2005 Update
Guidelines for Management of
Modifiable Risk Factors in Adults at
High Risk for Cardiovascular Events
This Guideline replaces the “Guideline for the Management
of Modifiable Risk Factors in Adults at High Risk for
Cardiovascular Events.”
GOALS
♦ To increase rates of investigation and treatment of
modifiable risk factors in patients at high risk for
cardiovascular events, which will, in turn, reduce
mortality and morbidity from cardiovascular disease
♦ To provide a simple, practical, and cost-effective
multidisciplinary approach to risk factor
modification
♦ To assist and empower patients to identify their risk
for cardiovascular events and take responsibility for
reducing this risk
The focus of this guideline will be on patients at high
risk for cardiovascular events. However,
cardiovascular risk is a continuum, and risk factor
modification should be considered in all patients,
regardless of their current level of risk.
RECOMMENDATIONS
Target Patients At High Risk:
♦ Adult patients with atherosclerotic vascular disease:
• clinical or angiographic evidence of coronary
artery disease
• peripheral arterial disease
• cerebrovascular disease
♦ All patients with diabetes mellitus >30 years of age
♦ All patients with chronic kidney disease (CKD)
(GFR <60 mL/min)
♦ All patients undergoing long term hemodialysis
♦ Patients with an estimated 10 year risk of
coronary artery disease of ≥ 20% (Framingham
Risk, see Appendix)
The above recommendations are systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical circumstances.
They should be used as an adjunct to sound clinical decision making.
Administered by the Alberta Medical
Association
Practice Point
An active (rather than passive) identification of patients
at risk is recommended, as many patients do not
present for cardiovascular risk assessment. Patients
may also be referred by other health professionals such
as pharmacists or public health workers.
Identify and Manage Modifiable Risk Factors
♦ Smoking:
• Target complete cessation (regular
counselling by physicians is very important
and effective. Nicotine replacement and
buproprion may be effective short-term
adjuncts)
♦ Excess Weight:
• Aim for healthy body weight. (Prescribe a
low-fat, heart-healthy diet. Refer patient
to a dietician for advice)
♦ Sedentary Lifestyle:
• Recommend at least 30 minutes of physical
activity per day, most days of the week
(encouragement by physicians is important)
♦ Hypertension:
• Target: systolic <140 and diastolic <90 mmHg
(in diabetics without nephropathy, systolic
<130 and diastolic <80 mmHg)
• In addition to diet and exercise, medications
(diuretics, beta blockers, ACE inhibitors,
angiotensin receptor blockers, or calcium
channel blockers) are often necessary.
♦ Dyslipidemias
• Targets and thresholds for treatment
depend upon risk level
− Initiate drug therapy concomitant with
lifestyle modification immediately in
high risk patients (see Tables 1, 2 & 3).
Drug therapy may be initiated in
moderate and low risk patients after a 3
or 6 month trial respectively of lifestyle
changes.
 Table 1
Risk Level Definition Target
LDL-C TC/HDL
(mmol/L)
HIGH Established CVD, diabetes, or <2.5 <4
CKD, or 10y risk ≥ 20%

