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The Evidence for Current Cardiovascular Disease
Prevention Guidelines:
Lifestyle Management Evidence and Guidelines
American College of Cardiology Best Practice Quality Initiative Subcommittee
and Prevention Committee
Classification of Classification of Recommendations and Levels Recommendations and Levels of Evidenceof 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.
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
Icons Representing the Classification and Icons Representing the Classification and Evidence Levels for RecommendationsEvidence Levels for Recommendations
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence and GuidelinesEvidence and Guidelines
Evidence for Current Cardiovascular Evidence for Current Cardiovascular Disease Disease
Prevention GuidelinesPrevention Guidelines
Smoking Prevalence in the United Smoking Prevalence in the United StatesStates
Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161
National Health Interview SurveyEstimated percentage of current smokers in the United
States by sex
There has been a decrease in the prevalence of cigarette smoking in men and women over time
Causes # (%) in 1990 # (%) in 2000
Tobacco 400,000 (19) 435,000 (18)
Poor diet and physical activity (obesity)
300,000 (14) 400,000 (17)
Alcohol consumption 100,000 (5) 85,000 (4)
Microbial agents 90,000 (4) 75,000 (3)
Toxic agents 60,000 (3) 55,000 (2)
Motor vehicle accidents 25,000 (1) 43,000 (2)
Firearms 35,000 (2) 29,000 (1)
Sexual behavior 30,000 (1) 20,000 (<1)
Illicit drug use 20,000 (<1) 17,000 (<1)
Total 1,060,000 (50*) 1,159,000 (48%*)
Source: Mokdad AH et al. JAMA 2004;291:1238-1245
Tobacco Use: Tobacco Use: Most Preventable Cause of DeathMost Preventable Cause of Death
Most preventable causes of death in the U.S. in 1990 and 2000
*Reflects percent total of 9 most preventable causes of death
0.1 1.0 10Ceased smoking Continued smoking
RR (95% Cl)Study
Aberg, et al. 1983 0.67(0.53-0.84)
Herlitz, et al. 1995 0.99(0.42-2.33)
Johansson, et al. 1985 0.79 (0.46-1.37)
Perkins, et al. 1985 3.87(0.81-18.37)
Sato, et al. 1992 0.10(0.00-1.95)
Sparrow, et al. 1978 0.76(0.37-1.58)
Vlietstra, et al. 1986 0.63(0.51-0.78)
Voors, et al. 1996 0.54(0.29-1.01)
Source: Critchley JA et al. JAMA 2003;290:86-97
*Includes those with known coronary heart disease
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Risk of Non-fatal Myocardial Risk of Non-fatal Myocardial Infarction*Infarction*
Abst
inence
rate
s (%
)
Self-help materials tailored for the needs of individual smokers are more effective than usual materials
Source: Sutton S et al. Addiction 2007;102:994-1000.
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Tailored MaterialsTailored Materials
0
5
10
15
20
25
30
35
24 hour
Duration of abstinence
Usual careTailored care
15.4
20.9
12.7
18.9
11.3
16.4
9.012.2
7 day 1 month 3 month
p=0.015 p=0.004p=0.013
p=0.080
1058 current and recent ex-smokers randomized to a smoking cessation strategy of usual care* vs. computed-generated tailored
advice**
*Usual care consists of telephone counselling and a mailed information packet**Tailored care consists of usual care + a computer-generated individually tailored advice letter
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Effect of Counseling Intervention Effect of Counseling Intervention
Intensity 1: Contact in hospital of <15 minutes only
Intensity 2: Contact in hospital of >15 minutes only
Intensity 3: Any hospital contact plus postdischarge support of <1 month
Intensity 4: Any hospital contact plus postdischarge support of >1 month
Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation counseling interventions with or without pharmacotherapy
Inpatient counseling with contact >1 month after discharge is associated with the greatest rate of smoking cessation
Percent Reporting >1 Indicators of Nicotine Dependence, by Age and Intensity of Smoking
Source: Substance Abuse and Mental Health Services Administration; United States, 2010 National Survey.
