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首页 > 2011年美国冠状动脉及其他动脉粥样硬化性血管疾病的二级预防和风险降低治疗指南

2011年美国冠状动脉及其他动脉粥样硬化性血管疾病的二级预防和风险降低治疗指南

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2011年美国冠状动脉及其他动脉粥样硬化性血管疾病的二级预防和风险降低治疗指南 Taubert Eric D. Peterson, Ralph L. Sacco, John Spertus, James H. Stein and Kathryn A. Hiratzka, Daniel W. Jones, Donald M. Lloyd-Jones, Margo Minissian, Lori Mosca, Creager, Barry A. Franklin, Raymond J. Gibbons, Scott M. Grundy, Loren F. Sidney C. Smith, Jr, E...
2011年美国冠状动脉及其他动脉粥样硬化性血管疾病的二级预防和风险降低治疗指南
Taubert Eric D. Peterson, Ralph L. Sacco, John Spertus, James H. Stein and Kathryn A. Hiratzka, Daniel W. Jones, Donald M. Lloyd-Jones, Margo Minissian, Lori Mosca, Creager, Barry A. Franklin, Raymond J. Gibbons, Scott M. Grundy, Loren F. Sidney C. Smith, Jr, Emelia J. Benjamin, Robert O. Bonow, Lynne T. Braun, Mark A. Cardiology Foundation Guideline From the American Heart Association and American College of With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update : A AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients ISSN: 1524-4539 Copyright © 2011 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX published online November 3, 2011Circulation http://circ.ahajournals.org/content/early/2011/11/01/CIR.0b013e318235eb4d.citation located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org//subscriptions/ Subscriptions: Information about subscribing to Circulation is online at at Pfizer DIS on November 27, 2011http://circ.ahajournals.org/Downloaded from AHA/ACCF Guideline AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update A Guideline From the American Heart Association and American College of Cardiology Foundation Endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association Sidney C. Smith, Jr, MD, FAHA, FACC, Chair; Emelia J. Benjamin, MD, ScM, FAHA, FACC; Robert O. Bonow, MD, FAHA, FACC; Lynne T. Braun, PhD, ANP, FAHA; Mark A. Creager, MD, FAHA, FACC; Barry A. Franklin, PhD, FAHA; Raymond J. Gibbons, MD, FAHA, FACC; Scott M. Grundy, MD, PhD, FAHA; Loren F. Hiratzka, MD, FAHA, FACC; Daniel W. Jones, MD, FAHA; Donald M. Lloyd-Jones, MD, ScM, FAHA, FACC; Margo Minissian, ACNP, AACC, FAHA; Lori Mosca, MD, PhD, MPH, FAHA; Eric D. Peterson, MD, MPH, FAHA, FACC; Ralph L. Sacco, MD, MS, FAHA; John Spertus, MD, MPH, FAHA, FACC; James H. Stein, MD, FAHA, FACC; Kathryn A. Taubert, PhD, FAHA Since the 2006 update of the American Heart Association(AHA)/American College of Cardiology Foundation (ACCF) guidelines on secondary prevention,1 important evi- dence from clinical trials has emerged that further supports and broadens the merits of intensive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral artery disease, atheroscle- rotic aortic disease, and carotid artery disease. In reviewing this evidence and its clinical impact, the writing group believed it would be more appropriate to expand the title of this guideline to “Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease.” Indeed, the growing body of evidence confirms that in patients with atherosclerotic vascular disease, comprehensive risk factor management reduces risk as assessed by a variety of outcomes, including improved survival, reduced recurrent events, the need for revascularization procedures, and improved quality of life. It is important not only that the healthcare provider implement these recommendations in appropriate patients but also that healthcare systems support this implementation to maximize the benefit to the patient. Compelling evidence-based results from recent clinical trials and revised practice guidelines provide the impetus for this update of the 2006 recommendations with evidence-based re- sults2–165 (Table 1). Classification of recommendations and level of evidence are expressed in ACCF/AHA format, as detailed in Table 2. Recommendations made herein are largely based on major practice guidelines from the National Institutes of Health and updated ACCF/AHA practice guidelines, as well as on results from recent clinical trials. Thus, the development of the present guideline involved a process of partial adaptation of other guideline statements and reports and supplemental litera- The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This document was approved by the American Heart Association Science Advisory and Coordinating Committee on October 5, 2011, and by the American College of Cardiology Foundation Board of Trustees on September 29, 2011. The American Heart Association requests that this document be cited as follows: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:●●●–●●●. Copies: This document is available on the World Wide Web site of the American Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/ Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. (Circulation. 2011;124:00-00.) © 2011 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e318235eb4d 1 at Pfizer DIS on November 27, 2011http://circ.ahajournals.org/Downloaded from Table 1. