The Evidence for Current
Cardiovascular Disease
Prevention Guidelines:
Lifestyle Management
American College of Cardiology...
Classification of
Recommendations and Levels of
Evidence

*Data available from clinical trials or
registries about the
use...
Icons Representing the Classification and
Evidence Levels for Recommendations
I IIa IIb III

I IIa IIb III

I IIa IIb III
...
Evidence for Current Cardiovascular Disease
Prevention Guidelines

Cigarette Smoking Cessation
Evidence and Guidelines
Smoking Prevalence in the United
States
National Health Interview Survey
Estimated percentage of current smokers in the Un...
Tobacco Use:
Most Preventable Cause of Death
Most preventable causes of death in the U.S. in 1990 and 2000
Causes

# (%) i...
Cigarette Smoking Cessation Evidence:
Risk of Non-fatal Myocardial
Infarction*

RR (95% Cl)

Study

Aberg, et al. 1983

0....
Cigarette Smoking Cessation Evidence:
Tailored Materials
1058 current and recent ex-smokers randomized to a smoking cessat...
Cigarette Smoking Cessation:
Effect of Counseling Intervention
Meta-analysis of 33 clinical trials assessing the benefit o...
Cigarette Smoking Cessation:
Frequency of Nicotine Dependence
Percent Reporting >1 Indicators of Nicotine Dependence, by A...
Cigarette Smoking Cessation:
Types of Nicotine Replacement
Increase in nicotine concentration (ng/ml)

Plasma nicotine con...
Cigarette Smoking Cessation Evidence:
Effect of Combination Therapy
Limited Behavioral Support
Intervention

Effect Size

...
Cigarette Smoking Cessation Evidence:
Primary Prevention
893 smokers randomized to 9 weeks of bupropion (150 mg daily for ...
Cigarette Smoking Cessation Evidence:
Primary Prevention
1,027 smokers randomized to 12 weeks of varenicline (titrated to ...
Cigarette Smoking Cessation:
Pharmacotherapy*
Agent

Caution

Side Effects

Dosage

Duration

Instructions

Bupropion SR
(...
Cigarette Smoking Cessation:
Effect of Pharmacotherapy
Meta-analysis of 33 clinical trials assessing the benefit of smokin...
Cigarette Smoking Cessation:
Benefit of Community Smoking Ban
Prospective assessment of smoking status and exposure to sec...
Cigarette Smoking Cessation:
Benefit of Community Smoking Ban
Meta-analysis evaluating the ratio of community rates of acu...
Cigarette Smoking Cessation:
Benefit of Financial Incentives
878 smokers working for a U.S. company randomized to receive ...
Tobacco Cessation Algorithm
Ask and document tobacco use status
Current User

Recent Quitter
(<6 months)

Advise Provide a...
AHA Primary Prevention of CV Disease in DM
Tobacco Recommendations
Primary Prevention
• All patients should be asked about...
ADA Smoking Cessation Recommendations
for Patients with Diabetes Mellitus
Primary Prevention
• All patients should be advi...
Tobacco Cessation Recommendations
Secondary Prevention
Goals:

Complete tobacco cessation and no environmental tobacco
smo...
Tobacco Cessation Recommendations
(Continued)
Secondary Prevention
I IIa IIb III

Patients should be assisted by counselin...
Evidence for Current Cardiovascular Disease
Prevention Guidelines

Diet and Weight Management
Evidence and Guidelines
Overweight and Obese States:
Definition Using the Body Mass Index
(BMI) Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht...
Prevalence of Obesity in U.S. Adults
1991

1996

2006

2008

Percentage of State Obese (BMI > 30)
No Data

<10%

10–14%

1...
Change in Body Mass Index Distribution
in the United States Over Time
National Health and Nutrition Examination Survey (NH...
Adult obesity
At age 21-29 years (%)

Body Mass Index:
Risk of Developing Obesity in Adulthood

Age of child (years)
BMI=B...
Body Mass Index:
Relationship with Waist Circumference

Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:10...
Body Mass Index:
Risk of Hypertension
Study to Help Improve Early Evaluation and Management of Risk
Factors Leading to Dia...
Body Mass Index:
Risk of Diabetes Mellitus
Study to Help Improve Early Evaluation and Management of Risk
Factors Leading t...
Body Mass Index:
Risk of Cardiovascular Disease

Hazard Ratio

4.0

Hemorrhagic
CVA

4.0

Ischemic
CVA

4.0

2.0

2.0

2.0...
Diet Evidence:
Types of Treatment Programs
Very low fat
– Ornish (Reversal diet and Prevention diet)
• Vegetarian with 10%...
Diet Evidence:
Types of Treatment Programs
(Continued)
Very low carbohydrate
– Atkins (Induction and Maintenance)
• 1st 2 ...
Diet Evidence:
Primary Prevention
160 overweight and obese patients randomized to the Atkins, Zone, Weight
Watchers, or Or...
AHA Primary Prevention of CV Disease in DM
Weight Management Recommendations
Primary Prevention
• Structured programs that...
Weight Management
Recommendations
Secondary Prevention
Goals:

I IIa IIb III

BMI 18.5-24.9 kg/m2, Waist circumference for...
Weight Management
Recommendations (Continued)
Secondary Prevention
I IIa IIb III

If waist circumference (measured horizon...
Evidence for Current Cardiovascular Disease
Prevention Guidelines

Diet Evidence,
Cardiovascular Events, and
Guidelines
Relationship Between Diet and CV
Disease

Diet

Intermediary Biological Mechanisms*

Risk of
Coronary Heart
Disease

*Incl...
Diet Evidence:
Effect on Lipid Parameters and CRP
46 dyslipidemic patients randomized to a low fat diet, a low fat diet an...
Diet Evidence:
Effect on Blood Pressure
Dietary Approaches to Stop Hypertension (DASH) Group
459 hypertensive patients ran...
Diet Evidence:
Benefits of Fruits and Vegetables
Nurses’ Health Study and Health Professional’s Follow-up Study
126,399 pe...
Diet Evidence:
Benefits of Whole Grains and Fiber
336,244 persons followed for 6-10 years to assess the relationship
betwe...
Diet Evidence:
Making Smart Food Choices

• Helps consumers make
better food choices
• Reminds individuals to eat
healthfu...
Diet Evidence:
Primary Prevention
22,043 adults evaluated for adherence to a Mediterranean diet, with points
given for hig...
Diet Evidence:
Secondary Prevention
Lyon Diet Heart Study
605 patients following a myocardial infarction randomized to a
M...
Adult Treatment Panel (ATP) III
Dietary Recommendations
Nutrient
Saturated fat*

