1. 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

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. I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII I IIaIIbIII Icons Representing the Classification and Evidence Levels for Recommendations

4. Cigarette Smoking Cessation Evidence and Guidelines Evidence for Current Cardiovascular Disease Prevention Guidelines

5. Smoking Prevalence in the United States Source: CDC, Morbidity and Mortality Weekly Report 2007;56:1157-1161 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

6. Causes# (%) in 1990# (%) in 2000 Tobacco400,000 (19)435,000 (18) Poor diet and physical activity (obesity)300,000 (14)400,000 (17) Alcohol consumption100,000 (5)85,000 (4) Microbial agents90,000 (4)75,000 (3) Toxic agents60,000 (3)55,000 (2) Motor vehicle accidents25,000 (1)43,000 (2) Firearms 35,000 (2)29,000 (1) Sexual behavior30,000 (1)20,000 (<1) Illicit drug use20,000 (<1)17,000 (<1) Total1,060,000 (50*)1,159,000 (48%*) Source: Mokdad AH et al. JAMA 2004;291:1238-1245 Tobacco Use: Most 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

7. 0.11.0 10 Ceased smokingContinued smoking RR (95% Cl) Study Aberg, et al. 19830.67(0.53-0.84) Herlitz, et al. 19950.99(0.42-2.33) Johansson, et al. 19850.79 (0.46-1.37) Perkins, et al. 19853.87(0.81-18.37) Sato, et al. 19920.10(0.00-1.95) Sparrow, et al. 19780.76(0.37-1.58) Vlietstra, et al. 19860.63(0.51-0.78) Voors, et al. 19960.54(0.29-1.01) Source: Critchley JA et al. JAMA 2003;290:86-97 *Includes those with known coronary heart disease Cigarette Smoking Cessation Evidence: Risk of Non-fatal Myocardial Infarction*

8. Abstinence rates (%) 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 Evidence: Tailored Materials 0 5 10 15 20 25 30 35 24 hour Duration of abstinence Usual care Tailored care 15.4 20.9 12.7 18.9 11.3 16.4 9.0 12.2 7 day1 month3 month p=0.015 p=0.004 p=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

9. Cigarette Smoking Cessation: 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

10. 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: Frequency of Nicotine Dependence 12-24 Years Old 25+ Years Old Less than 6*6-15*16-25*26+* *Cigarettes per day

11. Minutes Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 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 Increase in nicotine concentration (ng/ml) Plasma nicotine concentrations Cigarette Smoking Cessation: Types of Nicotine Replacement

12. Limited Behavioral Support InterventionEffect Size95% CI Nicotine gum5%4-6% Nicotine transdermal patch5%4-7% InterventionEffect Size95% CI Nicotine gum8%6-10% Nicotine transdermal patch6%5-8% Nicotine nasal spray12%7-17% Nicotine inhaler8%4-12% Nicotine sublingual tablet8%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 Evidence: Effect of Combination Therapy CI=Confidence interval

13. 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 a 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 NRT=Nicotine replacement therapy Bupropion with or without NRT provides the greatest benefit 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

14. 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 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 provides greater rates of abstinence than bupropion

15. AgentCautionSide EffectsDosageDurationInstructions Bupropion SR (Zyban®)** Seizure disorder Eating disorder Taking MAO inhibitor Pregnancy Insomnia Dry mouth Depression/ Suicide 150 mg QAM then 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 Nicotine Patch*** Within 2 weeks of a MI Unstable angina Arrhythmias Heart failure Skin reaction Insomnia 21 mg QAM 14 mg QAM 7 mg QAM or 15 mg QAM 4 weeks 2 weeks 8 weeks Apply to different hairless site daily. Remove before bed for insomnia. Start at <15 mg for <10 cigs/day Varenicline (Chantix®)** PregnancyNausea Sleep disorder Depression/ Suicide CV risk 0.5 mg QD then 0.5 mg BID then 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: Pharmacotherapy*

16. 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

17. Cigarette Smoking Cessation: Benefit 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

18. Cigarette Smoking Cessation: 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

19. Cigarette Smoking Cessation: 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

20. 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 **STAR Set quit date Tell family, friends, and coworkers Anticipate challenges: withdrawal, breaks Remove tobacco from the house, car, etc. Recent Quitter (<6 months) Current User Not Ready Ready Tobacco 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