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Frequency of Nicotine DependenceFrequency of Nicotine Dependence
12-24 Years Old 25+ Years Old
Less than 6* 6-15* 16-25* 26+*
*Cigarettes per day
Minutes
CigaretteGum 4 mg
Gum 2 mg
Inhaler
Nasal sprayPatch
5 10 15 20 25 30
0
2
4
6
8
10
12
14
Source: Balfour DJ et al. Pharmacol Ther 1996;72:51-81
Incr
ease
in n
icoti
ne c
once
ntr
ati
on
(ng/m
l)Plasma nicotine concentrations
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Types of Nicotine ReplacementTypes of Nicotine Replacement
Limited Behavioral Support
Intervention Effect Size 95% CI
Nicotine gum 5% 4-6%
Nicotine transdermal patch
5% 4-7%
Intervention Effect Size 95% CI
Nicotine gum 8% 6-10%
Nicotine transdermal patch
6% 5-8%
Nicotine nasal spray 12% 7-17%
Nicotine inhaler 8% 4-12%
Nicotine sublingual tablet 8% 1-14%
Intensive Behavioral Support
Sources: West R et al. Thorax 2000;55:987-999
Silagy C et al. Cochrane Database Syst Rev 2002;CD000146
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Effect of Combination TherapyEffect of Combination Therapy
CI=Confidence interval
Source: Jorenby DE et al. NEJM 1999;340:685-691
Placebo (n=160)
NRT (n=244)
Bupropion (n=244)
Nicotine patch and Bupropion (n=245)
Abstinence rate at 6 months
18.8% 21.3% 34.8%a,b 38.8%a,c,d
Abstinence rate at 12 months
15.6% 16.4% 30.3%a,c 35.5%a,c,e
ap<0.001 when compared to placebobp=0.001 when compared to NRTcp<0.001 when compared to NRT
dp=0.37 when compared to bupropionep=0.22 when compared to bupropion
NRT=Nicotine replacement therapy
Bupropion with or without NRT provides the greatest benefit
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Primary PreventionPrimary Prevention893 smokers randomized to 9 weeks of bupropion (150 mg daily for 3 days and then 150 mg bid), NRT (21 mg patch weeks 2-7, 14 mg patch week 8, and 7 mg patch week 9), bupropion and NRT, or
placebo
Source: Jorenby DE et al. JAMA 2006;296:56-63
Varenicline vs. Bupropion P<0.001 (weeks 9-12), P=0.004 (weeks
9-52)
Cigarette Smoking Cessation Cigarette Smoking Cessation Evidence: Evidence: Primary PreventionPrimary Prevention1,027 smokers randomized to 12 weeks of varenicline (titrated to 1
mg bid), bupropion (titrated to 150 mg bid), or placebo
Varenicline provides greater rates of abstinence than bupropion
Agent Caution Side Effects
Dosage Duration Instructions
Bupropion SR
(Zyban®)**
Seizure disorderEating
disorderTaking MAO
inhibitorPregnancy
InsomniaDry mouth
Depression/Suicide
150 mg QAMthen
150 mg BID
3 days
8 weeks, but up to 6 months
Start 1-2 weeks before quit date.Take 2nd dose in early afternoon or decrease to 150 mg QAM for
insomnia.
Transdermal
NicotinePatch***
Within 2 weeks of a MI
Unstable angina
ArrhythmiasHeart failure
Skin reactionInsomnia
21 mg QAM14 mg QAM 7 mg QAM
or15 mg QAM
4 weeks2 weeks2 weeks
8 weeks
Apply to different hairless site daily.
Remove before bed for insomnia.Start at <15 mg for <10 cigs/day
Varenicline(Chantix®)*
*
Pregnancy NauseaSleep
disorderDepression
/SuicideCV risk
0.5 mg QD then
0.5 mg BIDthen
1 mg BID
3 days
4 days
12 weeks
Start 1 week before the quit
date
*Pharmacotherapy combined with behavioral support provides the best success rate
***Other nicotine replacement therapy options include: nicotine gum, lozenge, inhaler, nasal spray
**The FDA has placed a black box warning on varenicline and buproprion SR due to the risk of depression and/or suicidal thoughts
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Pharmacotherapy*Pharmacotherapy*
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Effect of Pharmacotherapy Effect of Pharmacotherapy
Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation counseling interventions with or without
pharmacotherapy
Adding pharmacotherapy (nicotine replacement or bupropion) to counseling intervention does not improve rates of smoking
cessation NRT=Nicotine replacement therapy
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Community Smoking BanBenefit of Community Smoking Ban
Source: Pell JP et al. NEJM 2008;359:482-491
ACS=Acute coronary syndrome
Prospective assessment of smoking status and exposure to second-hand smoke among patients admitted with an ACS to 9
Scottish hospitals before and after legislation prohibiting smoking in enclosed public places
Smoke-free legislation results in reduced ACS admissions
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Community Smoking Ban Benefit of Community Smoking Ban
Source: Lightwood JM et al. Circulation 2009;120:1373-1379
MI=Myocardial infarction
Meta-analysis evaluating the ratio of community rates of acute MI before and after implementation of a smoking restriction law
Smoke-free legislation results in a rapid and substantial reduction in MI
Cigarette Smoking Cessation: Cigarette Smoking Cessation: Benefit of Financial Incentives Benefit of Financial Incentives
Source: Volpp KG et al. NEJM 2009;360:699-709
878 smokers working for a U.S. company randomized to receive information about smoking-cessation programs or information plus
financial incentives
Financial incentives for smokers increase the cessation rate
Ask and document tobacco use status
Advise Provide a strong, personalized message
Assess Readiness to quit in next 30 days
Prevent Relapse• Congratulate successes• Encourage • Discuss benefits experienced by patient• Address weight gain, negative mood, and lack of support
Increase Motivation• Relevance to personal situation• Risks: short and long-term, environmental• Rewards: potential benefits of quitting• Roadblocks: identify barriers and solutions• Repetition: repeat motivational intervention• Reassess readiness to quit
Assist: Negotiate plan • STAR**• Discuss pharmacotherapy• Social support• Provide educational materials
Arrange Follow-up to check plan or adjust meds• Call right before and after quit date• Weekly follow-up x 2 weeks, then monthly x 6 months• Ask about difficulties (withdrawal, depressed mood)• Build upon successes• Seek commitment to stay tobacco-free
**STARSet quit dateTell family, friends, and coworkersAnticipate challenges: withdrawal, breaksRemove tobacco from the house, car, etc.