MODERATE 10y risk of 11 to 19% <3.5 <5

LOW 10y risk of ≤ 10% <4.5 <6

Table 2: Drugs of Choice For Management

Lipid Profile 1st Choice 2nd Choice

↑↑ LDL Statin Resin or ezetimibe

↑↑ LDL, ↑ TG Statin Fibrate or niacin

↑ LDL, ↓ HDL Fibrate or statin Combination therapy

↑ LDL, ↑↑ TG Fibrate or niacin Combination therapy

↓ HDL, ↑ TG Fibrate or niacin Combination therapy

• Consider: heart disease (CHD), continues to be the leading cause

− ASA (80-325 mg daily or every other
day) if estimated risk of coronary artery
disease is >10%.
− Angiotensin Converting Enzyme (ACE)
inhibitors such as ramipril (10mg daily),
enalapril (10mg BID), lisinopril (20mg
daily), or quinapril (40mg daily) in moderate
to high risk patients.
Monitor and Follow-up
♦ Regular follow-up visits are necessary to:
• Titrate/change of medications to ensure
patients reach their targets for cholesterol
and blood pressure
• Reinforce adherence to lifestyle modifications
(smoking cessation, diet and exercise) and
medications
• Recheck lipid panel and blood pressure at
6 to 12 weeks if not at target values, after
medication changes, and yearly once targets
achieved.
BACKGROUND
Atherosclerotic vascular disease, particularly coronary
of death and disability for Canadian men and women1.
Substantial advances have been made in the treatment
of myocardial infarction and other acute ischemic
syndromes, and this has contributed to improved
survival following an acute event. However, these
survivors, along with others who have documented
atherosclerotic vascular disease (e.g., cerebrovascular
or peripheral vascular disease), remain at very high
risk for subsequent ischemic vascular events and/or
death. The risk of these individuals is considerably
higher than that of the general population. However,
this risk can be substantially lowered through stringent
control of known modifiable cardiovascular risk
factors, notably smoking, dyslipidemia, hypertension,
diabetes, and a sedentary lifestyle. Moreover, risk
factor modification in this high-risk population has
been shown to be cost effective.2
Despite the compelling scientific evidence for the
efficacy of aggressive risk factor modification in
patients at high risk, the application of risk reduction
3-5
strategies is often inconsistent and incomplete. A
multidisciplinary, systematic approach to the
identification of such individuals, and consistent and
aggressive attention to risk factor assessment and