21. 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 DM Tobacco Recommendations Primary Prevention

22. 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 Recommendations for Patients with Diabetes Mellitus Primary Prevention

23. Tobacco Cessation Recommendations 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 IIaIIbIII I IIaIIbIII I IIaIIbIII Secondary Prevention

24. Tobacco Cessation Recommendations (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 IIaIIbIII I IIaIIbIII I IIaIIbIII

25. Diet and Weight Management Evidence and Guidelines Evidence for Current Cardiovascular Disease Prevention Guidelines

26. Defined by Body Mass Index = (703.1)* Wt (lbs)/ Ht 2 (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 CategoryBMI (kg/m 2 ) Normal18.5-24.9 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: Definition Using the Body Mass Index (BMI)

27. Prevalence of Obesity in U.S. Adults 19911996 2006 No Data 30% Source: CDC Overweight and Obesity Percentage of State Obese (BMI > 30) 2008

28. Change in Body Mass Index Distribution in 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 mass index (kg/m 2 ) age-adjusted percentage >35 National Health and Nutrition Examination Survey (NHANES) 30-35 25-30 >25

29. Source: Whitaker RC et al. NEJM 1997;337:869-873 BMI=Body mass index Adult obesity At age 21-29 years (%) Age of child (years) Body Mass Index: Risk of Developing Obesity in Adulthood

30. Source: Despres JP et al. Arterioscler Thromb Vasc Biol 2008;48:1039-1049 Body Mass Index: Relationship with Waist Circumference

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. 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)

33. Source: Mhurchu N et al. Int J Epidemiol 2004;33:751-758 0.5 1.0 2.0 4.0 162024283236 Body Mass Index (kg/m 2 )* Hazard Ratio 0.5 1.0 2.0 4.0 162024283236 0.5 1.0 2.0 4.0 162024283236 Hemorrhagic CVA Ischemic CVA Ischemic Heart Disease CVA=Cerebrovascular accident *BMI is calculated as the weight in kg divided by the BSA in meters 2 Body Mass Index: Risk of Cardiovascular Disease

34. 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: Types of Treatment Programs

35. Very low carbohydrate –Atkins (Induction and Maintenance) 1 st 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) 1 st phase (2 weeks) significantly restricts carbohydrates 2 nd phase reintroduces low glycemic carbohydrates 3 rd 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: Types of Treatment Programs (Continued)

36. 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* 21/40* 0 369 Atkins Zone Weight Watchers Ornish Wt loss (lbs) *Ratio of individuals completing the study to those enrolled Diet Evidence: Primary Prevention

37. 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 DM Weight Management Recommendations Primary Prevention AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, HDL-C=High density lipoprotein cholesterol

38. Source: Smith SC Jr. et al. JACC 2011;58:2432-2446 BMI 18.5-24.9 kg/m 2, 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/m 2 Secondary Prevention I IIaIIbIII Weight Management Recommendations Goals:

39. 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 IIaIIbIII Weight Management Recommendations (Continued) I IIaIIbIII

40. Diet Evidence, Cardiovascular Events, and Guidelines Evidence for Current Cardiovascular Disease Prevention Guidelines

41. 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 Disease CV=Cardiovascular

42. 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 from Baseline (%) LDL-C:HDL-CCRP Weeks Low fat diet Statin Dietary portfolio* *Enriched in plant sterols, soy protein, viscous fiber, and almonds 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 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

43. 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: Effect on Blood Pressure 459 hypertensive patients randomized to 1 of 3 diets for 8 weeks A diversified diet improves blood pressure

44. 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: Benefits 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

45. 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: 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 Increased dietary fiber intake reduces CV risk

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. Source: Trichopoulou A et al. NEJM 2003;348:2599-2608 Variable # of Deaths/ # of Participants Fully Adjusted Hazard Ratio (95% CI) Death from any cause 275/22,0430.75 (0.64-0.87) Death from CHD 54/22,0430.67 (0.47-0.94) Death from cancer 97/22,0430.76 (0.59-0.98) Diet Evidence: Primary 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

48. 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: Secondary Prevention 12345 70 80 90 100 Year P=0.0001 Mediterranean diet Western diet Freedom from cardiac death or myocardial infarction (%)

