also have influenced major practice guidelines used to formulate the recommendations in this update. Thus, specific recommendations for clopidogrel use in post–acute coronary syndrome or post–percutaneous coronary intervention–stented patients are now included in this 2006 update. The present update also recommends lower-dose aspirin for chronic therapy. The results of additional studies have further confirmed the benefit of aldosterone antagonist therapy among patients with impaired left ventricular function. Finally, recently published findings of a trial involving angiotensin-converting enzyme inhibitor therapy among patients at relatively low risk with stable coronary disease and normal left ventricular function influenced the recommendations (26).

The writing group has for the first time added a recommendation with regard to influenza vaccination. According to the US Centers for Disease Control and Prevention, vaccination with inactivated influenza vaccine is recommended for individuals who have chronic disorders of the cardiovascular system because they are at increased risk for complications from influenza (38).

The writing group emphasizes the importance of giving consideration to the use of cardiovascular medications that have been proved in randomized clinical trials to be of benefit. This strengthens the evidence-based foundation for therapeutic application of these guidelines. The committee acknowledges that ethnic minorities, women, and the elderly are underrepresented in many trials and urges physician and patient participation in trials that will provide additional evidence with regard to therapeutic strategies for these groups of patients.

In the 11 years since the guidelines were first published, 2 other developments have made them even more important in clinical care. First, the aging of the population continues to expand the number of patients living with a diagnosis of cardiovascular disease (now estimated at 13 million for coronary heart disease alone) who might benefit from these therapies. Second, multiple studies of the use of these recommended therapies in appropriate patients, although showing slow improvement, continue to support the discouraging conclusion that many patients in whom therapies are indicated are not receiving them in actual clinical practice. The AHA and ACC recommend the use of programs such as the AHA’s Get With The Guidelines (39) or the ACC’s Guidelines Applied to Practice (40) to identify appropriate patients for therapy, provide practitioners with useful reminders based on the guidelines, and continuously assess the success achieved in providing these therapies to the patients who can benefit from them.

Appendix

Appendix: References and Supplemental Search Criteria Used to Support Each Recommendation and Level of Evidence

RecommendationReferences and Supplemental Search Criteria
SMOKING:Primary reference(s) used: 2, 3, 21, 22
Supplemental search done? No
BLOOD PRESSURE:Primary reference(s) used: 2, 4
Supplemental search done? Yes
Database(s) used: PubMed and EMBASE for all English-language human studies
Key words:
PubMed: blood pressureOR hypertensionAND practice guidelinesand/or preventionand/or clinical trialand/or pharmacology
EMBASE: secondary preventionOR guidelinesAND blood pressureAND Cochrane reviewOR controlled clinical trialOR randomized controlled trialAND pharmacologyOR hypertensionAND Cochrane reviewOR controlled clinical trialOR randomized controlled trialAND pharmacology
Years searched: 2003–March 2005
Supplemental search did not alter recommendations.
LIPID MANAGEMENT:Primary reference(s) used: 2, 5, 7
Supplemental search done? Yes
Database used: PubMed for all English-language human studies
Key words: cholesterol/lipids/lipoproteinsAND clinical trialsand/or meta-analysisand/or practice guidelines
Years searched: 2002–November 2005
Supplemental search added references 6, 8–12, and 33–37and altered the recommendations.
PHYSICAL ACTIVITY:Primary reference(s) used: 2, 13–16, 21, 22
Supplemental search done? No
WEIGHT MANAGEMENT:Primary reference(s) used: 2, 17–19, 21, 22
Supplemental search done? No
DIABETES MANAGEMENT:Primary reference(s) used: 2, 20–22
Supplemental search done? No
ANTIPLATELET AGENTS/ANTICOAGULANTS:Primary reference(s) used: 2, 21–25, 27, 29
Supplemental search done? Yes, for use of ASA after CABG
Database(s) used: PubMed for all English-language studies
Key words: antiplatelet agents, coronary artery bypass graft patency
Years searched: 2000–March 2005
Supplemental search did not alter the recommendations.
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM BLOCKERS:Primary reference(s) used: 2, 21, 22, 27, 28
Supplemental search done? Yes
Database used: PubMed for all English-language studies
Key words: ACE inhibitoror angiotensin receptor antagonistor aldosterone antagonistAND clinical trialsand/or meta-analysisand/or practice guidelines
Years searched: 2003–March 2005
Supplemental search added references 25 and 30–32 and altered the recommendations.
β-BLOCKERS:Primary reference(s) used: 2, 21, 22, 27, 28
Supplemental search done? Yes
Database used: PubMed for all English-language studies
Key words: beta blockersAND clinical trialsand/or meta-analysisand/or practice guidelines
Years searched: 2002–March 2005
Supplemental search did not alter recommendations.
INFLUENZA VACCINATION:Primary reference(s) used: 38
Supplemental search done? No

