“That's why the committee has said that in patients with normal left ventricular function, all patients should be considered as candidates but among those who have undergone revascularization therapy or who have a high use of other therapies known to reduce risk, it's reasonable not to place them on ACE inhibitors,” Dr. Smith said.
▸ β-Blockers. β-Blockers should be started and indefinitely continued in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms unless contraindicated.
Other updated recommendations include the more stringent management of the following risk factors:
▸ Blood pressure control. The aim is to keep patients' blood pressure under 140/90 mm Hg or less than 130/80 mm Hg in patients with diabetes or chronic kidney disease through lifestyle modification. In patients who do not meet this goal, blood pressure medication should be added as tolerated. Initially treatment should be with β-blockers and/or ACE inhibitors, adding other drugs such as thiazides as needed to achieve target blood pressure.
▸ Physical activity. The goal is 30–60 minutes of moderate-intensity aerobic activity 5–7 days per week, up from 3–4 days per week, supplemented by an increase in daily lifestyle activities, such as housework and gardening, and resistance training 2 days per week.
▸ Smoking. Not only should patients completely stop smoking but they also should not be exposed to any environmental tobacco smoke.
▸ Weight management. Not only should patients aim for a BMI between 18.5 and 24.9, but also a waist circumference of less than 40 inches for men and less than 35 inches for women. If waist circumference exceeds these values, patients should initiate lifestyle changes and physicians should consider treatment strategies for metabolic syndrome. The initial goal of weight loss should be to reduce body weight by roughly 10% from baseline. Once this goal has been met, further weight loss can be attempted if indicated.
▸ Flu vaccine. All patients with cardiovascular disease should receive inactivated influenza vaccinations because these individuals are at increased risk for complications from influenza.
The guidelines make a point of noting that ethnic minorities, women, and the elderly are underrepresented in many trials and urge greater participation by these populations in clinical trials to provide additional evidence about the best therapeutic strategies for these groups.
“Having worked in this area for 15 years … I think that it is very important that trials include older patients, that the trials include a high percentage of women … and that they recruit ethnic minorities, because I think that even though it seems logical to assume that the therapies may work, we need the evidence to really strengthen the basis for these recommendations,” Dr. Smith said.
The complete guidelines are available in the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2006; 47:2130–2139).