Recommended Intake
<7% of total calories
...
American Heart Association Nutrition
Committee Dietary Recommendations
Recommendations for Cardiovascular Disease Risk Red...
Dietary Recommendations
Primary Prevention

I IIa IIb III

Women should consume a diet rich in fruits and vegetables;
choo...
AHA Primary Prevention of CV Disease in DM
Dietary Recommendations
Primary Prevention
• To achieve reductions in LDL-C lev...
AHA Primary Prevention of CV Disease in DM
Dietary Recommendations
Primary Prevention
• Ample intake of dietary fiber (>14...
ADA Medical Nutrition Therapy
Recommendations
for Patients with Primary Prevention
Diabetes Mellitus
• Weight loss is reco...
ADA Medical Nutrition Therapy
Recommendations
for Patients with Primary Prevention
Diabetes Mellitus (Continued)
• Individ...
ADA Medical Nutrition Therapy
Recommendations
for Patients with Primary Prevention
Diabetes Mellitus (Continued)
• For ind...
ADA Medical Nutrition Therapy
Recommendations
for Patients with Primary Prevention
Diabetes Mellitus (Continued)
• Routine...
Dietary Recommendations
Secondary Prevention
I IIa IIb III

I IIa IIb III

Dietary therapy for all patients should include...
Evidence for Current Cardiovascular Disease
Prevention Guidelines

Physical Activity Evidence
and Guidelines
Adverse Effects of Physical Inactivity
Physical Inactivity
Inflammation

Dyslipidemia

Age

Hypertension

Diabetes Mellitu...
Prevalence of Physical Activity
Prevalence of physical activity among individuals >18 years of age

Over half the U.S. adu...
Exercise Evidence:
Effect on Body Composition
173 sedentary, overweight (body mass index >24 kg/m2) post-menopausal
women ...
Exercise Evidence:
Effect on Lipid Parameters
Assessment of lipid profiles in 719 patients undergoing cardiac rehab
Year a...
Exercise Evidence:
Effect on Lipid Parameters
Look AHEAD Trial
5,145 patients aged 45-74 years with type 2 DM and BMI of 2...
Exercise Evidence:
Effect on Obesity and Diabetes Mellitus (DM)
Nurse’s Health Study
35%
30%

Risk of obesity
Risk of DM

...
Exercise Evidence:
Effect on Coronary Heart Disease Risk
Women’s Health Initiative Observational Study
P=0.008

P=0.004

R...
Physical Activity:
Effect on Mortality
13,344 healthy men and women followed for 8 years
Death Rate (per 10,000)

70
60

M...
Physical Activity:
Secondary Prevention

Age-adjusted mortality
rate/1000 person-years

Observational study of self-report...
Cardiac Rehabilitation:
Benefits Following a Myocardial Infarction
Effect of cardiac rehabilitation in randomized controll...
Cardiac Rehabilitation:
Prevalence of Incomplete Attendance

Sessions attended (%)

Observational study of 30,161 Medicare...
Cardiac Rehabilitation:
Greater Benefit with Greater
Attendance study of 30,161 Medicare patients attending at least 1
Obs...
Cardiac Rehabilitation:
Benefit of Secondary Prevention
Programs
Meta-analysis of 63 randomized clinical trials evaluating...
AHA Primary Prevention of CV Disease in DM
Physical Activity Recommendations
Primary Prevention
• To improve glycemic cont...
ADA Physical Activity Recommendations
for Patients with Diabetes Mellitus
Primary Prevention
• People with DM should be ad...
Physical Activity
Recommendations
Secondary Prevention
Goal:

I IIa IIb III

At least 30 minutes, 7 days per week (minimum...
Physical Activity
Recommendations (Continued)
Secondary Prevention
I IIa IIb III

For all patients, risk assessment with a...
Cardiac Rehabilitation
Recommendations
Secondary Prevention
I IIa IIb III

All eligible patients with ACS or whose status ...
Cardiac Rehabilitation
Recommendations (Continued)
Secondary Prevention
I IIa IIb III