Disclosures

Writing Group Disclosures

Writing Group MemberEmploymentResearch GrantOther Research SupportSpeakers Bureau/HonorariaOwnership InterestConsultant/Advisory BoardOther
Sidney C. Smith Jr, MDUniversity of North Carolina, Chapel HillNoneNoneHonoraria: Bayer, BMS, Sanofi-AventisNoneSanofi-Aventis, GlaxoSmithKline, Eli Lilly, Pfizer, MerckAstra-Zeneca (Data Safety Monitoring Board)
Jerilyn Allen, RN, ScDJohns Hopkins University, School of NursingNoneNoneNoneNoneBoard of Directors, Preventive Cardiovascular Nurses Association; Board of Directors, Southeast Lipid AssociationNone
Steven N. Blair, PEDCooper InstituteHealthTech, Jenny CraigNoneDonates all honoraria to The Cooper InstituteNoneMiavita, Life Fitness, Jenny CraigAll items listed pertain to the Cooper Institute. Does not personally receive money from any of these.
Robert O. Bonow, MDNorthwestern University, School of MedicineNoneNoneBristol-Myers Squibb Medical ImagingNoneBristol-Myers Squibb Medical Imaging, King PharmaceuticalsThese are no relationship to current writing committee; they are included for completeness.
Lawrence M. Brass, MDYale UniversityBristol-Myers Squibb, Sanofi/SynthelaboNoneBristol-Myers Squibb, Sanofi/Synthelabo, Solvay Pharmaceuticals, WyethNoneAstraZeneca, Bristol-Myers Squibb, Johnson&Johnson, Merck, ONO Pharmaceuticals, Sanofi/Synthelabo, Solvay Pharmaceuticals, WyethNone
Gregg C. Fonarow, MDUniversity of California, Los AngelesGlaxoSmithKline, Pfizer, MedtronicNoneGlaxoSmithKline, Pfizer, Merck–Schering Plough, Bristol-Myers Squibb–Sanofi, AstraZeneca, WyethNoneGlaxoSmithKline, Pfizer, Merck–Schering Plough, Bristol-Myers Squibb–Sanofi, AstraZeneca, WyethNone
Scott M. Grundy, MD, PhDUniversity of Texas SouthwesternAbbott, GlaxoSmithKlineDonald W. Reynolds Foundation, VA HospitalMerck, Schering-Plough, GlaxoSmithKline, Pfizer, Kos, Bristol-Myers Squibb, LillyNonePfizer, Sanofi-Aventis, Abbott, AstraZeneca, GlaxoSmithKlineNone
Loren Hiratzka, MDTriHealth, IncNoneNoneNoneNoneNoneNone
Daniel Jones, MDUniversity of Mississippi Medical CenterNoneNoneNoneNoneNoneNone
Harlan M. Krumholz, MDYale UniversityCV TherapeuticsNoneNoneNoneCV Therapeutics, VHA Inc (Consultant), United Healthcare (Advisory), CFMC (Clin Coordinator), MMS (Editorial Board)
Lori Mosca, MD, PhD, MPHNew York PresbyterianNIHPfizerKos, Abbott, AstraZeneca, Pfizer, Sanofi-AventisNoneKos, Pfizer, Sanofi-Aventis, Schering-PloughNone
Thomas Pearson, MD, MPH, PhDUniversity of RochesterWorld Heart Federation, Schering-Plough, Pfizer, Merck, Sanofi-AventisNoneKos, Abbott, AstraZeneca, Pfizer, Schering-Plough, Bayer, MerckNoneMeditech, Johnson&Johnson, Merck, Bayer, Sanofi-AventisNone
Marc A. Pfeffer, MD, PhDBrigham & Women’s HospitalAmgen, Atherogenics, Novartis, Bristol-Myers, Squibb, Sanofi-SynthelaboNoneNoneThe Brigham & Women’s Hospital has been awarded patents related to the use of inhibitors of the renin-angiotensin system in selected surviors. He is co-inventor. However, the licensing agreement is not linked to sales.AstraZeneca, Genzyme, Guidant, Mitsubishi, Abbott, Amgen, Bristol-Myers Squibb, CSL, Novartis, Sankyo, PfizerNone
Kathryn A. Taubert, PhDAmerican Heart AssociationNoneNoneNoneNoneNoneNone