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update: Intervention Recommendations With Class of Recommendation and Level of Evidence Area for Intervention Recommendations Smoking Goal: Complete cessation. No exposure to environmental tobacco smoke Class I 1. Patients should be asked about tobacco use status at every office visit.2,3,4,5,7 (Level of Evidence: B) 2. Every tobacco user should be advised at every visit to quit.4,5,7,9 (Level of Evidence: A) 3. The tobacco user’s willingness to quit should be assessed at every visit. (Level of Evidence: C) 4. Patients should be assisted by counseling and by development of a plan for quitting that may include pharmacotherapy and/or referral to a smoking cessation program.4–9 (Level of Evidence: A) 5. Arrangement for follow up is recommended. (Level of Evidence: C) 6. All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at work, home, and public places.10,11 (Level of Evidence: B) Blood pressure control Goal: �140/90 mm Hg Note: The writing committee did not think that the 2006 recommendations for blood pressure control (below) should be modified at this time. The writing committee anticipates that the recommendations will be reviewed when the updated JNC guidelines are released. Class I 1. All patients should be counseled regarding the need for 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.12–16 (Level of Evidence: B) 2. Patients with blood pressure �140/90 mm Hg should be treated, as tolerated, with blood pressure medication, treating initially with �-blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve goal blood pressure.12,17,18 (Level of Evidence: A) Lipid management Goal: Treatment with statin therapy; use statin therapy to achieve an LDL-C of �100 mg/dL; for very high risk* patients an LDL-C �70 mg/dL is reasonable; if triglycerides are �200 mg/dL, non–HDL-C† should be �130 mg/dL, whereas non–HDL-C �100 mg/dL for very high risk patients is reasonable Note: The writing committee anticipates that the recommendations will be reviewed when the updated ATP guidelines are released. Class I 1. A lipid profile in all patients should be established, and for hospitalized patients, lipid-lowering therapy as recommended below should be initiated before discharge.20 (Level of Evidence: B) 2. Lifestyle modifications including daily physical activity and weight management are strongly recommended for all patients.19,29 (Level of Evidence: B) 3. Dietary therapy for all patients should include reduced intake of saturated fats (to �7% of total calories), trans fatty acids (to �1% of total calories), and cholesterol (to �200 mg/d).21–24,29 (Level of Evidence: B) 4. In addition to therapeutic lifestyle changes, statin therapy should be prescribed in the absence of contraindications or documented adverse effects.25–29 (Level of Evidence: A) 5. An adequate dose of statin should be used that reduces LDL-C to �100 mg/dL AND achieves at least a 30% lowering of LDL-C.25–29 (Level of Evidence: C) 6. Patients who have triglycerides �200 mg/dL should be treated with statins to lower non–HDL-C to �130 mg/dL.25–27,30 (Level of Evidence: B) 7. Patients who have triglycerides �500 mg/dL should be started on fibrate therapy in addition to statin therapy to prevent acute pancreatitis. (Level of Evidence: C) Class IIa 1. If treatment with a statin (including trials of higher-dose statins and higher-potency statins) does not achieve the goal selected for a patient, intensification of LDL-C–lowering drug therapy with a bile acid sequestrant‡ or niacin§ is reasonable.31–33 (Level of Evidence: B) 2. For patients who do not tolerate statins, LDL-C–lowering therapy with bile acid sequestrants‡ and/or niacin§ is reasonable.35,36 (Level of Evidence: B) 3. It is reasonable to treat very high-risk patients* with statin therapy to lower LDL-C to �70 mg/dL.26–28,37,38,166 (Level of Evidence: C) 4. In patients who are at very high risk* and who have triglycerides �200 mg/dL, a non–HDL-C goal of �100 mg/dL is reasonable.25–27,30 (Level of Evidence: B) (Continued) 2 Circulation November 29, 2011 at Pfizer DIS on November 27, 2011http://circ.ahajournals.org/Downloaded from Table 1. Continued Area for Intervention Recommendations Lipid management cont’d Class IIb 1. The use of ezetimibe may be considered for patients who do not tolerate or achieve target LDL-C with statins, bile acid sequestrants,‡ and/or niacin.§ (Level of Evidence: C) 2. For patients who continue to have an elevated non–HDL-C while on adequate statin therapy, niacin§ or fibrate� therapy32,35,41 (Level of Evidence: B) or fish oil (Level of Evidence: C) may be reasonable. 3. For all patients, it may be reasonable to recommend omega-3 fatty acids from fish¶ or fish oil capsules (1 g/d) for cardiovascular disease risk reduction.44–46 (Level of Evidence: B) Physical activity Class I Goal: At least 30 minutes, 7 days per week (minimum 5 days per week) 1. For all patients, the clinician should encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, at least 5 days and preferably 7 days per week, supplemented by an increase in daily lifestyle activities (eg, walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least fit, least active high-risk cohort (bottom 20%).54,55,58 (Level of Evidence: B) 2. For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription.47–52,58 (Level of Evidence: B) 3. The clinician should counsel patients to report and be evaluated for symptoms related to exercise. (Level of Evidence: C) Class IIa 1. It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week.59 (Level of Evidence: C) Weight management Class I Goals: Body mass index: 18.5 to 24.9 kg/m2 Waist circumference: women �35 inches (�89 cm), men �40 inches (�102 cm) 1. Body mass index and/or waist circumference should be assessed at every visit, and the clinician should consistently encourage weight maintenance/reduction through an appropriate balance of lifestyle physical activity, structured