I IIa IIb III

A home-based cardiac...
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  • Smoking is the #1 risk factor for atherosclerotic vascular disease. Smoking prevalence deceased significantly from 1965-1990 but the rate appears to have stabilized.
  • Tobacco abuse remains the most common preventable cause of death in the United States.
  • A meta-analysis of 20 prospective cohort studies demonstrated a 36% crude relative risk reduction in mortality for CHD patients among individuals that quit smoking as compared to those that continued to smoke (RR 0.64; 95% confidence interval [CI], 0.58-0.71). Among the 8 studies that included data on nonfatal reinfarction, the pooled relative risk for nonfatal MI was 0.68 (95% CI, 0.57-0.82).
  • Individualized self-help materials to assist in smoking cessation are more beneficial than generic materials in light to moderate smokers but not in heavy smokers.
  • Offering smoking cessation counseling to all hospitalized smokers is effective as long as supportive contact continues for &gt;1 month after discharge.
  • Nicotine dependence is common among smokers, regardless of the number of cigarettes smoked per day.
  • Nicotine replacement by various vehicles is one modality that increases the success of smoking cessation. This slide demonstrates the nicotine concentrations obtained from smoking as compared to various forms of nicotine supplementation.
  • Combination therapy, including behavioral support, improves the success of smoking cessation.
  • This study randomized 893 smokers to 9 weeks of sustained-release bupropion (150 mg daily for 3 days, then 150mg twice a day), a nicotine patch (21 mg patch weeks 2-7, 14 mg patch week 8, and 7 mg patch week 9), sustained-release bupropion and a nicotine patch, or placebo. Day 8 was usually the target day for quitting.
    At 12 months, the abstinence rates were 15.6% in the placebo group, 16.4% in the nicotine patch group, 30.3% in the bupropion group (p&lt;0.001) and 35.5% in the combined nicotine patch + bupropion group (p&lt;0.001). Treatment with sustained-release bupropion with or without nicotine replacement therapy provides the greatest success rate for smoking cessation.
  • Varenicline is a partial agonist of the 4beta2 nicotinic acetylcholine receptor. This study randomized 1027 smokers to 12 weeks of varenicline (titrated to 1 mg twice daily), bupropion (titrated to 150 mg twice daily) or placebo. During the last 4 weeks of treatment (weeks 9-12), abstinence rates were 44% in the varencicline group, 30% in the bupropion group (OR, 1.90; 95% CI, 1.38-2.62; P&lt;.001), and 17.6% in the placebo group (odds ratio [OR], 3.85; 95% confidence interval [CI], 2.69-5.50; P&lt;.001). For weeks 9 through 52, abstinence rates were 23% in the varenicline group, 14.6% in the bupropion group (OR, 1.77; 95% CI, 1.19-2.63; P = .004), and 10.3% in the placebo group (OR, 2.66; 95% CI, 1.72-4.11; P&lt;.001).
    Varenicline appears to be more effective for smoking cessation than bupropion.
  • Bupropion, nicotine replacement, and varenicline have differing side effects that deserve consideration when prescribing these agents.
    The U.S. Food and Drug Administration announced on July 1, 2009 that it is requiring manufacturers to put a Black Box warning on the prescribing information for the smoking cessation drugs Chantix (varenicline) and Zyban (bupropion). The warning will highlight the risk of serious mental health events including changes in behavior, depressed mood, hostility, and suicidal thoughts when taking these drugs. [http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm170100.htm]
  • This meta-analysis also demonstrated that addition of nicotine replacement or bupropion therapy to counseling may further increase smoking cessation rates.
  • This study sought to evaluate benefits from anti-smoking legislation at the population level. In an analysis of patients at 9 Scottish hospitals, the overall number of acute coronary syndrome (ACS) admissions decreased by 17% following prohibition of smoking in enclosed public spaces. This contrasts with only a 4% reduction in ACS admissions in England (which has no such legislation) during the same period and a 3% mean annual decrease in Scotland during the preceding decade. The reduction in the number of admissions was not due to an increase in the number of ACS deaths. The smoking ban benefited smokers and non-smokers alike, with a 14% reduction in the admission rate among smokers, a 19% reduction among former smokers, and a 21% reduction among persons who had never smoked. In this last group, there was a decrease in the weekly duration of exposure to secondhand smoke (P&lt;0.001 by the chi-square test for trend), as evidenced by a decrease in the mean concentration of serum cotinine from 0.68 to 0.56 ng per milliliter (P&lt;0.001 by the t-test).
  • This meta-analysis of 13 trials demonstrated a 17% relative risk reduction in the rate of acute myocardial infarction with anti-smoking legislation.
  • This study sought to evaluate whether financial incentives for smoking cessation could improve cessation rates. The financial incentives were $100 for completion of a smoking-cessation program, $250 for cessation of smoking within 6 months after study enrollment (as confirmed by a biochemical test), and $400 for abstinence 6 additional months after the initial cessation (as confirmed by a biochemical test). The incentive group had significantly higher rates of smoking cessation than did the information-only group 9-12 months (14.7% vs. 5.0%, P&lt;0.001) and 15-18 months (9.4% vs. 3.6%, P&lt;0.001) after enrollment . Incentive-group participants also had significantly higher rates of enrollment in a smoking-cessation program (15.4% vs. 5.4%, P&lt;0.001), completion of a smoking-cessation program (10.8% vs. 2.5%, P&lt;0.001), and cessation of smoking within 6 months after enrollment (20.9% vs. 11.8%, P&lt;0.001).
  • This slide provides a simple approach to assisting patients with smoking cessation.
  • This slide displays the formula used to calculate body mass index and the categories of weight based on body mass index.
  • There is an epidemic of obesity in this country and the prevalence is dramatically increasing. In 1991 most states had a prevalence of obesity (BMI &gt; 30) of 10-15%. In 2008, 32 states had a prevalence equal to or greater than 25%; six of these states (Alabama, Mississippi, Oklahoma, South Carolina, Tennessee, and West Virginia ) had a prevalence of obesity equal to or greater than 30%.