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “Significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “Modest” if it is less than “Significant” under the preceding definition.

⁎ Modest

† Significant

Reviewers’ Disclosures

ReviewerEmploymentResearch GrantOther Research SupportSpeakers Bureau/HonorariaOwnership InterestConsultant/Advisory BoardOther
Jonathan Abrams, MDUniversity of New Mexico Health Science CenterNoneNoneNoneNoneNoneNone
Joseph Alpert, MDUniversity of Arizona Department of MedicineNoneNoneNoneNoneNoneNone
Jeffrey L. Anderson, MDLDS Hospital CardiologyBristol-Myers Squibb (grant pending)NoneBristol-Myers Squibb, Dia Dexus, Guilford, Merck, Johnson&Johnson/Merck, Merck-Schering, Sanofi-AventisNoneBristol-Myers Squibb, Guilford, Merck, Johnson&Johnson/Merck, Merck-ScheringNone
Eric R. Bates, MDUniversity of Michigan Medical CenterNoneNoneNoneNoneNoneNone
Vera Bittner, MDUniversity of Alabama at BirminghamNHLBI, Pfizer, AtheroGenicsNonePfizer, Merck, Kos, ReliantNoneCV Therapeutics, ReliantNone
Ann Bolger, MDUniversity of California San FranciscoNoneNoneNoneNoneNoneNone
Roger S. Blumenthal, MDJohns Hopkins HospitalMerck, PfizerNonePfizer, Merck, Astra Zeneca, Kos, Schering-PloughNoneNoneNone
Prakash Deedwania, MDUniversity of California San FranciscoPfizer, AstraZenecaNoneNoneNonePfizer, AstraZeneca, NovartisNone
Mark J. Eisenberg, MDMcGill UniversityNoneNoneNoneNoneNoneNone
Gerald Fletcher, MDMayo ClinicNoneNoneNoneNoneNoneNone
Alan D. Forker, MDSt. Lukes HospitalPfizer, Merck, Kos, Novartis, Sankyo, Bristol-Myers SquibbNonePfizer, Merck, TakedaNoneNoneNone
Timothy Gardner, MDClinical Practices of the University of PennsylvaniaNoneNoneNoneNoneNoneNone
Cindy L. Grines, MDWilliam Beaumont HospitalBerlex, Pfizer, GlaxoSmithKline, Aventis, Guidant Eli Lilly, SCIMED, Johnson&Johnson, Amersham Health, Otsuka, Esperion Therapeutics, Innercool Therapies, AstraZenecaNoneNoneNoneInnercool Therapies, Pfizer, Sanofi-Synthelabo, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, GlaxoSmithKline Global Cardiovascular Advisory BoardNone
Suzanne Hughes, MSN, RNNoneNoneKos PharmaceuticalsNoneGuidant Corporation, Johnson&Johnson MerckFreelance writer—honoraria paid by the ACCF; Associate Editor, CardiosourceNone
Edgar J. Kenton, MDLankenau HospitalNoneNoneNoneNoneNoneNone
Marian Limacher, MDUniversity of FloridaBoehringer IngelheimNIH, NHLBIKos PharmaceuticalsNoneNIH Advisory Committee on Research on Women’s HealthNone
Jonathan R. Lindner, MDUniversity of VirginiaNoneNoneNoneNoneNoneNone
Janet B. Long, MSN, ACNPUniversity Cardiology FoundationNoneNoneAstraZenecaNoneNoneNone
Patrick McBride, MDUniversity of Wisconsin Medical SchoolNoneNoneKos, Merck, Pfizer, Sanyko, Schering PloughNoneMerckNone
Dale Owen, MDNoneNoneNoneNoneNoneNoneNone
Rita F. Redberg, MD, MScNoneNoneNoneNoneNoneNoneNone
Samuel J. Shubrooks, Jr, MDHarvard Medical SchoolNoneNoneNoneNoneNoneNone
Robert A. Vogel, MDUniversity of Maryland HospitalPfizer, Novartis, Schering-PloughNonePfizer, MerckNoneNoneNone