Recent Quitter(<6 months) Current
User
Not Ready Ready
Tobacco Cessation AlgorithmTobacco Cessation Algorithm
Source: Fiore MC et al. Treating tobacco use and dependence: an
evidence based clinical practice guideline for tobacco cessation. U.S. Department of Health and Human Services, 2000
Source: Buse JB et al. Circulation 2007;115:114-126
AHA=American Heart Association, CV=Cardiovascular,DM=Diabetes mellitus, NRT=Nicotine replacement therapy
• All patients should be asked about tobacco use status at every visit.
• Every tobacco user should be advised to quit.
• The tobacco user’s willingness to quit should be assessed.
•The patient can be assisted by counseling and by developing a plan to quit.
• Follow-up, referral to special programs, or pharmacotherapy (e.g., NRT and buproprion) should be incorporated as needed.
AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMTobacco RecommendationsTobacco RecommendationsPrimary Prevention
• All patients should be advised not to smoke.
• Smoking cessation counseling and other forms of treatment should be included as a routine component of diabetes care.
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA=American Diabetes Association
ADA Smoking Cessation RecommendationsADA Smoking Cessation Recommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes Mellitus
Primary Prevention
Tobacco Cessation Tobacco Cessation RecommendationsRecommendations
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Complete tobacco cessation and no environmental tobacco smoke exposure
Patients should be asked about tobacco use status at every office visit
Every tobacco user should be advised at every visit to quit
The tobacco user’s willingness to quit should be assessed at every visit.
Goals:
I IIa IIb III
I IIa IIb III
I IIa IIb III
Secondary Prevention
Tobacco Cessation Recommendations Tobacco Cessation Recommendations (Continued)(Continued)
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
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
Arrangement for follow up is recommended.
All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at work, home, and public places
Secondary Prevention
I IIa IIb III
I IIa IIb III
I IIa IIb III
Diet and Weight Management Diet and Weight Management Evidence and GuidelinesEvidence and Guidelines
Evidence for Current Cardiovascular Evidence for Current Cardiovascular Disease Disease
Prevention GuidelinesPrevention Guidelines
Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in)
Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084
*Measurement of waist circumference is most helpful in this category
Weight Category BMI (kg/m2)
Normal 18.5-24.9
Overweight* 25.0-29.9
Obesity (Class I) 30.0-34.9
Obesity (Class II) 35.0-39.9
Obesity (Class III) >40.0
Overweight and Obese States: Overweight and Obese States: Definition Using the Body Mass Definition Using the Body Mass Index (BMI)Index (BMI)
Prevalence of Obesity in U.S. Prevalence of Obesity in U.S. AdultsAdults
1991 1996
2006
No Data <10% 10–14% 15–19% 20–24% 25-29% >30%
Source: CDC Overweight and Obesity
Percentage of State Obese (BMI > 30)
2008
Change in Body Mass Index Change in Body Mass Index DistributionDistributionin the United States Over Timein the United States Over Time
Source: Ford ES et al. Circulation 2009;120:1181-1188
0%
10%
20%
60%
40%
50%
30%
70%
80%
90%
100%
Body m
ass
index (
kg/m
2)
age-a
dju
sted p
erc
enta
ge
>35
National Health and Nutrition Examination Survey (NHANES)
30-3525-30>25
Source: Whitaker RC et al. NEJM 1997;337:869-873
BMI=Body mass index
Ad
ult
ob
esi
ty
At
ag
e 2
1-2
9 y
ears
(%
)
Age of child (years)
Body Mass Index: Body Mass Index: Risk of Developing Obesity in Risk of Developing Obesity in AdulthoodAdulthood
Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:1039-1049
Body Mass Index: Body Mass Index: Relationship with Waist Relationship with Waist CircumferenceCircumference
Body Mass Index: Body Mass Index: Risk of HypertensionRisk of Hypertension
Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD) and National
Health and Nutrition Examination Survey (NHANES)
Source: Bays HE et al. Int J Clin Pract 2007;61:737-747
Source: Bays HE et al. Int J Clin Pract 2007;61:737-747
Body Mass Index: Body Mass Index: Risk of Diabetes MellitusRisk of Diabetes Mellitus
Study to Help Improve Early Evaluation and Management of Risk Factors Leading to Diabetes (SHIELD) and National
Health and Nutrition Examination Survey (NHANES)
Source: Mhurchu N et al. Int J Epidemiol 2004;33:751-758
0.5
1.0
2.0
4.0
16 20 24 28 32 36
Body Mass Index (kg/m2)*
Haza
rd R
ati
o
0.5
1.0
2.0
4.0
16 20 24 28 32 36
0.5
1.0
2.0
4.0
16 20 24 28 32 36
HemorrhagicCVA
IschemicCVA
Ischemic HeartDisease
CVA=Cerebrovascular accident
*BMI is calculated as the weight in kg divided by the BSA in meters2
Body Mass Index: Body Mass Index: Risk of Cardiovascular DiseaseRisk of Cardiovascular Disease
Very low fat– Ornish (Reversal diet and Prevention diet)
• Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction.