  • The age-adjusted prevalence of an ideal (low risk) BMI (&lt;25 kg/m2) has decreased over time. During the four above time intervals, the calculated prevalence of an ideal body weight was 49.9%, 50.4%, 41.4%, and 32.3% respectively.
  • This study investigated the risk of obesity in young adulthood based on obesity in childhood and obesity in one or both parents. The study found that in young adulthood (defined as 21 to 29 years of age), 16% were obese. Among those that were obese during childhood, the chance of being obese in adulthood ranged from 8% for 1- or 2-year-olds without obese parents to 79% for 10 to 14 year-olds with at least one obese parent. After adjustment for parental obesity, the odds ratios for obesity in adulthood associated with childhood obesity ranged from 1.3 (0.6 to 3.0) for obesity at 1 or 2 years of age to 17.5 (7.7 to 39.5) for obesity at 15 to 17 years of age.
    After adjustment for the child&apos;s obesity status, the odds ratios for obesity in adulthood associated with having one obese parent ranged from 2.2 (95 percent confidence interval, 1.1 to 4.3) at 15 to 17 years of age to 3.2 (1.8 to 5.7) at 1 or 2 years of age. Obese children under three years of age without obese parents are at low risk for obesity in adulthood, but among older children, obesity is an increasingly important predictor of adult obesity, regardless of whether the parents are obese. Parental obesity more than doubles the risk of adult obesity among both obese and non-obese children &lt;10 years of age.
  • In this study of 48 healthy men between the ages of 18 to 55 years with a body mass index (BMI) of 21-95 kg/m2, BMI was highly correlated with total body fat content (r = 0.96; P less than 0.001). Thus, BMI is an appropriate measure of obesity.
  • The risk of hypertension increases proportionally to increases in BMI.
  • In this study of 3,137 Pima Indians, the incidence of diabetes mellitus was strong related to body mass index, ranging from 0.8 cases/1000 person-years in subjects with a BMI&lt;20 to 72.2 cases/1000 person-years in subjects with a BMI  40.
  • A meta-analysis of 33 cohort studies, including 310,283 participants from the Asia-Pacific region, found strong associations between baseline BMI and the risk of hemorrhagic stroke, ischemic stroke, and ischemic heart disease. Each 2 kg/m2 reduction in BMI resulted in a 11% lower risk of ischemic heart disease (95% CI, 9-13%), an 8% lower risk of hemorrhagic stroke (95% CI, 4-12%), and a 12% lower risk of ischemic stroke (95% CI, 9-15%).
  • With rising rates of obesity, there is an increased interest in weight loss. Several diet programs have been developed, with varying dietary content.
  • With rising rates of obesity, there is an increased interest in weight loss. Several diet programs have been developed, with varying dietary content.
  • Diet program adherence remains a significant hurdle to sustain weight loss with a &gt;50% drop out rate, regardless of the weight loss program studied.
  • This slide demonstrates a short list of the many factors that interplay between diet and risk of coronary heart disease.
  • This trial randomized 46 healthy hyperlipidemic adults to one of three interventions for one month: (a) a low-fat diet, (b) a low-fat diet plus lovastatin (20 mg daily), or (c) a dietary portfolio high in almonds, plant sterols, soy protein, and viscous fibers.
    The low-fat diet, low-fat diet + statin, and dietary portfolio groups had mean reductions in C-reactive protein of 10.0% (p=0.27), 33.3% (p=0.002) and 28.2% (p=0.02), respectively. The reductions in levels of LDL-C were 8.0% (p=0.002), 30.9% (p&lt;0.001) and 28.6% (p&lt;0.001), respectively. The CRP and LDL-C levels were significantly reduced in the dietary portfolio and low-fat diet + statin groups as compared to the low-fat diet alone group. There were no significant reductions in CRP and LDL-C levels in the low-fat diet + statin group as compared to the dietary portfolio group.
  • The Dietary Approaches to Stop Hypertension (DASH) trial randomized 459 adults with systolic blood pressures &lt;160 mmHg and diastolic blood pressures between 80-95 mmHg to a control diet, a diet enriched in fruits and vegetables, or a combination diet that was enriched in fruits and vegetables and low in fat and cholesterol. The sodium content did not differ across the three diets.
    Compared to the control diet, the fruits and vegetables diet decreased systolic and diastolic blood pressure by 2.8 mmHg and 1.1 mmHg, respectively (P&lt;0.001 for systolic, p=0.07 for diastolic). Compared to the control diet, the combination diet decreased systolic and diastolic blood pressure by 5.5 mmHg and 3.0 mmHg, respectively (P&lt;0.001 for each).
  • The Nurses’ Health Study included 84,251 women between the ages of 34 to 59 years that were followed for 14 years. The Health Professional’s Follow-Up Study included 42,148 men between the ages of 40 to 75 years that were followed for 8 years. In these cohorts, each additional daily serving of fruits and vegetables was associated with a 4% lower risk of coronary heart disease (RR 0.96 [CI, 0.94 to 0.99]; P = 0.01). Men and women in the highest quintile of fruit and vegetable intake had a lower risk of coronary heart disease (RR 0.80 [95% CI, 0.69 to 0.93]) compared with those in the lowest quintile of intake.
  • A meta-analysis of 336,244 persons in 10 prospective cohort studies with 6-10 years of follow-up evaluated the association between dietary fiber intake and risk of coronary heart disease. Each additional 10 grams of daily fiber intake was associated with a 14% relative reduction in risk of coronary events (relative risk [RR], 0.86; 95% confidence interval [CI], 0.78-0.96) and a 27% relative reduction in risk of coronary death (RR, 0.73; 95% CI, 0.61-0.87).
  • B
  • In this study, 22,043 Greek adults were evaluated for adherence to a Mediterranean diet. Points were given for high vegetables, legumes, fruits &amp; nuts, cereal, fish and subtracted for high intakes of meat, poultry, and dairy to comprise a 10 point Mediterranean diet adherence score. During a median follow up of 44 months, a 2 point increment on the Mediterranean adherence score was associated with a significant survival benefit after adjustment for 10 other traditional cardiovascular risk factors (HR 0.75, CI 0.64-0.87). This association was even larger for coronary heart disease mortality (HR 0.67, CI 0.47-0.94).