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.

  • 1. Smith S.C., Blair S.N., Bonow R.O.et al. : "AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology". Circulation 2001; 104: 1577.

    CrossrefMedlineGoogle Scholar
  • 2. Mosca L., Appel L.J., Benjamin E.J., et al. and American Heart Association : "Evidence-based guidelines for cardiovascular disease prevention in women". Circulation 2004; 109: 672.

    CrossrefMedlineGoogle Scholar
  • 3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; May 27, 2004. Available at: http://www.surgeongeneral.gov/library/smokingconsequences. Accessed March 15, 2006.

    Google Scholar
  • 4. Chobanian A.V., Bakris G.L., Black H.R., et al., Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National Heart, Lung, and Blood Institute and National High Blood Pressure Education Program Coordinating Committee : "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension 2003; 42: 1206.

    CrossrefMedlineGoogle Scholar
  • 5. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults : "Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)". JAMA 2001; 285: 2486.

    CrossrefMedlineGoogle Scholar
  • 6. Grundy S.M., Cleeman J.I., Merz C.N., et al., National Heart, Lung, and Blood Institute, American College of Cardiology Foundation and American Heart Association : "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines". Circulation 2004; 110: 227. Erratum in: Circulation2004;110:763.

    CrossrefMedlineGoogle Scholar
  • 7. Kris-Etherton P.M., Harris W.S., Appel L.J., American Heart Association and Nutrition Committee : "Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease". Circulation 2002; 106: 2747. Erratum in: Circulation2003;107:512.

    CrossrefMedlineGoogle Scholar
  • 8. LaRosa J.C., Grundy S.M., Waters D.D., et al. and Treating to New Targets (TNT) Investigators : "Intensive lipid lowering with atorvastatin in patients with stable coronary disease". N Engl J Med 2005; 352: 1425.

    CrossrefMedlineGoogle Scholar
  • 9. Pedersen T.R., Faergeman O., Kastelein J.J., et al. and Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study Group : "High-dose atorvastatin vs usual-dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial". JAMA 2005; 294: 2437. Erratum in: JAMA2005;294:3092.

    CrossrefMedlineGoogle Scholar
  • 10. Baigent C., Keech A., Kearney P.M., et al. and Cholesterol Treatment Trialists’ (CTT) Collaborators : "Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins". Lancet 2005; 366: 1267. Erratum in: Lancet2005;366:1358.

    CrossrefMedlineGoogle Scholar
  • 11. Ballantyne C.M., Abate N., Yuan Z., King T.R. and Palmisano J. : "Dose-comparison study of the combination of ezetimibe and simvastatin (Vytorin) versus atorvastatin in patients with hypercholesterolemia: the Vytorin Versus Atorvastatin (VYVA) study". Am Heart J 2005; 149: 464. Erratum in: Am Heart J2005;149:882.

    CrossrefMedlineGoogle Scholar
  • 12. de Lemos J.A., Blazing M.A., Wiviott S.D., et al. and A to Z Investigators : "Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial". JAMA 2004; 292: 1307.

    CrossrefMedlineGoogle Scholar
  • 13. Thompson P.D., Buchner D., Pina I.L., et al., American Heart Association Council on Clinical Cardiology Subcommittee on Exercise, Rehabilitation, and Prevention and American Heart Association Council on Nutrition, Physical Activity, and Metabolism Subcommittee on Physical Activity : "Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity)". Circulation 2003; 107: 3109.

