Primary And Secondary Prevention Of Cardiovascular Disease
Publication Date: February 1, 2012
Last Updated: March 14, 2022
Recommendations
Primary Prevention of Cardiovascular Disease
2.1 For persons aged 50 years or older without symptomatic cardiovascular disease, we suggest low-dose aspirin 75 to 100 mg daily over no aspirin therapy. (2, B)
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Secondary Prevention of Cardiovascular Disease
3.1.1-3.1.5. For patients with established coronary artery disease (CAD), defined as patients 1-year post-acute coronary syndrome (ACS), with prior revascularization, coronary stenoses >50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, (including patients after the first year post-ACS and/or with prior coronary artery bypass graft [CABG] surgery):
- We recommend long-term single antiplatelet therapy with aspirin 75 to 100 mg daily or clopidogrel 75 mg daily over no antiplatelet therapy.
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- We suggest single over dual antiplatelet therapy with aspirin plus clopidogrel.
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3.2.1-3.2.5. For patients in the first year after an ACS who have not undergone PCI:
- We recommend dual antiplatelet therapy (ticagrelor 90 mg twice daily plus low-dose aspirin 75-100 mg daily or clopidogrel 75 mg daily plus low-dose aspirin 75-100 mg daily) over single antiplatelet therapy.
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- We suggest ticagrelor 90 mg daily plus lowdose aspirin over clopidogrel 75 mg daily plus low-dose aspirin.
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For patients in the first year after an ACS who have undergone PCI with stent placement:
- We recommend dual antiplatelet therapy (ticagrelor 90 mg twice daily plus low-dose aspirin 75-100 mg daily, clopidogrel 75 mg daily plus low-dose aspirin, or prasugrel 10 mg daily plus low-dose aspirin over single antiplatelet therapy).
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- We suggest ticagrelor 90 mg twice daily plus low-dose aspirin over clopidogrel 75 mg daily plus low-dose aspirin.
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For patients with ACS who undergo PCI with stent placement, we refer to sections 4.3.1 to 4.3.5 for recommendations concerning minimum and prolonged duration of treatment. (-)
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3.2.6-3.2.7. For patients with anterior MI and LV thrombus or at high risk for LV thrombus (ejection fraction >40%, anteroapical wall motion abnormality) who do not undergo stenting:
- We recommend warfarin (INR 2.0-3.0) plus low-dose aspirin 75 to 100 mg daily over single antiplatelet therapy or dual antiplatelet therapy for the first 3 months.
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- Thereafter, we recommend discontinuation of warfarin and continuation of dual antiplatelet therapy for up to 12 months as per the ACS recommendations (see recommendations 3.2.1-3.2.5).
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- After 12 months, single antiplatelet therapy is recommended as per the established CAD recommendations (see recommendations 3.1.1-3.1.5).
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For patients with anterior MI and LV thrombus, or at high risk for LV thrombus (ejection fraction <40%, anteroapical wall motion abnormality), who undergo BMS placement:
- We suggest triple therapy (warfarin [INR 2.0-3.0], low-dose aspirin, clopidogrel 75 mg daily) for 1 month over dual antiplatelet therapy.
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- We suggest warfarin (INR 2.0-3.0) and single antiplatelet therapy for the second and third month post-BMS over alternative regimens and alternative time frames for warfarin use.
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- Thereafter, we recommend discontinuation of warfarin and use of dual antiplatelet therapy for up to 12 months as per the ACS recommendations (see recommendations 3.2.1-3.2.5).
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- After 12 months, antiplatelet therapy is recommended as per the established CAD recommendations (see recommendations 3.1.1-3.1.5).
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For patients with anterior MI and LV thrombus or at high risk for LV thrombus (ejection fraction <40%, anteroapical wall motion abnormality) who undergo DES placement:
- We suggest triple therapy (warfarin [INR 2.0-3.0], low-dose aspirin, clopidogrel 75 mg daily) for 3 to 6 months over alternative regimens and alternative durations of warfarin therapy.