49. <200 mg/dCholesterol ~15% of total caloriesProtein 20–30 g/dFiber 50%–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) III Dietary Recommendations *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

50. American Heart Association Nutrition Committee 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

51. 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 Recommendations I IIaIIbIII

52. 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 DM Dietary Recommendations Primary Prevention AHA=American Heart Association, CV=Cardiovascular, DM=Diabetes mellitus, LDL-C=Low density lipoprotein cholesterol

53. 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 DM Dietary Recommendations Primary Prevention

54. 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 Recommendations for Patients with Diabetes Mellitus Primary Prevention

55. 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 Recommendations for Patients with Diabetes Mellitus (Continued) Primary Prevention

56. 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 Recommendations for Patients with Diabetes Mellitus (Continued) Primary Prevention AHA=American Heart Association, DM=Diabetes mellitus, FDA=Food and Drug Administration

57. 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 Recommendations for Patients with Diabetes Mellitus (Continued) Primary Prevention

58. 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 Recommendations Secondary Prevention I IIaIIbIII I IIaIIbIII

59. Physical Activity Evidence and Guidelines Evidence for Current Cardiovascular Disease Prevention Guidelines

60. Adverse Effects of Physical Inactivity Age Diabetes Mellitus Obesity Genetics Atherosclerosis Hypercoagulability Smoking Hypertension Novel Risk Factors InflammationDyslipidemia Physical Inactivity

61. Prevalence 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 inactive NH=Non-Hispanic

62. 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) Total Body FatIntra-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: Effect on Body Composition

63. NS  5%  20% †  15%  34%*  8%  20%* Change from Baseline 202 171 199 174 197 190 200 188 TG Men Women 39 56 41 55 40 50 37 47 HDL-C Men Women 118 102 131 120 134 135 138 155 LDL-C Men Women Year and Lipid Level (mg/dL) 196 193 210 209 213 223 214 239 TC Men Women 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: Effect on Lipid Parameters Assessment of lipid profiles in 719 patients undergoing cardiac rehab

64. ILIDSEP value LDL (mg/dL)-5.2 ± 0.6-5.7 ± 0.60.49 HDL (mg/dL)3.4 ± 0.21.4 ± 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/m 2 (27 kg/m 2 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: Effect 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

65. 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 obesity Risk of DM 0% 5% 10% 15% 20% 25% 30% 35% Exercise Evidence: Effect on Obesity and Diabetes Mellitus (DM)

66. Source: Manson JE et al. NEJM 2002;347:716-725 Quintiles of activity (MET-hour/week**) Walking Relative Risk of CHD Vigorous exercise* Relative Risk of CHD P=0.004P=0.008 1 2 345 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: Effect on Coronary Heart Disease Risk

67. Death Rate (per 10,000) Fitness Level (Low to High) Source: Blair SN et al. JAMA 1998;262:2395-2401 Men Women Physical Activity: Effect 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)

68. 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: Secondary Prevention Age-adjusted mortality rate/1000 person-years Physical activity

69. * * 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: Benefits Following a Myocardial Infarction Cardiac rehabilitation reduces CV events after a MI CV=Cardiovascular, MI=Myocardial infarction

70. 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: Prevalence of Incomplete Attendance Sessions attended (%) Number of Sessions Attended

71. Source: Hammill BG et al. Circulation 2010;121:63-70 Cardiac Rehabilitation: Greater Benefit with Greater Attendance Observational 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 (%)Myocardial infarction (%) Years after Index Date CV=Cardiovascular

72. 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: Benefit of Secondary Prevention Programs All cause mortalityRecurrent myocardial infarction Secondary prevention programs provide CV benefit CV=Cardiovascular

73. 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 DM Physical Activity Recommendations Primary Prevention

74. 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 Recommendations for Patients with Diabetes Mellitus Primary Prevention

75. 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 IIaIIbIII Physical Activity Recommendations Goal:

76. 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 Activity Recommendations (Continued) I IIaIIbIII I IIaIIbIII I IIaIIbIII

77. 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 Rehabilitation Recommendations I IIaIIbIII I IIaIIbIII I IIaIIbIII

78. 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 Rehabilitation Recommendations (Continued) I IIaIIbIII I IIaIIbIII