– Pritikin
• Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables
Intermediate– Sugar Busters
• 30% protein, 40% fat, 30% carbohydrates (low glycemic index)
– Zone
• 30% protein, 30% fat, 40% carbohydrates
Diet Evidence: Diet Evidence: Types of Treatment ProgramsTypes of Treatment Programs
Very low carbohydrate– Atkins (Induction and Maintenance)
• 1st 2 weeks (<20 grams of carbohydrates/day with no high glycemic foods).
• Then can add 5 grams of carbohydrates/day each week to maximum of 90 grams of carbohydrates/day long term.
– South Beach (3 Phases)• 1st phase (2 weeks) significantly restricts carbohydrates• 2nd phase reintroduces low glycemic carbohydrates• 3rd phase attempts to maintain weight
Caloric restriction– Weight watchers
• Assigns foods a point value and restricts the number of points that can be consumed/day
Diet Evidence: Diet Evidence: Types of Treatment Programs Types of Treatment Programs (Continued)(Continued)
160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or Ornish diets for 1 year
Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance
Source: Dansinger, ML et al. JAMA 2005;293:43-53
20/40*
26/40*
26/40*
21/40*
0 3 6 9
Atkins
Zone
Weight Watchers
Ornish
Wt loss (lbs)
*Ratio of individuals completing the study to those enrolled
Diet Evidence: Diet Evidence: Primary PreventionPrimary Prevention
Source: Buse JB et al. Circulation 2007;115:114-126
• Structured programs that emphasize lifestyle changes such as reduced fat (<30% of daily energy) and total energy intake and increased regular physical activity, alone with regular participant contact, can produce long-term weight loss on the order of 5-7% of starting weight, with improvement in blood pressure.
• For individuals with elevated plasma triglycerides and reduced HDL-C, improved glycemic control, moderate weight loss (5-7% of starting weight), increased physical activity, dietary saturated fat restriction, and modest replacement of dietary carbohydrates (5-7%) by either monounsaturated or polyunsaturated fats may be beneficial.
AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMWeight Management RecommendationsWeight Management RecommendationsPrimary Prevention
AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
BMI 18.5-24.9 kg/m2, Waist circumference for women: <35 inches, men: <40 inches*
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
Secondary Prevention
I IIa IIb III
Weight ManagementWeight ManagementRecommendationsRecommendations
Goals:
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
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
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.