  • The Lyon Diet Heart Study sought to determine whether a Mediterranean diet could reduce the risk of cardiovascular events following a myocardial infarction. The study randomized 605 patients to a Mediterranean diet high in polyunsaturated fat and fiber or a Western diet high in saturated fat and low in fiber. Three composite outcomes were studied: (a) cardiac death and nonfatal myocardial infarction, (b) cardiac death, nonfatal MI, and major secondary end points (unstable angina, stroke, heart failure, pulmonary or peripheral embolism, and (c) cardiac death, nonfatal MI, major secondary end points, and minor events requiring hospital admission.
    All three composite outcomes were significantly reduced in the Mediterranean diet group. This slide shows cumulative survival without MI among control and experimental (Mediterranean group) subjects.
  • The ATP III recommended dietary intake of different nutrients is listed on this slide.
  • The AHA Nutrition Committee’s dietary recommendations for CV disease risk reduction are listed on this slide.
  • Physical inactivity directly and indirectly increases the risk of coronary heart disease by multiple distinct and interrelated mechanisms.
  • A large proportion of the U.S. adult population is physically inactive, with little change between 2001 to 2005.
  • A total of 173 sedentary, overweight (BMI &gt;27kg/m2) postmenopausal women were randomized to moderate intensity exercise vs. stretching for one year. Among those in the exercise group, there was a decrease in total body fat (–1.0%; 95% CI, –1.6% to –0.4%), subcutaneous abdominal fat (–28.8 g/cm2; 95% CI, –47.5 to –10.0 g/cm2), intra-abdominal fat (–8.6 g/cm2; 95% CI, –17.8 to 0.9 g/cm2), and weight (-1.4 kg; 95% confidence interval [CI], -2.5 to -0.3 kg). Overall, an increase in cardiorespiratory fitness level and duration of exercise resulted in greater total body and intra-abdominal fat loss.
  • Lipid profile parameters were evaluated in 719 men and women participating in a cardiac rehabilitation program for up to 5 years. With the exception of triglyceride levels, each of the other lipid parameters improved with exercise (particularly in women).
  • This slide presents 1 year data from the LOOK AHEAD trial. Among diabetic patients randomized to more intense lifestyle interventions (ILI), there was an increase in HDL-C levels and a decrease in triglyceride levels compared with education alone. Those with ILI were less likely to have metabolic syndrome. There was no effect on LDL-C levels in this study. Approximately 50% of these patients were on lipid lowering medications at the start of the study.
  • The Nurses’ Health Study sought to evaluate the effect of exercise and sedentary activity on obesity and diabetes. The obesity analysis included 50,277 healthy nondiabetic women with a BMI of less than 30 at baseline. The diabetes analysis included 68,497 healthy nondiabetic women at baseline.
    Each one hour of daily walking reduced the risk of obesity by 24% (95% CI, 19%-29%) and diabetes by 34% (95% CI, 27%-41%). Each two hour increment of daily TV watching increased the risk of obesity by 23% (95% CI, 17%-30%) and diabetes by 14% (95% CI, 5%-23%). Each two hour increment of sitting at work or driving increased the risk of obesity by 5% (95% CI, 0%-10%) and diabetes by 7% (95% CI, 0%-16%).
    This study highlights the importance of reducing sedentary behaviors and increasing physical activity in order to prevent diabetes and obesity.
  • This prospective study evaluated the role of walking and vigorous exercise in 73,743 postmenopausal women. Increasing quintiles of energy expenditure were inversely associated with the risk of coronary events (as depicted in this slide) and total cardiovascular events (p value for trend of coronary events is 0.004 for walking, 0.008 for vigorous exercise; p value for trend of total cardiovascular events is &lt;0.001 for both walking and vigorous exercise).
  • This study sought to correlate the level of physical fitness (measured by a treadmill exercise test) with mortality in 13,344 healthy men and women over 8 years. The least fit men had an age-adjusted all-cause mortality rate of 64.0 per 10,000 person-years, whereas the most fit men had a mortality rate of 18.6 per 10,000 person-years. The least fit women had an age-adjusted all-cause mortality rate of 39.5 per 10,000 person-years, whereas the most fit women had a mortality rate of 8.5 per 10,000 person-years.
  • This observational survey of self-reported physical activity in 772 British men with CHD found that those with light or moderate activity had the lowest all-cause and cardiovascular mortality. The adjusted relative risks compared to inactive/occasionally active men were 0.42 for light activity (95% CI 0.25-0.71), 0.47 for moderate activity (95% CI, 0.24-0.92), and 0.63 for moderately vigorous/vigorous activity (95% CI 0.39-1.03).
  • In a large meta-analysis of ten randomized controlled trials, use of cardiac rehabilitation following a MI (4,347 patients total) resulted in lower rates of all-cause death (OR 0.76, 95% CI 0.63 to 0.92) and cardiovascular death (OR 0.75, 95% CI 0.62 to 0.93), with no effect on nonfatal recurrent MI.
  • Less than 20% of Medicare beneficiaries attend all 36 sessions of phase II cardiac rehabilitation. In this study, the median number of sessions attended was 25 (interquartile range, 13 to 34), with more than 40% attending at least 30 sessions and 13% attending less than 6 sessions.
  • In this study, after adjustment for demographic characteristics, comorbid conditions, and subsequent hospitalization, patients attending 36 sessions of cardiac rehabilitation had a 14% lower risk of death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 to 0.97) and a 12% lower risk of MI (HR, 0.88; 95% CI, 0.83 to 0.93) than those who attended 24 sessions; a 22% lower risk of death (HR, 0.78; 95% CI, 0.71 to 0.87) and a 23% lower risk of MI (HR, 0.77; 95% CI, 0.69 to 0.87) than those who attended 12 sessions; and a 47% lower risk of death (HR, 0.53; 95% CI, 0.48 to 0.59) and a 31% lower risk of MI (HR, 0.69; 95% CI, 0.58 to 0.81) than those who attended only 1 session.
  • In this meta-analysis of 63 randomized clinical trials, participation in a secondary prevention program (including those with and without exercise) resulted in lower rates of all cause mortality and recurrent myocardial infarction.
  • 5 acc prevention lifestyle changes