2
 Table 3: Lipid Lowering Agents
DRUGS INITIAL DOSE MAINTENANCE MAXIMUM POTENTIAL REQUIRED SIDE-EFFECTS COMMENTS
DOSE DOSE INTERACTIONS LABORATORY
Resins • Decreased absorption of • None • GI upset, • Space administration of
Cholestyramine 4 g qd - bid 4-8 g (qd-bid) 24 g/d digoxin, warfarin,thyroid, constipation other agents 1h before or
oral hypoglycemics, • Esophageal spasms 2h after resin
Colestipol statins, folic acid, or respiratory • Increase fluid and fiber
- granules 5 g qd-bid 5-15 g (qd-bid) 30 g/d gemfibrozil, thiazides, distress (if ingested
- tablets 2 g qd-bid 2-8 g (qd-bid) 16 g/d tetracycline, vitamins in dry form)
A,D,K
Fibrates • Displacement of warfarin • LFTs at baseline, 6 months, • GI upset, • Take with food (except
Gemfibrozil 300 mg bid 600 mg bid 1500 mg/d or oral hypoglycemics and 6 months to 1 year hepatoxocity, rash, gemfibrozil which should
Bezafibrate 400 mg qd 400 mg qd 400 mg/d • Increased risk of thereafter pruritis, headaches, be taken 30 min. prior
Fenofibrate myopathies with statins, • CK at first sign of muscle insomnia, myopathies to meals)
- regular 100 mg tid 400 mg/d niacin, or cyclosporine pain (d/c drug if CKs 10x
- micronized (Lipidil upper limit of normal)
Micro) 200 mg/d 200 mg/d 200 mg/d
- macrocoated (Lipidil
Supra) 160 mg/d 160 mg/d 200 mg/d
Niacin • Decreased effects of • LFTs at baseline, every 6 to • Flushing, headache, • Always take with food
(nicotinic acid) 125 mg bid 500mg tid-qd 2 g tid insulin or oral 12 weeks for first year then pruritis, GI upset, • Tolerance often develops to
hypoglycemics every 6 months thereafter hyperuricemia and flushing
Niacin Timed Release 500 mg qd 1500 tid-qd 2000 mg tid • Increased risk of • Uric acid and glucose at gout, hyperglycemia, • 325mg ASA 30 min. prior
myopathies with statins or baseline and as necessary hepatoxocity to niacin may help to
fibrates thereafter alleviate flushing
• Avoid hot beverages
Statins • Increased risk of • LFTs at baseline, every 6 to • GI upset, • All statins should be taken
Atorvastatin 10 mg 10-60 mg qd 80 mg qd myopathies with niacin, 12 weeks for first year then myopathies, with evening meal or at
Fluvastatin 20 mg 20-60 mg qd or bid 40 mg bid erythromycin, every 6 months thereafter hepatoxocity bedtime
Lovastatin 20 mg 20-60 mg qd 40 mg bid clarithromycin, gemfibrozil, • Uric acid and glucose at • Taking with food helps to
Pravastatin 10-20 mg 20-40 mg qd 60 mg qd ketoconazole, itraconazole, baseline and as necessary alleviate side-effects
Simvastatin 5-40 mg 10-40 mg qd 80 mg qd or cyclosporine thereafter • No clinical endpoint data
Rosuvastatin 10 mg 10-40 mg qd 40 mg qd (atorvastatin, ovastatin, and available for rosuvastatin at
simvastatin only). present.
• Increased digoxin with
atorvastatin or fluvastatin
• Increased warfarin levels
with fluvastatin
Ezetimibe 10 mg qd 10 mg qd 10 mg qd • Decreased ezetimibe in • None • Similar to placebo • May be used as
combination with monotherapy or in
cholestyramine combination with a low-
• Ezetimibe increased by dose statin
concomitant cyclosporin • No clinical endpoint data
and fibrate administration available at present
modification in the population at highest risk is will
result in reduced clinical event rates and enhanced patient
outcomes. Recommendations and targets for risk factor
modification are outlined here.
Research Findings
Accumulated scientific data clearly demonstrate that risk
factor interventions, when effectively applied to
population groups at high risk for future atherosclerotic
vascular events reduce morbidity, as well as total and
cardiovascular disease (CVD) mortality.
Risk Stratification
A simple scheme for risk stratification of patients will
help to guide treatment decisions and set targets for
risk factors:
♦ All patients with evidence of atherosclerotic
vascular disease (coronary artery disease, including
stable or unstable angina, myocardial infarction, or
revascularization, peripheral arterial disease, or
cerebrovascular disease) are automatically
considered at high risk for cardiovascular events.7
♦ All patients with diabetes mellitus (> 30 years of
age) are also automatically considered at high risk
for cardiovascular events.7
Studies have shown that interventions delivered by
physicians can have13a significant impact on patients’
smoking behaviour. Advice to stop smoking is
associated with a cessation rate of 3%. Advice given
in a 3 to 5 minute counselling session, with follow up
visits at 1, 3, and 6 months,
13-14
can increase the cessation
rate to 23% or more.
Control of Hypertension
Extensive clinical and epidemiologic investigations
have clearly demonstrated that hypertension is associated
with accelerated coronary atherosclerosis, development of
congestive failure, and up to a six-fold increase in stroke
risk.15-19 Treatment of mild-to-moderate hypertension is
associated with significant decreases, approaching 40%,
in risk for stroke, with reductions of 8 to 12% in CHD
risk.16 Among high risk subjects, including those with
established CHD or multiple risk factors, even minor
decreases in blood pressure can result in marked benefits
in terms of prevention of premature death or disabling
vascular event.20
Blood pressure targets have been defined by various
hypertension working groups..
Patient Group Target Blood
Pressure (mmHg)
Systolic and / or diastolic
hypertension <140 and <90

♦ All patients with chonic kidney disease and those on Isolated systolic hypertension <140
long-term dialysis are also automatically considered
at high risk for cardiovascular events.7 Renal disease <130 and <80