Secondary Prevention
I IIa IIb III
Weight ManagementWeight ManagementRecommendations (Continued)Recommendations (Continued)
I IIa IIb III
Diet Evidence, Diet Evidence, Cardiovascular Events, and Cardiovascular Events, and
GuidelinesGuidelines
Evidence for Current Cardiovascular Evidence for Current Cardiovascular Disease Disease
Prevention GuidelinesPrevention Guidelines
Source: Hu FB et al. JAMA. 2002;288:2569-2578
Diet Intermediary Biological Mechanisms*
Risk of Coronary
Heart Disease
*Includes lipid levels [LDL-C, HDL-C, triglycerides, Lp(a), blood pressure, thrombotic tendency, cardiac rhythm, endothelial function, systemic
inflammation, insulin sensitivity, oxidative stress, homocysteine level
Relationship Between Diet and CV Relationship Between Diet and CV DiseaseDisease
CV=Cardiovascular
Source: Jenkins DJ et al. JAMA 2003;290:502-510
0
10
20
30
-50
-40
-30
-20
-10
0 2 4 0 2 4 0 2 4
LDL-C
Change f
rom
Base
line
(%)
LDL-C:HDL-C CRP
Weeks
Weeks
Weeks
Low fat dietStatin
Dietary portfolio*
*Enriched in plant sterols, soy protein, viscous fiber, and almonds
Diet Evidence:Diet Evidence:Effect on Lipid Parameters and CRPEffect on Lipid Parameters and CRP
46 dyslipidemic patients randomized to a low fat diet, a low fat diet and lovastatin (20 mg), or a dietary portfolio* for 4 weeks
A diversified diet improves lipid parameters and CRP levels
CRP=C-reactive protein, HDl-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol
Source: Appel LJ et al. NEJM 1997;336:1117-1124
Dietary Approaches to Stop Hypertension (DASH) Group
Diet low in fruits, vegetables, and dairy products
Diet enriched in fruits, vegetables, and fiber
Diet enriched in fruits and vegetables and low in fat and cholesterol
132
130
128
126
124
86
84
82
80
78 1 2 0 3 4 5 6
Systolic blood pressure
(mm Hg)
Diastolic blood pressure
(mm Hg)
Weeks
7/8
Diet Evidence:Diet Evidence:Effect on Blood PressureEffect on Blood Pressure
459 hypertensive patients randomized to 1 of 3 diets for 8 weeks
A diversified diet improves blood pressure
Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114
Nurses’ Health Study and Health Professional’s Follow-up Study
*Includes nonfatal MI and fatal coronary heart disease
CV=Cardiovascular
Diet Evidence:Diet Evidence:Benefits of Fruits and VegetablesBenefits of Fruits and Vegetables
126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*
Increased fruit and vegetable intake reduces CV risk
Source: Pereira MA et al. Arch Int Med 2004;164:370-376
RR=0.73, P<0.001
CV=Cardiovascular, CHD=Coronary heart disease
Diet Evidence:Diet Evidence:Benefits of Whole Grains and FiberBenefits of Whole Grains and Fiber
336,244 persons followed for 6-10 years to assess the relationship between dietary fiber intake and adverse CV
outcomes
Increased dietary fiber intake reduces CV risk
Diet Evidence:Diet Evidence:Making Smart Food ChoicesMaking Smart Food Choices
• Helps consumers make better food choices• Reminds individuals to eat healthfully• Illustrates the 5 food groups using a mealtime visual• Selected messages include:
• Balancing calories• Foods to increase• Foods to reduce
Source: United States Department of Agriculture, http://www.choosemyplate.gov/index.html
Source: Trichopoulou A et al. NEJM 2003;348:2599-2608
Variable# of Deaths/
# of ParticipantsFully Adjusted Hazard
Ratio (95% CI)
Death from any cause
275/22,043 0.75 (0.64-0.87)
Death from CHD
54/22,043 0.67 (0.47-0.94)
Death from cancer
97/22,043 0.76 (0.59-0.98)
Diet Evidence:Diet Evidence:Primary PreventionPrimary Prevention
CHD=Coronary heart disease
22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits,
nuts, cereal, and fish and points subtracted for high consumption of meat, poultry, and dairy
High adherence to a Mediterranean diet is associated with a reduction in death
Lyon Diet Heart Study
Source: De Lorgeril M et al. Circulation 1999;99:779-785
*High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber
605 patients following a myocardial infarction randomized to a Mediterranean* or Western** diet for 4 years
A Mediterranean diet reduces cardiovascular events
Diet Evidence:Diet Evidence:Secondary PreventionSecondary Prevention
1 2 3 4 570
80
90
100
Year
P=0.0001
Mediterranean dietWestern diet
Freedom
fro
m c
ard
iac
death
or
myoca
rdia
l in
farc
tion (
%)
<200 mg/dCholesterol
~15% of total caloriesProtein
20–30 g/dFiber50%–60% of total caloriesCarbohydrate (esp. complex
carbs)
25%–35% of total caloriesTotal fat
Up to 20% of total caloriesMonounsaturated fat
Up to 10% of total caloriesPolyunsaturated fat
<7% of total caloriesSaturated fat*
Recommended IntakeNutrient
Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497
Adult Treatment Panel (ATP) IIIAdult Treatment Panel (ATP) IIIDietary RecommendationsDietary Recommendations
*Trans fatty acids also raise LDL-C and should be kept at a low intakeNote: Regarding total calories, balance energy intake and expenditure to
maintain desirable body weight
LDL-C=Low density lipoprotein cholesterol
American Heart Association Nutrition American Heart Association Nutrition Committee Dietary RecommendationsCommittee Dietary Recommendations
• Balance calorie intake and physical activity to achieve or maintain a healthy body weight• Consume a diet rich in fruits and vegetables• Consume whole-grain, high-fiber foods• Consume fish, especially oily fish, at least twice a week• Limit intake of saturated fat to <7%, trans fat to <1% of energy, and cholesterol <300 mg/day by:
– Choosing lean mean and vegetable alternatives– Choosing fat free (skim), 1% fat, and low-fat dairy products,– Minimizing intake of partially hydrogenated fats
• Minimize intake of beverages and foods with added sugar• Choose and prepare foods with little or no salt• If alcohol is consumed, do so in moderation
Recommendations for Cardiovascular Disease Risk Reduction
Source: AHA Nutrition Committee. Circulation 2006;114:82-96
AHA=American Heart Association
Primary Prevention
Women should consume a diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish,* at least twice a week; limit intake of saturated fat to <10% of energy, and if possible to <7%, cholesterol to <300 mg/d, alcohol intake to no more than 1 drink per day, and sodium intake to <2.3 g/d (approximately 1 tsp salt). Consumption of trans-fatty acids should be as low as possible (eg, <1% of energy)
*Pregnant and lactating women should avoid eating fish potentially high in methylmercury
Source: Mosca L et al. Circulation 2007;115:1481-1501
Dietary RecommendationsDietary Recommendations
I IIa IIb III
Source: Buse JB et al. Circulation 2007;115:114-126
• To achieve reductions in LDL-C levels:
o Saturated fats should be <7% of energy intake.
