2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines

Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended. Follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement) is recommended, as is a stepwise strategy for smoking cessation (Ask, Advise, Assess, Assist, Arrange).
Patients should initiate and/or maintain lifestyle modifications-weight control; increased physical activity; moderation of alcohol consumption; limited sodium intake; and maintenance of a diet high in fresh fruits, vegetables, and low-fat dairy products.
Blood pressure control according to Joint National Committee VII guidelines is recommended (i.e., blood pressure <140/90 mm Hg or <130/80 mm Hg for patients with diabetes or chronic kidney disease).
Low-density lipoprotein cholesterol (LDL-C) should be <100 mg/dl and reduction of LDL-C to <70 mg/dl or high-dose statin therapy is reasonable.
If triglycerides are 200-499 mg/dl, non-high-density lipoprotein cholesterol (non-HDL-C) should be <130 mg/dl, and further reduction of non-HDL-C to <100 mg/dl is reasonable, if triglycerides are ≥200-499 mg/dl.
Physical activity of 30-60 minutes, 7 days per week (minimum 5 days per week) is recommended. All patients should be encouraged to obtain 30-60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily activities (such as walking breaks at work, gardening, or household work).
Body mass index (BMI) and waist circumference should be assessed regularly. On each patient visit, it is useful to consistently encourage weight maintenance/reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs, when indicated, to achieve and maintain a BMI between 18.5 and 24.9 kg/m.
If waist circumference is ≥35 inches (89 cm) in women or ≥40 inches (102 cm) in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.g., 37-40 inches [94-102 cm]). Such persons may have a strong genetic contribution to insulin resistance. They should benefit from changes in lifestyle habits, similarly to men with categorical increases in waist circumference.
Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA_1c.
Aspirin should be started at 75-162 mg/d and continued indefinitely in all patients unless contraindicated.
Angiotensin-converting enzyme (ACE) inhibitors should be started and continued indefinitely in all patients with left ventricular ejection fraction ≥40% and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated.
Angiotensin receptor blockers are recommended for patients who have hypertension, have indications for but are intolerant of ACE inhibitors, have heart failure, or have had a myocardial infarction with left ventricular ejection fraction ≥40%.
It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had a myocardial infarction, acute coronary syndrome, or left ventricular dysfunction, with or without heart failure symptoms, unless contraindicated.
An annual influenza vaccination is recommended for patients with cardiovascular disease.
Chelation therapy (intravenous infusions of ethylenediamine tetraacetic acid [EDTA]) is not recommended for the treatment of chronic angina or arteriosclerotic cardiovascular disease, and may be harmful because of its potential to cause hypocalcemia. Debabrata Mukherjee, M.D., F.A.C.C.