♦ All other patients should have a risk estimation Diabetes without nephropathy <130 and <80
performed using the Framingham Risk Calculator
(see Appendix). Those with 10 year risk estimates of Proteinuria >1g/day <125 and <75
≥ 20% are considered at high risk. The Framingham
Risk Calculator does not account for all known Unfortunately, most patients do not reach their target
cardiovascular risk factors. Risk factors such as blood pressure, highlighting the importance of close
obesity, sedentary lifestyle and significant family follow-up, medication titration, and use of combinaiton
history should be taken into account when risk antihypertensive therapy.
stratifying.
Management: Initial Drugs of Choice18
Smoking Cessation
Age <60y Low-dose thiazide diuretics, beta-
Successful smoking cessation in patients with CVD blockers, ACE inhibitors, angiotensin
substantially reduces mortality risk.10-12 A decrease in receptor blockers, or long-acting
total mortality up to 50% has been shown for individuals dihydropyridine calcium channel
who discontinue smoking after a first myocardial blockers
9
infarction. Similar findings have been documented in Age >60y Low-dose thiazide diuretics, ACE
10
the Coronary Artery Surgery Study. In this study, inhibitors, angiotensin receptor
smokers also spent more days in hospital than non- blockers, or long-acting
smokers, with a substantial concomitant excess in dihydropyridine calcium channel
11
hospital costs.
blockers
4
The recommendations for initial drugs of choice are for
patients with uncomplicated hypertension. For patients
with concurrent disease states, please refer to the
guidelines for treatment recommendations. If
monotherapy is insufficient after dosage increases,
consider use of combination therapy. The reader is
referred to recent Canadian and U.S. guidelines for the
diagnosis and treatment of hypertension.9,17-19
Management of Diabetes Mellitus
There is a well-documented excess of mortality in
persons with diabetes mellitus compared to the general
population, and estimates indicate 75 to 80% of
adults with diabetes die from coronary, peripheral
or cerebrovascular disease.21,22 Epidemiologic studies have
indicated that patients with diabetes (and ‘no evidence of
heart disease) have an equal risk of myocardial infarction
to those patients with a previous myocardial infarction but
23
without diabetes. This has led to the recommendation
that all patients with diabetes mellitus >30 years of
age be automatically considered at very high risk for
cardiovascular events, regardless of clinical history.7
Although optimization of glucose control has historically
been central to the management of diabetes, smoking
cessation and aggressive control of cholesterol and blood
pressure are critical to improve patient outcomes and
considered a priority by the Canadian Diabetes Associaiton
Clinical Practice Guidelines Expert Committee in the
prevention of complications associated with diabetes.24 At
any given level of risk, individuals with diabetes have a 4
to 5 fold increase in risk for CVD and its attendant
complications.While it is controversial whether or not
macrovascular complications are tightly linked to
glycemic control, clinical and laboratory studies do
indicate that lipoprotein particles undergo glycation and
oxidation with increased frequency in the presence of
hyperglycemia. Such altered lipoprotein particles are
believed to stimulate atherogenesis, underscoring the
importance of optimizing both glycemic control, and
serum lipid levels, in persons with diabetes.
Similarly, blood pressure control is of particular
importance in patients with diabetes, and lower target
values of <130/80 reflect this.
Routine screening for diabetes is recommended in the
following patients24:
♦ every 3 years in individuals >40 years of age
♦ screening should be performed more frequently or
earlier if additional risk factors are present (eg., First
degree relative with diabetes, vascular disease,
hypertension, etc.)
5
Modification of Activity
Physical activity has beneficial effects on several risk
factors, including serum lipids, blood pressure,
glucose/insulin utilization, and body weight.25 Recent
studies suggest a 34% population-attributable risk of CHD
death related to physical inactivity.25 Conversely,
numerous epidemiologic studies have demonstrated that
regular physical activity is associated with reductions in
CHD incidence and mortality.25 Randomized trials of
exercise have suggested reductions of about 25% in
cardiovascular mortality for men with CHD.26
Recommendations for the appropriate types, intensity,
and duration of physical activity should be routinely,
provided to high risk patients. Many patients will begin
from a low fitness level, and a mild activity that is
convenient and safe if preferable in the initial phase. This
can be increased gradually to achieve 30 minutes of
accumulated moderate-intensity activity on most,
preferably all, days.27
Modification of Serum Cholesterol
Compelling scientific evidence, including data from large
scale randomized clinical trials, have demonstrated that a
lipid lowering diet and/or drug therapies result in
improved arteriographic measurements, reductions in
clinical events, and decreased CVD and all-cause
mortality, even in patients with average cholesterol
levels.26-37
Thus, the research evidence is clear for the benefit of
aggressive treatment of cholesterol risk in those at
moderate to high risk.
Treatment Targets
Treatment targets are based upon LDL cholesterol levels,
and are determined by the level of risk of the individual
patient.7(See Table 1)
* For information on how to calculate the 10 year
Framingham Risk (for subsequent development of
cardiovascular disease), please consult Appendix 1).
Initiate drug therapy immediately in high risk patients.
Drug therapy may be initiated in moderate and low risk
patients after a 3 month or 6 month trial respectively of
lifestyle changes. For management drugs of choice see
Table 2.
Despite the unequivocal scientific evidence supporting the
need for assessment and treatment of dyslipidemia
in patients at high risk for atherosclerotic vascular events,
 Summary of Major Cholesterol Trials28-37

