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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesPrimary and Secondary Prevention of Cardiovascular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
Summary of Recommendations
Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.
2.1. For persons aged 50 years or older without symptomatic cardiovascular disease, we suggest low-dose
Methods
Table 1 describes the clinical questions (ie, population, intervention, comparator, and outcome) for each of the recommendations that follow. We define only patient characteristics relevant to our questions. For example, because whether ACS occurs with or without ST-segment elevation is not relevant to long-term secondary prevention, we provide a single set of recommendations for all patients following ACS. We have selected the same patient-important outcomes across all recommendations (eg,
Primary Prevention of Cardiovascular Disease
In this section, we address the effects of aspirin in primary prevention of cardiovascular disease. In addition, we consider recent meta-analyses demonstrating a reduction in cancer mortality and total mortality with long-term use of aspirin.4, 5, 6 We do not include other antiplatelet therapies (eg, clopidogrel alone or in combination with aspirin) or oral anticoagulation (eg, warfarin) because they are not likely used in primary prevention. Whether aspirin should be prescribed in patients
Secondary Prevention of Cardiovascular Disease
The evidence supporting the use of specific antithrombotic therapies sometimes differs between patients who have recently experienced an ACS and those with stable CAD. For purposes of these guidelines, and based on available data, recommendations for therapy following ACS will apply to the postdischarge period and extend to 1 year. Thereafter, patients will be considered to have established CAD. This definition is by necessity somewhat arbitrary, and we acknowledge that the higher-risk period
Antithrombotic Therapy Following Elective PCI
Choice and duration of antiplatelet therapy following PCI depends on the setting (acute vs elective), whether a stent is placed, and the type of stent (DES vs BMS) placed. We have previously discussed evidence for antithrombotic therapy following PCI in patients with ACS. In this section, we discuss antithrombotic therapy following elective PCI. As in prior sections, we address the patient-important outcomes of death, nonfatal MI, nonfatal stroke (if reported), and major bleeding.
Antithrombotic Therapy in Patients With Systolic LV Dysfunction
Approximately 70% of patients with systolic LV dysfunction and heart failure have ischemic heart disease. The remaining 30% of patients with systolic heart failure are considered to have a nonischemic etiology (eg, hypertensive heart disease, valvular heart disease, idiopathic). Because the majority of these latter patients are free of concomitant CAD, risk for MI is lower than that of patients with ischemic systolic LV dysfunction.
Acknowledgments
Author contributions: As Topic Editor, Dr Vandvik oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Vandvik: served as Topic Editor.
Dr Lincoff: served as a panelist.
Dr Gore: served as a panelist.
Dr Gutterman: served as a panelist.
Dr Sonnenberg: served as a resource consultant.
Dr Alonso-Coello: served as a panelist.
Dr Akl: served as a panelist.
Dr Lansberg: served as a panelist.
Dr Guyatt: served as a panelist.
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Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
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