exercise, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m2.60–62,65–70 (Level of Evidence: B) 2. If waist circumference (measured horizontally at the iliac crest) is �35 inches (�89 cm) in women and �40 inches (�102 cm) in men, therapeutic lifestyle interventions should be intensified and focused on weight management.66–70 (Level of Evidence: B) 3. The initial goal of weight loss therapy should be to reduce body weight by approximately 5% to 10% from baseline. With success, further weight loss can be attempted if indicated. (Level of Evidence: C) Type 2 diabetes mellitus management Note: Recommendations below are for prevention of cardiovascular complications. Class I 1. Care for diabetes should be coordinated with the patient’s primary care physician and/or endocrinologist. (Level of Evidence: C) 2. Lifestyle modifications including daily physical activity, weight management, blood pressure control, and lipid management are recommended for all patients with diabetes.19,22-24,29,56,58,59,62,66,74,162 (Level of Evidence: B) Class IIa 1. Metformin is an effective first-line pharmacotherapy and can be useful if not contraindicated.74–76 (Level of Evidence: A) 2. It is reasonable to individualize the intensity of blood sugar–lowering interventions based on the individual patient’s risk of hypoglycemia during treatment. (Level of Evidence: C) Class IIb 1. Initiation of pharmacotherapy interventions to achieve target HbA1c may be reasonable.71,72,74-80 (Level of Evidence: A) 2. A target HbA1c of �7% may be considered. (Level of Evidence: C) 3. Less stringent HbA1c goals may be considered for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbidities, or those in whom the goal is difficult to attain despite intensive therapeutic interventions. (Level of Evidence: C) Antiplatelet agents/anticoagulants Class I 1. Aspirin 75–162 mg daily is recommended in all patients with coronary artery disease unless contraindicated.64,81,82,116 (Level of Evidence: A) ● Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin.117 (Level of Evidence: B) 2. A P2Y12 receptor antagonist in combination with aspirin is indicated in patients after ACS or PCI with stent placement.83–85 (Level of Evidence: A) ● For patients receiving a bare-metal stent or drug-eluting stent during PCI for ACS, clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily should be given for at least 12 months.84,86,113,114 (Level of Evidence: A) (Continued) Smith et al AHA/ACCF Secondary Prevention: 2011 Update 3 at Pfizer DIS on November 27, 2011http://circ.ahajournals.org/Downloaded from Table 1. Continued Area for Intervention Recommendations Antiplatelet agents/anticoagulants cont’d 3. For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg daily for 1 year appear to be efficacious.87–90 (Level of Evidence: A) 4. In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75–325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily, respectively) should be started and continued.91,104,116 (Level of Evidence: B) 5. For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with aspirin (75–325 mg daily) or clopidogrel (75 mg daily) should be started and continued.92,107,116,117 (Level of Evidence: A) 6. Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis.93,94,105,110 (Level of Evidence: A) ● If there is a compelling indication for anticoagulant therapy, such as atrial fibrillation, prosthetic heart valve, left ventricular thrombus, or concomitant venous thromboembolic disease, warfarin should be administered in addition to the low-dose aspirin (75–81 mg daily).95,99–102 (Level of Evidence: A) ● For patients requiring warfarin, therapy should be administered to achieve the recommended INR for the specific condition.81,96 (Level of Evidence: B) ● Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely.97,98,110 (Level of Evidence: A) Class IIa 1. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by thienopyridine therapy after stent implantation, earlier discontinuation (eg, �12 months) is reasonable. (Level of Evidence: C) (Note: the risk for serious cardiovascular events because of early discontinuation of thienopyridines is greater for patients with drug-eluting stents than those with bare-metal stents.) 2. After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses.84,85,118–122 (Level of Evidence: B) 3. For patients undergoing coronary artery bypass grafting, clopidogrel (75 mg daily) is a reasonable alternative in patients who are intolerant of or allergic to aspirin. (Level of Evidence: C) Class IIb 1. The benefits of aspirin in patients with asymptomatic peripheral artery disease of the lower extremities are not well established.108,109 (Level of Evidence: B) 2. Combination therapy with both aspirin 75 to 162 mg daily and clopidogrel 75 mg daily may be considered in patients with stable coronary artery disease.112 (Level of Evidence: B) Renin-angiotensin-aldosterone system blockers ACE inhibitors Class I 1. ACE inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction �40% and in those with hypertension, diabetes, or chronic kidney disease, unless contraindicated.124,125 (Level of Evidence: A) Class IIa 1. It is reasonable to use ACE inhibitors in all other patients.126 (Level of Evidence: B) ARBs Class I 1. The use of ARBs is recommended in patients who have heart failure or who have had a myocardial infarction with left ventricular ejection fraction �40% and who are ACE-inhibitor
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