STUDY INTERVENTION AVERAGE ↓ IN TOTAL

%↓ ↓ IN
%↓
BASELINE LDL
MORTALITY CARDIOVASCULAR
EVENTS
Secondary Prevention Trials

4S Simvastin 20-40 mg/d 4.9 30 34

CARE Pravastatin 40 mg/d 3.6 NS* 24

LIPID Pravastatin 40 mg/d 3.9 22 24

HPS** Simvastatin 40 mg/d 3.4 13 27

PROSPER** Pravastatin 40 mg/d 3.8 NS* 19

GREACE Atorvastatin 10 - 80 mg/d 4.7 43 51

Primary Prevention Trials
WOSCOPS Pravastatin 40 mg/d 5.0 22 31

AFCAPS/ Lovastatin 20 - 40 mg/d 3.9 NS 37

TexCAPS

ASCOT-LLA Atorvastatin 10 mg/d 3.4 NS 29

ALLHAT-LLT Pravastatin 40 mg/d 3.8 NS NS

* Not statistically significant

** Primary and secondary prevention trials

numerous studies indicate that risk factor assessment
and modification is inconsistent and often incomplete. A
study by the Clinical Quality Improvement Network in 4
Western Canadian hospitals has shown that, among
3,304 patients with documented artherosclerotic
vascular disease recently discharged from hospital, only
28% had a serum cholesterol measurement documented
in the medical record. Overll, only 7% of patients were
prescribed lipid-lowering medication. Evaluation and
treatment of other risk factors were at even lower levels.
These findings have been replicated by numerous other
investigators. Moreover, based upon a review of the
literature describing practice patterns in lipid
management, as few as 8% of patients do not reach their
LDL cholesterol targets, highlighting the need for close
follow-up and medication adjustment where necessary.
Summary
Extensive clinical and observational research has
established that CVD risk factor control in patients at
high risk for atherosclerotic vascular events is associated
with improved survival and a reduced need for
revascularization and hospitalization. Despite wide
dissemination of the scientific evidence, application of risk
assessment and intervention strategies in the high risk
population appears inconsistent and suboptimal. A
comprehensive, patient-centred multidisciplinary approach
to risk factor modification will improve outcomes for the
entire population at risk, and can be expected to reduce the
economic and societal burden of atherosclerotic vascular
disease.
NOTES ON THE APPLICABILITY
OF THIS GUIDELINE
The recommendations in this Guideline are based on
scientific evidence that aggressive risk factor modification
in patients at high risk for athersclerotic vascular events
will improve or delay the need for hospitalization and
invasive interventional procedures. It is acknowledged that
major lifestyle modification requires cooperation between