o Dietary cholesterol intake should be <200 mg/day.
o Intake of trans-unsaturated fatty acids should be <1% of energy intake.
• Total energy intake should be adjusted to achieve body-weight goals.
• Total dietary fat intake should be moderated (25-35% of total calories) and should consist mainly of monounsaturated or polyunsaturated fat.
AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMDietary RecommendationsDietary RecommendationsPrimary Prevention
AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, LDL-C=Low density lipoprotein cholesterol
Source: Buse JB et al. Circulation 2007;115:114-126
AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus
• Ample intake of dietary fiber (>14 grams/1000 calories consumed) may be of benefit.
• If individuals choose to drink alcohol, daily intake should be limited to 1 drink* for adult women and 2 drinks* for adult men. Alcohol ingestion increase caloric intake and should be minimized when weight loss is the goal. Individuals with elevated plasma triglyceride levels should limit alcohol intake, because intake may exacerbate hypertriglyceridemia.
• In both normotensive and hypertensive individuals, a reduction in sodium intake may lower blood pressure. The goal should be to reduce sodium intake to 1200-2300 mg/day.**
* Defined as a 12 ounce beer, a 4 ounce glass of wine, or a 1.5 ounce glass of distilled spirits
** Equivalent to 3000-6000 mg/day of sodium chloride
AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMDietary RecommendationsDietary RecommendationsPrimary Prevention
• Weight loss is recommended for all overweight or obese individuals who are at risk for DM.
• For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year).
• Among individuals at high risk for developing type II DM, structured programs emphasizing lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 minutes/week) with dietary strategies include reduced intake of dietary fat and can reduce the risk of developing DM and are therefore recommended.
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA=American Diabetes Association, DM=Diabetes mellitus
ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes MellitusPrimary Prevention
• Individuals at high risk for type II DM should be encouraged to achieve USDA recommendation for dietary fiber (14 grams fiber/1000 kcal) and foods containing whole grains (one-half of gram intake).
• Saturated fat intake should be <7% of total calories.
• Reducing intake of trans-fat lowers LDL-C and increase HDL-C. Therefore, intake of trans-fat should be minimized.
• Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experience-based estimation remains a key strategy in achieving glycemic control.
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA=American Diabetes Association, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol
ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitus for Patients with Diabetes Mellitus (Continued)(Continued)
Primary Prevention
• For individuals with DM, use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone.
• Sugar alcohols and nonnutritive sweeteners are safe when consumed within the acceptable daily intake levels established by the FDA.
• If adults with DM choose to use alcohol, daily intake should be limited to a moderate amount (<1 drink per day for adult women and <2 drinks per day for adult men).
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitus for Patients with Diabetes Mellitus (Continued)(Continued)
Primary Prevention
AHA=American Heart Association, DM=Diabetes mellitus, FDA=Food and Drug Administration
• Routine supplementation with antioxidants, such as Vitamin E and C, and carotene, is not advised because of lack of evidence of efficacy and concerns related to long-term safety.
• Benefit from chromium supplementation in patients with DM or obesity has not been conclusively demonstrated and therefore cannot be recommended.
• Individualized meal planning should include optimization of food choices to meet recommended dietary allowances (RDAs)/dietary reference intakes (DRIs) for all micronutrients.