    1. 1. The Evidence for Current Cardiovascular Disease Prevention Guidelines: Lifestyle Management American College of Cardiology BestEvidence and Guidelines Practice Quality Initiative Subcommittee and Prevention Committee
    2. 2. Classification of Recommendations and Levels of 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.
    3. 3. Icons Representing the Classification and Evidence Levels for Recommendations 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
    4. 4. Evidence for Current Cardiovascular Disease Prevention Guidelines Cigarette Smoking Cessation Evidence and Guidelines
    5. 5. Smoking Prevalence in the United States National Health Interview Survey Estimated 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 Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161
    6. 6. Tobacco Use: Most Preventable Cause of Death Most preventable causes of death in the U.S. in 1990 and 2000 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) 1,060,000 (50*) 1,159,000 (48%*) Total *Reflects percent total of 9 most preventable causes of death Source: Mokdad AH et al. JAMA 2004;291:1238-1245
    7. 7. Cigarette Smoking Cessation Evidence: Risk of Non-fatal Myocardial Infarction* 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) 0.1 Ceased smoking 1.0 Continued smoking 10 *Includes those with known coronary heart disease Source: Critchley JA et al. JAMA 2003;290:86-97
    8. 8. Cigarette Smoking Cessation Evidence: Tailored Materials 1058 current and recent ex-smokers randomized to a smoking cessation strategy of usual care* vs. computed-generated tailored advice** Abstinence rates (%) 35 30 25 20 p=0.015 20.9 Usual care Tailored care p=0.004 18.9 15.4 15 p=0.013 16.4 12.7 p=0.080 11.3 10 12.2 9.0 5 0 24 hour 7 day 1 month Duration of abstinence 3 month Self-help materials tailored for the needs of individual smokers are more effective than usual materials *Usual care consists of telephone counselling and a mailed information packet **Tailored care consists of usual care + a computer-generated individually tailored advice letter Source: Sutton S et al. Addiction 2007;102:994-1000.
    9. 9. Cigarette Smoking Cessation: Effect of Counseling Intervention Meta-analysis of 33 clinical trials assessing the benefit of smoking cessation counseling interventions with or without pharmacotherapy 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 Inpatient counseling with contact >1 month after discharge is associated with the greatest rate of smoking cessation Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
    10. 10. Cigarette Smoking Cessation: Frequency of Nicotine Dependence Percent Reporting >1 Indicators of Nicotine Dependence, by Age and Intensity of Smoking 12-24 Years Old Less than 6* 25+ Years Old 6-15* 16-25* 26+* *Cigarettes per day Source: Substance Abuse and Mental Health Services Administration; United States, 2010 National Survey.
    11. 11. Cigarette Smoking Cessation: Types of Nicotine Replacement Increase in nicotine concentration (ng/ml) Plasma nicotine concentrations 14 12 10 8 Cigarette Gum 4 mg 6 Gum 2 mg 4 Inhaler 2 Nasal spray Patch 0 5 10 15 Minutes 20 25 30 Source: Balfour DJ et al. Pharmacol Ther 1996;72:51-81
    12. 12. Cigarette Smoking Cessation Evidence: Effect of Combination Therapy Limited Behavioral Support Intervention Effect Size 95% CI Nicotine gum 5% 4-6% Nicotine transdermal patch 5% 4-7% Intensive Behavioral Support 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% CI=Confidence interval Sources: West R et al. Thorax 2000;55:987-999 Silagy C et al. Cochrane Database Syst Rev 2002;CD000146
    13. 13. Cigarette Smoking Cessation Evidence: Primary Prevention 893 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 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 Bupropion with or without NRT provides the greatest benefit p<0.001 when compared to placebo b p=0.001 when compared to NRT c p<0.001 when compared to NRT d p=0.37 when compared to bupropion e p=0.22 when compared to bupropion a NRT=Nicotine replacement therapy Source: Jorenby DE et al. NEJM 1999;340:685-691
    14. 14. Cigarette Smoking Cessation Evidence: Primary Prevention 1,027 smokers randomized to 12 weeks of varenicline (titrated to 1 mg bid), bupropion (titrated to 150 mg bid), or placebo Varenicline vs. Bupropion P<0.001 (weeks 9-12), P=0.004 (weeks 9-52) Varenicline provides greater rates of abstinence than bupropion Source: Jorenby DE et al. JAMA 2006;296:56-63
    15. 15. Cigarette Smoking Cessation: Pharmacotherapy* Agent Caution Side Effects Dosage Duration Instructions Bupropion SR (Zyban®)** Seizure disorder Eating disorder Taking MAO inhibitor Pregnancy Insomnia Dry mouth 150 mg QAM then 150 mg BID 3 days Start 1-2 weeks before quit date. Take 2nd dose in early afternoon or decrease to 150 mg QAM for insomnia. Transdermal Nicotine Patch*** Varenicline (Chantix®)** Depression/ Suicide Within 2 weeks of a MI Unstable angina Arrhythmias Heart failure Skin reaction Insomnia Pregnancy Nausea Sleep disorder Depression/ Suicide CV risk 8 weeks, but up to 6 months 21 mg QAM 14 mg QAM 7 mg QAM or 15 mg QAM 4 weeks 2 weeks 2 weeks 0.5 mg QD then 0.5 mg BID then 1 mg BID 3 days 8 weeks Apply to different hairless site daily. Remove before bed for insomnia. Start at <15 mg for <10 cigs/day Start 1 week before the quit date 4 days 12 weeks *Pharmacotherapy combined with behavioral support provides the best success rate **The FDA has placed a black box warning on varenicline and buproprion SR due to the risk of depression and/or suicidal thoughts ***Other nicotine replacement therapy options include: nicotine gum, lozenge, inhaler, nasal spray
    16. 16. Cigarette Smoking Cessation: Effect of Pharmacotherapy 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 Source: Rigotti NA et al. Arch Intern Med 2008;168:1950-1960
    17. 17. Cigarette Smoking Cessation: Benefit of Community Smoking Ban 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 ACS=Acute coronary syndrome Source: Pell JP et al. NEJM 2008;359:482-491
    18. 18. Cigarette Smoking Cessation: Benefit of Community Smoking Ban 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 MI=Myocardial infarction Source: Lightwood JM et al. Circulation 2009;120:1373-1379
    19. 19. Cigarette Smoking Cessation: Benefit of Financial Incentives 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 Source: Volpp KG et al. NEJM 2009;360:699-709
    20. 20. Tobacco Cessation Algorithm Ask and document tobacco use status Current User Recent Quitter (<6 months) Advise Provide a strong, personalized message Assess Readiness to quit in next 30 days Ready Not Ready Assist: Negotiate plan • STAR** • Discuss pharmacotherapy • Social support • Provide educational materials 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 **STAR 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 Set quit date Tell family, friends, and coworkers Anticipate challenges: withdrawal, breaks Remove tobacco from the house, car, etc. 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
    21. 21. AHA Primary Prevention of CV Disease in DM Tobacco Recommendations Primary Prevention • 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=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, NRT=Nicotine replacement therapy Source: Buse JB et al. Circulation 2007;115:114-126
    22. 22. ADA Smoking Cessation Recommendations for Patients with Diabetes Mellitus Primary 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. ADA=American Diabetes Association Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    23. 23. Tobacco Cessation Recommendations Secondary Prevention Goals: Complete tobacco cessation and no environmental tobacco smoke exposure I IIa IIb III Patients should be asked about tobacco use status at every office visit I IIa IIb III Every tobacco user should be advised at every visit to quit I IIa IIb III The tobacco user’s willingness to quit should be assessed at every visit. Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    24. 24. Tobacco Cessation Recommendations (Continued) Secondary Prevention I IIa IIb III 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 I IIa IIb III Arrangement for follow up is recommended. I IIa IIb III All patients should be advised at every office visit to avoid exposure to environmental tobacco smoke at work, home, and public places Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    25. 25. Evidence for Current Cardiovascular Disease Prevention Guidelines Diet and Weight Management Evidence and Guidelines