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- Thereafter, we recommend discontinuation of warfarin and continuation of dual antiplatelet therapy for up to 12 months as per the ACS recommendations (see recommendations 3.2.1-3.2.5).
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After 12 months, antiplatelet therapy is recommended as per the established CAD recommendations (see recommendations 3.1.1-3.1.5). (-)
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Antithrombotic Therapy Following Elective PCI
4.1.1-4.3.5. For patients who have undergone elective PCI with placement of BMS:
- For the first month, we recommend dual antiplatelet therapy with aspirin 75 to 325 mg daily and clopidogrel 75 mg daily over single antiplatelet therapy.
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- For the subsequent 11 months, we suggest dual antiplatelet therapy with combination of low-dose aspirin 75 to 100 mg daily and clopidogrel 75 mg daily over single antiplatelet therapy.
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After 12 months, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy. (1, B)
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For patients who have undergone elective PCI with placement of DES:
- For the first 3 to 6 months, we recommend dual antiplatelet therapy with aspirin 75 to 325 mg daily and clopidogrel 75 mg daily over single antiplatelet therapy.
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- After 3 to 6 months, we suggest continuation of dual antiplatelet therapy with lowdose aspirin 75 to 100 mg and clopidogrel (75 mg daily) until 12 months over single antiplatelet therapy.
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- After 12 months, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy.
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- Single antiplatelet therapy thereafter is recommended as per the established CAD recommendations (see recommendations 3.1.1-3.1.5).
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For patients who have undergone elective BMS or DES stent placement:
- We recommend use of low-dose aspirin 75 to 100 mg daily and clopidogrel 75 mg daily alone rather than cilostazol in addition to these drugs.
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- We suggest aspirin 75 to 100 mg daily and clopidogrel 75 mg daily as part of dual antiplatelet therapy rather than the use of either drug with cilostazol.
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- We suggest cilostazol 100 mg twice daily as substitute for either low-dose aspirin 75 to 100 mg daily or clopidogrel 75 mg daily as part of a dual antiplatelet regimen in patients with an allergy or intolerance of either drug class.
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For patients with CAD undergoing elective PCI but no stent placement:
- We suggest for the first month, dual antiplatelet therapy with aspirin 75 to 325 mg daily and clopidogrel 75 mg daily over single antiplatelet therapy.
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- Single antiplatelet therapy thereafter is recommended as per the established CAD recommendations (see recommendations 3.1.1-3.1.5).
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Antithrombotic Therapy in Patients With Systolic LV Dysfunction
5.1-5.3. For patients with systolic LV dysfunction without established CAD and no LV thrombus, we suggest not to use antiplatelet therapy or warfarin. (2, C)
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For patients with systolic LV dysfunction without established CAD with identifi ed acute LV thrombus (eg, Takotsubo cardiomyopathy), we suggest moderate-intensity warfarin (INR 2.0-3.0) for at least 3 months. (2, C)
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For patients with systolic LV dysfunction and established CAD, recommendations are as per the established CAD recommendations (see recommendations 3.1.1-3.1.5). (-)
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Recommendation Grading
Overview
Title
Primary And Secondary Prevention Of Cardiovascular Disease
Authoring Organization
American College of Chest Physicians
Publication Month/Year
February 1, 2012
Last Updated Month/Year
May 15, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies.
Target Patient Population
Patients on long-term anti thrombotic agents
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Home health, Hospital, Long term care, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D013923 - Thromboembolism, D011315 - Preventive Medicine, D003324 - Coronary Artery Disease, D003323 - Coronary Aneurysm, D003328 - Coronary Thrombosis, D010975 - Platelet Aggregation Inhibitors
Keywords
coronary heart disease, primary prevention, prevention, thromboembolism, anticoagulation, antiplatelet, myocardial infarction (MI), antiplatelet agents, coronary artery disease, Anticoagulation