6
patients, physicians and other health care professionals.
Additionally, the preferences of individual patients with
regard to lifestyle changes must be taken into account in
selecting risk modification strategies. Patient education
and empowerment is an integral component of optimal
risk factor management.
This Guideline reflects current knowledge of
cardiovascular risk factors and efficacious risk factor
modification strategies. Guidelines may be subject to
changes in the event of the following:
♦ Identification of additional risk factors which are
amenable to modification.
♦ Development of new strategies for risk factor
modification.
♦ Improved ability to predict the benefits to individual
patients of aggressive risk factor modification.
♦ Target lipid levels were derived from published
recommendations from the Canadian Working
Group on Hypercholesterolemia and Other
Dyslipidemias,6,7 the National Cholesterol Education
Program (NCEP III),8 the Canadian Hypertension
Recommendation Working Group,17-19 and the Joint
National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure9,
and may change as new evidence is published.
AUTHORS
Ross T. Tsuyuki, BSc(Pharm), PharmD, FCSHP, FACC.
Professor of Medicine (Cardiology) and Director,
EPICORE Centre, Faculty of Medicine and Dentistry,
University of Alberta.
Sheri Koshman, BSc Pharm, PharmD (candidate).
EPICORE Centre.
Glen J Pearson, BSc, BScPharm, PharmD, FCSHP.
Associate Professor of Medicine (Cardiology), Faculty
of Medicine and Dentistry, University of Alberta.
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 APPENDIX 1: Determine Risk Points36,37

Risk factor Risk points: Risk points: 10 yr Risk %

Age group, yr Men Wo m e n <1
20-34 -9 -7 1
35-39 -4 -3 2
40-44 0 0 3
45-49 3 3 4
50-54 6 6 5
55-59 8 8 6
60-64 10 10 8
65-69 11 12 10
70-74 12 14
75-79 13 16 12
Total cholesterol level, mmol/L Age Group, Yr Age Group, Yr 16
20-39 40-49 50-59 60-69 70-79 20-39 40-49 50-59 60-69 70-79
<4.14 0 0 0 0 0 0 0 0 0 200
4.14-5.19 4 3 2 1 0 4 3 2 1 215
5.20-6.19 7 5 3 1 0 8 6 4 2 ≥30
1
6.20-7.20 9 6 4 2 1 11 8 5 3 2
≥7.21 11 8 5 3 1 13 10 7 4 2
Smoker
No 0 0 0 0 0 0 0 0 0 0
Yes 8 5 3 1 1 9 7 4 2 1
HDL-C level, mmol/L
≥1.55 -1 -1
1.30-1.54 0 0
1.04-1.29 1 1
<1.04 2 2
Systolic BP mmHg Untreated Treated Untreated Treated
<120 0 0 0 0
120-129 0 1 1 3
130-139 1 2 2 4
140-159 1 2 3 5
≥160 2 3 4 6
Risk Category Total Risk Points 10 yr Risk % Total Risk Points 10 yr Risk %
Low Risk <0 <1 <9 <1
0-4 1 9-12 1
5-6 2 13-14 2
7 3 15 3
8 4 16 4
9 5 17 5
10 6 18 6
11 8 19 8
12 10
Moderate Risk 20 11
13 12 21 14
14 16 22 17
High Risk 15 20 23 22
16 25 24 27
≥17 ≥30 ≥25 ≥30
Toward Optimized Practice (TOP)
Program

Arising out of the 2003 Master Agreement, TOP succeeds the

former Alberta Clinical Practice Guidelines program, and
maintains and distributes Alberta CPGs. TOP is a health
quality improvement initiative that fits within the broader
health system focus on quality and complements other
strategies such as Primary Care Initiative and the Physician
Office System Program.

The TOP program supports physician practices, and the

teams they work with, by fostering the use of evidence-based
best practices and quality initiatives in medical care in
Alberta. The program offers a variety of tools and out-reach
services to help physicians and their colleagues meet the
challenge of keeping practices current in an environment of
continually emerging evidence.

TO PROVIDE FEEDBACK

The TOP Program encourages your feedback. If you need

further information or if you have difficulty applying this
guideline, please contact:

Clinical Practice Guidelines Manager

TOP Program
12230 - 106 Avenue NW
Edmonton AB T5N 3Z1
Phone: 780.482.0319
or toll free 1.866.505.3302
Fax: 780.482.5445
Email: cpg@topalbertadoctors.org
Website: www.topalbertadoctors.org

Cardiovascular Guideline: Revised February 2005