    26. 26. Overweight and Obese States: Definition Using the Body Mass Index (BMI) Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht2 (in) 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 *Measurement of waist circumference is most helpful in this category Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October, 2000. NIH publication No. 00-4084
    27. 27. Prevalence of Obesity in U.S. Adults 1991 1996 2006 2008 Percentage of State Obese (BMI > 30) No Data <10% 10–14% 15–19% 20–24% 25-29% >30% Source: CDC Overweight and Obesity
    28. 28. Change in Body Mass Index Distribution in the United States Over Time National Health and Nutrition Examination Survey (NHANES) 100% Body mass index (kg/m2) age-adjusted percentage 90% 80% 70% 60% 50% 40% 30% >35 30-35 25-30 >25 20% 10% 0% Source: Ford ES et al. Circulation 2009;120:1181-1188
    29. 29. Adult obesity At age 21-29 years (%) Body Mass Index: Risk of Developing Obesity in Adulthood Age of child (years) BMI=Body mass index Source: Whitaker RC et al. NEJM 1997;337:869-873
    30. 30. Body Mass Index: Relationship with Waist Circumference Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:1039-1049
    31. 31. Body Mass Index: Risk 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
    32. 32. Body Mass Index: Risk 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: Bays HE et al. Int J Clin Pract 2007;61:737-747
    33. 33. Body Mass Index: Risk of Cardiovascular Disease Hazard Ratio 4.0 Hemorrhagic CVA 4.0 Ischemic CVA 4.0 2.0 2.0 2.0 1.0 1.0 1.0 0.5 0.5 Ischemic Heart Disease 0.5 16 20 24 28 32 36 16 20 24 28 32 36 16 20 24 28 32 36 Body Mass Index (kg/m2)* *BMI is calculated as the weight in kg divided by the BSA in meters2 CVA=Cerebrovascular accident Source: Mhurchu N et al. Int J Epidemiol 2004;33:751-758
    34. 34. Diet Evidence: Types of Treatment Programs 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
    35. 35. Diet Evidence: Types of Treatment Programs (Continued) 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
    36. 36. Diet Evidence: Primary Prevention 160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or Ornish diets for 1 year Ornish 20/40* Weight Watchers 26/40* Zone 26/40* Atkins 21/40* 0 3 Wt loss (lbs) 6 9 Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance *Ratio of individuals completing the study to those enrolled Source: Dansinger, ML et al. JAMA 2005;293:43-53
    37. 37. AHA Primary Prevention of CV Disease in DM Weight Management Recommendations Primary Prevention • 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=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol Source: Buse JB et al. Circulation 2007;115:114-126
    38. 38. Weight Management Recommendations Secondary Prevention Goals: I IIa IIb III 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 Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    39. 39. Weight Management Recommendations (Continued) Secondary Prevention I IIa IIb III 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 I IIa IIb III 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. Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    40. 40. Evidence for Current Cardiovascular Disease Prevention Guidelines Diet Evidence, Cardiovascular Events, and Guidelines
    41. 41. Relationship Between Diet and CV Disease 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 CV=Cardiovascular Source: Hu FB et al. JAMA. 2002;288:2569-2578
    42. 42. Diet Evidence: Effect 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 Change from Baseline (%) 30 LDL-C 20 LDL-C:HDL-C CRP 10 Low fat diet 0 Statin -10 Dietary portfolio* -20 -30 -40 -50 0 2 Weeks 4 0 2 Weeks 4 0 2 4 Weeks A diversified diet improves lipid parameters and CRP levels *Enriched in plant sterols, soy protein, viscous fiber, and almonds CRP=C-reactive protein, HDl-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol Source: Jenkins DJ et al. JAMA 2003;290:502-510
    43. 43. Diet Evidence: Effect on Blood Pressure Dietary Approaches to Stop Hypertension (DASH) Group 459 hypertensive patients randomized to 1 of 3 diets for 8 weeks 132 Systolic blood pressure 130 (mm Hg) 126 128 Diet low in fruits, vegetables, and dairy products 124 Diet enriched in fruits, vegetables, and fiber 86 Diastolic blood pressure 84 (mm Hg) 80 Diet enriched in fruits and vegetables and low in fat and cholesterol 82 78 0 1 2 3 4 5 6 7/8 Weeks A diversified diet improves blood pressure Source: Appel LJ et al. NEJM 1997;336:1117-1124
    44. 44. Diet Evidence: Benefits of Fruits and Vegetables Nurses’ Health Study and Health Professional’s Follow-up Study 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 *Includes nonfatal MI and fatal coronary heart disease CV=Cardiovascular Joshipura KJ et al. Ann Intern Med 2001;134:1106-1114
    45. 45. Diet Evidence: Benefits 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 RR=0.73, P<0.001 Increased dietary fiber intake reduces CV risk CV=Cardiovascular, CHD=Coronary heart disease Source: Pereira MA et al. Arch Int Med 2004;164:370-376
    46. 46. Diet Evidence: Making 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
    47. 47. Diet Evidence: Primary Prevention 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 Variable # of Deaths/ # of Participants Death from any cause Death from CHD Death from cancer Fully Adjusted Hazard Ratio (95% CI) 275/22,043 0.75 (0.64-0.87) 54/22,043 0.67 (0.47-0.94) 97/22,043 0.76 (0.59-0.98) High adherence to a Mediterranean diet is associated with a reduction in death CHD=Coronary heart disease Source: Trichopoulou A et al. NEJM 2003;348:2599-2608
    48. 48. Diet Evidence: Secondary Prevention Lyon Diet Heart Study 605 patients following a myocardial infarction randomized to a Mediterranean* or Western** diet for 4 years Freedom from cardiac death or myocardial infarction (%) 100 90 Mediterranean diet Western diet 80 70 P=0.0001 1 2 3 Year 4 5 A Mediterranean diet reduces cardiovascular events *High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber Source: De Lorgeril M et al. Circulation 1999;99:779-785
    49. 49. Adult Treatment Panel (ATP) III Dietary Recommendations Nutrient Saturated fat* Recommended Intake <7% of total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat 25%–35% of total calories Carbohydrate (esp. complex carbs) Fiber 50%–60% of total calories 20–30 g/d Protein Cholesterol ~15% of total calories <200 mg/d *Trans fatty acids also raise LDL-C and should be kept at a low intake Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight LDL-C=Low density lipoprotein cholesterol Source: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497
    50. 50. American Heart Association Nutrition Committee Dietary Recommendations Recommendations for Cardiovascular Disease Risk Reduction • 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 AHA=American Heart Association Source: AHA Nutrition Committee. Circulation 2006;114:82-96
    51. 51. Dietary Recommendations Primary Prevention I IIa IIb III 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
    52. 52. AHA Primary Prevention of CV Disease in DM Dietary Recommendations Primary Prevention • 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=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, LDL-C=Low density lipoprotein cholesterol Source: Buse JB et al. Circulation 2007;115:114-126
    53. 53. AHA Primary Prevention of CV Disease in DM Dietary Recommendations Primary Prevention • 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=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus Source: Buse JB et al. Circulation 2007;115:114-126