    CrossrefMedlineGoogle Scholar
  • 14. UK Department of Health. At Least Five a Week: Evidence on the Impact of Physical Activity and Its Relationship to Health: A Report From the Chief Medical Officer.London, England: Wellington House; April 29, 2004. Available at: http://www.dh.gov.uk/assetRoot/04/08/09/81/04080981.pdf. Accessed March 15, 2006.

    Google Scholar
  • 15. Pate R.R., Pratt M., Blair S.N.et al. : "Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine". JAMA 1995; 273: 402.

    CrossrefMedlineGoogle Scholar
  • 16. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General.Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. Available at: http://www.cdc.gov/nccdphp/sgr/summary.htm. Accessed March 15, 2006.

    Google Scholar
  • 17. National Institutes of Health; National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. National Institutes of Health; National Heart, Lung, and Blood Institute; September 1998. Publication No. 98-4083. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed March 15, 2006.

    Google Scholar
  • 18. Klein S., Burke L.E., Bray G.A., et al. and American Heart Association Council on Nutrition, Physical Activity, and Metabolism : "Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation". Circulation 2004; 110: 2952.

    CrossrefMedlineGoogle Scholar
  • 19. Grundy S.M., Cleeman J.I., Daniels S.R., et al. and American Heart Association; National Heart, Lung, and Blood Institute : "Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement". Circulation 2005; 112: 2735. Errata in: Circulation2005;112:e297; Circulation2005;112:e298.

    CrossrefMedlineGoogle Scholar
  • 20. American Diabetes Association : "Standards of medical care in diabetes". Diabetes Care 2004; 27: S15.

    CrossrefMedlineGoogle Scholar
  • 21. Antman E.M., Anbe D.T., Armstrong P.W., et al., American College of Cardiology, American Heart Association Task Force on Practice Guidelines and Canadian Cardiovascular Society : "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation 2004; 110: e82. Erratum in: Circulation2005;111:2013–4.

    MedlineGoogle Scholar
  • 22. Gibbons R.J., Abrams J., Chatterjee K., et al., American College of Cardiology, American Heart Association Task Force on Practice Guidelines and Committee on the Management of Patients With Chronic Stable Angina : "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina)". Circulation 2003; 107: 149.

    CrossrefMedlineGoogle Scholar
  • 23. Smith S.C., Feldman T.E., Hirshfeld J.W.et al. : "ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)". Circulation 2006; 113: e166. Available at: http://circ.ahajournals.org/cgi/reprint/113/7/e166. Accessed March 15, 2006.

    MedlineGoogle Scholar
  • 24. Eagle K.A., Guyton R.A., Davidoff R., et al. and American College of Cardiology; American Heart Association : "ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery)". Circulation 2004; 110: e340. Erratum in: Circulation2005;111:2014.

    MedlineGoogle Scholar
  • 25. Ferraris V.A., Ferraris S.P., Moliterno D.J., et al. and Society of Thoracic Surgeons : "The Society of Thoracic Surgeons practice guideline series: aspirin and other antiplatelet agents during operative coronary revascularization (executive summary)". Ann Thorac Surg 2005; 79: 1454.

    CrossrefMedlineGoogle Scholar
  • 26. Braunwald E., Domanski M.J., Fowler S.E., et al. and PEACE Trial Investigators : "Angiotensin-converting-enzyme inhibition in stable coronary artery disease". N Engl J Med 2004; 351: 2058.

    CrossrefMedlineGoogle Scholar
  • 27. Braunwald E., Antman E.M., Beasley J.W., et al., American College of Cardiology, American Heart Association and Committee on the Management of Patients With Unstable Angina : "ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)". J Am Coll Cardiol 2002; 40: 1366.

    View ArticleGoogle Scholar
  • 28. Hunt S.A., Abraham W.T., Chin M.H., et al., American College of Cardiology, American Heart Association Task Force on Practice Guidelines, American College of Chest Physicians, International Society for Heart and Lung Transplantation and Heart Rhythm Society : "ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society". Circulation 2005; 112: e154.

