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
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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
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Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
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(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)
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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)
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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