    54. 54. ADA Medical Nutrition Therapy Recommendations for Patients with Primary Prevention Diabetes Mellitus • 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. ADA=American Diabetes Association, DM=Diabetes mellitus Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    55. 55. ADA Medical Nutrition Therapy Recommendations for Patients with Primary Prevention Diabetes Mellitus (Continued) • 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. ADA=American Diabetes Association, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol, LDL-C=Low density lipoprotein cholesterol Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    56. 56. ADA Medical Nutrition Therapy Recommendations for Patients with Primary Prevention Diabetes Mellitus (Continued) • 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). AHA=American Heart Association, DM=Diabetes mellitus, FDA=Food and Drug Administration Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    57. 57. ADA Medical Nutrition Therapy Recommendations for Patients with Primary Prevention Diabetes Mellitus (Continued) • 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. ADA=American Diabetes Association, DM=Diabetes mellitus Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    58. 58. Dietary Recommendations Secondary Prevention I IIa IIb III I IIa IIb III 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 omega3 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
    59. 59. Evidence for Current Cardiovascular Disease Prevention Guidelines Physical Activity Evidence and Guidelines
    60. 60. Adverse Effects of Physical Inactivity Physical Inactivity Inflammation Dyslipidemia Age Hypertension Diabetes Mellitus Smoking Obesity Hypercoagulability Genetics Atherosclerosis Novel Risk Factors
    61. 61. Prevalence of Physical Activity Prevalence of physical activity among individuals >18 years of age Over half the U.S. adult population is physically inactive NH=Non-Hispanic Source: Lloyd-Jones D et al. Circulation 2010;121:46-215
    62. 62. Exercise Evidence: Effect on Body Composition 173 sedentary, overweight (body mass index >24 kg/m2) post-menopausal women randomized to moderate intensity exercise vs. stretching for 1 year Total Body Fat Intra-abdominal Fat Moderate exercise reduces total and intra-abdominal fat Note: Minutes per week spent in moderate-intensity sports activity (low-active, 135 min/wk; intermediately active, 136-195 min/wk; and highly active, >195 min/wk) Source: Irwin ML et al. JAMA 2003;289:323-330
    63. 63. Exercise Evidence: Effect on Lipid Parameters Assessment of lipid profiles in 719 patients undergoing cardiac rehab Year and Lipid Level (mg/dL) Baseline 1 3 5 Change from Baseline TC Men Women 214 239 213 223 210 209 196 193 ↓ 8% ↓ 20%* LDL-C Men Women 138 155 134 135 131 120 118 102 ↓ 15% ↓ 34%* HDL-C Men Women 37 47 40 50 41 55 39 56 ↑ 5% ↑ 20%† TG Men Women 200 188 197 190 199 174 202 171 NS Lipids *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 Source: Warner JG et al. Circulation 1995;92:773-777
    64. 64. Exercise Evidence: Effect on Lipid Parameters Look AHEAD Trial 5,145 patients aged 45-74 years with type 2 DM and BMI of 25 kg/m 2 (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) 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 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: Look AHEAD investigators. Diabetes Care 2007;30:1374-1383
    65. 65. Exercise Evidence: Effect on Obesity and Diabetes Mellitus (DM) Nurse’s Health Study 35% 30% Risk of obesity Risk of DM 25% 20% 15% 10% 5% 0% Reduction: Increase: Increase: Each hour a day spent walking briskly Each two hours a day spent watching TV Each two hours a day spent sitting at work Exercise reduces the incidence of obesity and DM Source: Hu FB et al. JAMA 2003;289:1785-1791
    66. 66. Exercise Evidence: Effect on Coronary Heart Disease Risk Women’s Health Initiative Observational Study P=0.008 P=0.004 Relative Risk of CHD Walking Relative Risk of CHD Vigorous exercise* 1 2 3 4 5 1 2 3 4 5 Quintiles of activity (MET-hour/week**) *Includes aerobics, aerobic dancing, jogging, tennis, and swimming laps **Average active hours per week × energy expenditure per activity CHD=Coronary heart disease Source: Manson JE et al. NEJM 2002;347:716-725
    67. 67. Physical Activity: Effect on Mortality 13,344 healthy men and women followed for 8 years Death Rate (per 10,000) 70 60 Men Women 50 40 30 20 10 0 1 2 3 4 5 Fitness Level to High) Fitness Level (Low(Low to High) Low physical fitness is associated with increased mortality Source: Blair SN et al. JAMA 1998;262:2395-2401
    68. 68. Physical Activity: Secondary Prevention Age-adjusted mortality rate/1000 person-years Observational study of self-reported physical activity in 772 men with CHD Physical activity Moderate exercise is associated with reduced mortality CHD=Coronary heart disease, CVD=Cardiovascular disease Source: Wannamethee SG et al. Circulation 2000;102:1358-1363
    69. 69. Cardiac Rehabilitation: Benefits Following a Myocardial Infarction Effect of cardiac rehabilitation in randomized controlled trials following a MI * * Cardiac rehabilitation reduces CV events after a MI *p<0.0125 CV=Cardiovascular, MI=Myocardial infarction Source: Oldridge NB et al. JAMA 1988;260:945-950
    70. 70. Cardiac Rehabilitation: Prevalence of Incomplete Attendance Sessions attended (%) Observational study of 30,161 Medicare patients attending at least 1 phase II cardiac rehabilitation session Number of Sessions Attended A large number of patients fail to complete 36 sessions of cardiac rehabilitation Source: Hammill BG et al. Circulation 2010;121:63-70
    71. 71. Cardiac Rehabilitation: Greater Benefit with Greater Attendance study of 30,161 Medicare patients attending at least 1 Observational Death (%) Myocardial infarction (%) phase II cardiac rehabilitation session Years after Index Date Years after Index Date There is a strong dose-response relationship between the number of cardiac rehabilitation sessions attended and long-term CV outcomes CV=Cardiovascular Source: Hammill BG et al. Circulation 2010;121:63-70
    72. 72. Cardiac Rehabilitation: Benefit of Secondary Prevention Programs Meta-analysis of 63 randomized clinical trials evaluating cardiac secondary prevention programs with or without exercise programs All cause mortality Recurrent myocardial infarction Secondary prevention programs provide CV benefit CV=Cardiovascular Source: Clark AM et al. Ann of Intern Med 2005;143:659-72
    73. 73. AHA Primary Prevention of CV Disease in DM Physical Activity Recommendations Primary Prevention • 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 Source: Buse JB et al. Circulation 2007;115:114-126
    74. 74. ADA Physical Activity Recommendations for Patients with Diabetes Mellitus Primary 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. ADA=American Diabetes Association, DM=Diabetes mellitus Source: American Diabetes Association. Diabetes Care 2010;33:S11-61
    75. 75. Physical Activity Recommendations Secondary Prevention Goal: I IIa IIb III 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 Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    76. 76. Physical Activity Recommendations (Continued) Secondary Prevention I IIa IIb III For all patients, risk assessment with a physical activity history and/or an exercise test is recommended to guide prognosis and prescription I IIa IIb III The clinician should counsel patients to report and be evaluated for symptoms related to exercise. I IIa IIb III It is reasonable for the clinician to recommend complementary resistance training at least 2 days per week Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    77. 77. Cardiac Rehabilitation Recommendations Secondary Prevention I IIa IIb III All eligible patients with ACS or whose status is immediately post coronary artery bypass surgery or postPCI should be referred to a comprehensive outpatient cardiovascular rehabilitation program either prior to hospital discharge or during the first follow-up office visit I IIa IIb III I IIa IIb III 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. Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
    78. 78. Cardiac Rehabilitation Recommendations (Continued) Secondary Prevention I IIa IIb III I IIa IIb III A home-based cardiac rehabilitation program can be substituted for a supervised, center-based program for lowrisk patients A comprehensive exercise-based outpatient cardiac rehabilitation program can be safe and beneficial for clinically stable outpatients with a history of heart failure Source: Smith SC Jr. et al. JACC 2011;58:2432-2446
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