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA=American Diabetes Association, DM=Diabetes mellitus
ADA Medical Nutrition Therapy ADA Medical Nutrition Therapy RecommendationsRecommendationsfor Patients with Diabetes Mellitus for Patients with Diabetes Mellitus (Continued)(Continued)
Primary Prevention
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)
For all patients, it may be reasonable to recommend omega-3 fatty acids from fish or fish oil capsules (1 gram/day) for cardiovascular disease risk reduction
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
Dietary RecommendationsDietary Recommendations
Secondary PreventionI IIa IIb III
I IIa IIb III
Physical Activity Evidence Physical Activity Evidence and Guidelinesand Guidelines
Evidence for Current Cardiovascular Evidence for Current Cardiovascular Disease Disease
Prevention GuidelinesPrevention Guidelines
Adverse Effects of Physical Adverse Effects of Physical InactivityInactivity
Age
Diabetes Mellitus
Obesity
Genetics Atherosclerosis
Hypercoagulability
Smoking
Hypertension
Novel Risk Factors
Inflammation Dyslipidemia
Physical Inactivity
Prevalence of Physical ActivityPrevalence of Physical Activity
Source: Lloyd-Jones D et al. Circulation 2010;121:46-215
Prevalence of physical activity among individuals >18 years of age
Over half the U.S. adult population is physically inactiveNH=Non-Hispanic
Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk)
Total Body Fat Intra-abdominal Fat
Source: Irwin ML et al. JAMA 2003;289:323-330
173 sedentary, overweight (body mass index >24 kg/m2) post-menopausal women randomized to moderate intensity exercise
vs. stretching for 1 year
Moderate exercise reduces total and intra-abdominal fat
Exercise Evidence:Exercise Evidence:Effect on Body CompositionEffect on Body Composition
NS
5% 20%†
15% 34%*
8% 20%*
Change from Baseline
202171
199174
197190
200188
TGMenWomen
3956
4155
4050
3747
HDL-CMenWomen
118102
131120
134135
138155
LDL-CMenWomen
Year and Lipid Level (mg/dL)
196193
210209
213223
214239
TCMenWomen
531BaselineLipids
Source: Warner JG et al. Circulation 1995;92:773-777
*P=0.0001 for change in women vs men†P=0.03 for change in women vs men
HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol, TG=Triglyceride
Exercise Evidence:Exercise Evidence:Effect on Lipid ParametersEffect on Lipid Parameters
Assessment of lipid profiles in 719 patients undergoing cardiac rehab
ILI DSE P value
LDL (mg/dL) -5.2 ± 0.6 -5.7 ± 0.6 0.49
HDL (mg/dL) 3.4 ± 0.2 1.4 ± 0.1 <0.001
Triglycerides (mg/dL) -30.3 ± 2.0 -14.6 ± 1.8 <0.001
% Metabolic Syndrome -14.7 ± 0.8 -7.1 ± 0.7 <0.001
5,145 patients aged 45-74 years with type 2 DM and BMI of 25 kg/m2 (27 kg/m2 if taking insulin) randomized to an intensive lifestyle intervention (ILI) involving group and individual meetings
to achieve and maintain weight loss through decreased caloric intake and increased physical activity versus diabetes support and
education (DSE)
Source: Look AHEAD investigators. Diabetes Care 2007;30:1374-1383
Exercise Evidence:Exercise Evidence:Effect on Lipid ParametersEffect on Lipid Parameters
Look AHEAD Trial
Intensive lifestyle intervention results in greater improvement in lipid parameters
BMI=Body mass index, DM=Diabetes mellitus, DSE=Diabetes support and education, ILI=Intensive lifestyle intervention
Source: Hu FB et al. JAMA 2003;289:1785-1791
Reduction:
Each hour a day spent walking
briskly
Increase:
Each two hours a day spent watching
TV
Increase:
Each two hours a day spent sitting at
work
Nurse’s Health Study
Exercise reduces the incidence of obesity and DM
Risk of obesityRisk of DM
0%
5%
10%
15%
20%
25%
30%
35%
Exercise Evidence:Exercise Evidence:Effect on Obesity and Diabetes Mellitus Effect on Obesity and Diabetes Mellitus (DM)(DM)
Source: Manson JE et al. NEJM 2002;347:716-725
Quintiles of activity (MET-hour/week**)
Walking
Rela
tive R
isk
of
CH
D
Vigorous exercise*
Rela
tive R
isk
of
CH
D
P=0.004
P=0.008
1 2 3 4 5
Women’s Health Initiative Observational Study
1 2 3 4 5
*Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps**Average active hours per week energy expenditure per activity
CHD=Coronary heart disease
Exercise Evidence:Exercise Evidence:Effect on Coronary Heart Disease Effect on Coronary Heart Disease RiskRisk
0
10
20
30
40
50
60
70
1 2 3 4 5
Death
Rate
(p
er
10
,00
0)
Fitness Level (Low to High)
Source: Blair SN et al. JAMA 1998;262:2395-2401
MenWomen
Physical Activity:Physical Activity:Effect on MortalityEffect on Mortality
13,344 healthy men and women followed for 8 years
Low physical fitness is associated with increased mortality
Fitness Level (Low to High)
Source: Wannamethee SG et al. Circulation 2000;102:1358-1363
CHD=Coronary heart disease, CVD=Cardiovascular disease
Moderate exercise is associated with reduced mortality
Observational study of self-reported physical activity in 772 men with CHD
Physical Activity:Physical Activity:Secondary PreventionSecondary Prevention
Age-a
dju
sted m
ort
alit
y
rate
/100
0 p
ers
on-y
ears
Physical activity
* *
Effect of cardiac rehabilitation in randomized controlled trials following a MI