    MedlineGoogle Scholar
  • 29. Coull B.M., Williams L.S., Goldstein L.B., et al., Joint Stroke Guideline Development Committee of the American Academy of Neurology and American Stroke Association : "Anticoagulants and antiplatelet agents in acute ischemic stroke: report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a division of the American Heart Association)". Stroke 2002; 33: 1934.

    CrossrefMedlineGoogle Scholar
  • 30. Pfeffer M.A., McMurray J.J., Velazquez E.J., et al. and Valsartan in Acute Myocardial Infarction Trial Investigators : "Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both". N Engl J Med 2003; 349: 1893. Erratum in: N Engl J Med2004;350:203.

    CrossrefMedlineGoogle Scholar
  • 31. McMurray J.J., Ostergren J., Swedberg K., et al. and CHARM Investigators and Committees : "Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial". Lancet 2003; 362: 767.

    CrossrefMedlineGoogle Scholar
  • 32. Granger C.B., McMurray J.J., Yusuf S., et al. and CHARM Investigators and Committees : "Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial". Lancet 2003; 362: 772.

    CrossrefMedlineGoogle Scholar
  • 33. Cannon C.P., Braunwald E., McCabe C.H., et al. and Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators : "Intensive versus moderate lipid lowering with statins after acute coronary syndromes". N Engl J Med 2004; 350: 1495. Erratum in: N Engl J Med2006;354:778.

    CrossrefMedlineGoogle Scholar
  • 34. Heart Protection Study Collaborative Group : "MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial". Lancet 2002; 360: 7. Summary for patients in: Curr Cardiol Rep2002;4:486–7.

    CrossrefMedlineGoogle Scholar
  • 35. Shepherd J., Blauw G.J., Murphy M.B., et al. and PROSPER Study Group : "PROspective Study of Pravastatin in the Elderly at Risk. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial". Lancet 2002; 360: 1623.

    CrossrefMedlineGoogle Scholar
  • 36. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group : "The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT)". JAMA 2002; 288: 2998.

    CrossrefMedlineGoogle Scholar
  • 37. Sever P.S., Dahlof B., Poulter N.R., et al. and ASCOT investigators : "Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial". Lancet 2003; 361: 1149.

    MedlineGoogle Scholar
  • 38. Harper S.A., Fukuda K., Uyeki T.M., Cox N.J., Bridges C.B., Advisory Committee on Immunization Practices (ACIP) and Centers for Disease Control and Prevention (CDC) : "Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP)". MMWR Recomm Rep 2005; 54: 1. Erratum in: MMWR Morb Mortal Wkly Rep2005;54(30):750.

    MedlineGoogle Scholar
  • 39. LaBresh K.A., Ellrodt A.G., Gliklich R., Liljestrand J. and Peto R. : "Get with the guidelines for cardiovascular secondary prevention: pilot results". Arch Intern Med 2004; 164: 203.

    CrossrefMedlineGoogle Scholar
  • 40. Mehta R.H., Montoye C.K., Gallogly M., et al. and GAP Steering Committee of the American College of Cardiology : "Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative". JAMA 2002; 287: 1269.

    CrossrefMedlineGoogle Scholar

Footnotes

This document was approved by the American Heart Association Science Advisory and Coordinating Committee on November 11, 2005, and by the American College of Cardiology Foundation Board of Trustees on November 10, 2005.

The American Heart Association and American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur. The relationships with industry for writing committee members, as well as peer reviewers of the document, are located before the references.

When this document is cited, the American College of Cardiology requests that the following citation format be used: Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, Grundy SM, Hiratzka L, Jones D, Krumholz HM, Mosca L, Pasternak RC, Pearson T, Pfeffer MA, Taubert KA. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol2006;47:2130–9. doi:10.1016/j.jacc.2006.04.026.

This article has been copublished in the May 16, 2006, issue of the Circulation(Circulation 2006;113).

Copies: This document is available on the World Wide Web sites of the American Heart Association ( www.americanheart.org) and the American College of Cardiology ( www.acc.org). A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0361. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail [email protected]. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.