Source: Oldridge NB et al. JAMA 1988;260:945-950
*p<0.0125
Cardiac Rehabilitation:Cardiac Rehabilitation:Benefits Following a Myocardial Benefits Following a Myocardial InfarctionInfarction
Cardiac rehabilitation reduces CV events after a MI
CV=Cardiovascular, MI=Myocardial infarction
Source: Hammill BG et al. Circulation 2010;121:63-70
Observational study of 30,161 Medicare patients attending at least 1 phase II cardiac rehabilitation session
A large number of patients fail to complete 36 sessions of cardiac rehabilitation
Cardiac Rehabilitation:Cardiac Rehabilitation:Prevalence of Incomplete Prevalence of Incomplete AttendanceAttendance
Sess
ions
att
ended (
%)
Number of Sessions Attended
Source: Hammill BG et al. Circulation 2010;121:63-70
Cardiac Rehabilitation:Cardiac Rehabilitation:Greater Benefit with Greater Greater Benefit with Greater AttendanceAttendanceObservational study of 30,161 Medicare patients attending at
least 1 phase II cardiac rehabilitation session
There is a strong dose-response relationship between the number of cardiac rehabilitation sessions attended and long-term CV
outcomes
Death
(%
)
Myoca
rdia
l in
farc
tion
(%)
Years after Index Date Years after Index Date
CV=Cardiovascular
Source: Clark AM et al. Ann of Intern Med 2005;143:659-72
Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without
exercise programs
Cardiac Rehabilitation:Cardiac Rehabilitation:Benefit of Secondary Prevention Benefit of Secondary Prevention ProgramsPrograms
All cause mortality Recurrent myocardial infarctionSecondary prevention programs provide CV benefit
CV=Cardiovascular
Source: Buse JB et al. Circulation 2007;115:114-126
• To improve glycemic control, assist with weight loss or maintenance, and reduce the risk of CVD, at least 150 minutes of moderate-intensity aerobic physical activity or at least 90 minutes of vigorous aerobic exercise per week is recommended. The physical activity should be distributed over at least 3 days per week, with no more than 2 consecutive days without physical activity.
• For long-term maintenance of major weight loss, a larger amount of exercise (7 hours of moderate or vigorous aerobic physical activity per week) may be helpful.
AHA=American Heart Association, CV=Cardiovascular, CVD=Cardiovascular disease, DM=Diabetes mellitus
AHA Primary Prevention of CV Disease in AHA Primary Prevention of CV Disease in DMDMPhysical Activity RecommendationsPhysical Activity RecommendationsPrimary Prevention
• People with DM should be advised to perform at least 150 minutes/week of moderate-intensity aerobic physical activity (50-70% of maximum heart rate).
• In the absence of contraindications, people with type II DM should be encouraged to perform resistance training three times per week.
Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
ADA=American Diabetes Association, DM=Diabetes mellitus
ADA Physical Activity RecommendationsADA Physical Activity Recommendationsfor Patients with Diabetes Mellitusfor Patients with Diabetes Mellitus
Primary Prevention
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
At least 30 minutes, 7 days per week (minimum 5 days per week) of physical activity
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 (e.g., walking breaks at work, gardening, household work) to improve cardiorespiratory fitness and move patients out of the least fit, least active high-risk cohort
Secondary Prevention
I IIa IIb III
Physical ActivityPhysical ActivityRecommendationsRecommendations
Goal:
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription
The clinician should counsel patients to report and be evaluated for symptoms related to exercise.
It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week
Secondary Prevention
Physical ActivityPhysical ActivityRecommendations (Continued)Recommendations (Continued)
I IIa IIb III
I IIa IIb III
I IIa IIb III
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
All eligible patients with ACS or whose status is immediately post coronary artery bypass surgery or post-PCI should be referred to a comprehensive outpatient cardiovascular rehabilitation program either prior to hospital discharge or during the first follow-up office visit
All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery or PCI (Level of Evidence: A), chronic angina (Level of Evidence: B), and/or peripheral artery disease (Level of Evidence: A) within the past year should be referred to a comprehensive outpatient cardiovascular rehabilitation program.
Secondary Prevention
Cardiac RehabilitationCardiac RehabilitationRecommendationsRecommendations
I IIa IIb III
I IIa IIb III
I IIa IIb III
Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
A home-based cardiac rehabilitation program can be substituted for a supervised, center-based program for low-risk patients
A comprehensive exercise-based outpatient cardiac rehabilitation program can be safe and beneficial for clinically stable outpatients with a history of heart failure
Secondary Prevention
Cardiac RehabilitationCardiac RehabilitationRecommendations (Continued)Recommendations (Continued)
I IIa IIb III
I IIa IIb III