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## Complete Summary

#### GUIDELINE TITLE

Secondary prevention of coronary artery disease clinical practice
guidelines.

#### BIBLIOGRAPHIC SOURCE(S)

Kaiser Permanente Care Management Institute. Secondary prevention of
coronary artery disease clinical practice guideline. Oakland (CA):
Kaiser Permanente Care Management Institute; 2006 Mar. 117 p. \[51
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Coronary artery disease (CAD)

#### GUIDELINE CATEGORY

Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To assist primary care physicians and other health care professionals in
the treatment of patients with coronary artery disease in order to
prevent subsequent cardiovascular (CV) events

#### TARGET POPULATION

Patients with coronary artery disease in the outpatient primary care
setting, care management programs, home health, skilled nursing
facilities, and custodial care facilities

Inpatient and emergency department settings are not addressed

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Angiotensin-converting enzyme (ACE) inhibitor therapy

2.  Angiotensin II receptor blocker (ARB) therapy

3.  Antiplatelet therapy

    -   Aspirin

    -   Clopidogrel

    -   Ticlopidine

4.  Beta blockers, including carvedilol, metoprolol CR/XL, bisoprolol,
    metoprolol tartrate

5.  Lipid management

    -   Statins

    -   Dietary fat modification

**Note**: Dietary supplement therapy with vitamins C, E, B6, B12, beta
carotene, and folic acid is considered but not recommended.

#### MAJOR OUTCOMES CONSIDERED

-   Mortality due to cardiac causes

-   All cause mortality

-   Hospitalization, including non-fatal myocardial infarction (MI),
    nonfatal stroke, transient ischemic attack (TIA), unstable angina,
    and revascularization procedures

-   Side effects of treatment

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Guidelines are developed using an \"evidence-based methodology\" and
involve a systematic literature search, critical appraisal of the
research design and statistical results of relevant studies, and grading
of the sufficiency (quantity, quality, consistency, and relevancy) of
the evidence for drawing conclusions.

During the guideline development process, the Guideline Development Team
reviews evidence published in peer-reviewed scientific journals,
existing evidence-based guidelines, and consensus-based statements from
external professional societies and government health organizations, and
clinical expert opinion of Kaiser Permanente regional specialty groups.

For details of the literature search, including databases searched and
search terms for each clinical question, see the original guideline
document.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Refer to Table 2 in the Appendix in the original guideline document for
the system for grading the strength of a body of evidence.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Guidelines are developed using an \"evidence-based methodology\" and
involve a systematic literature search, critical appraisal of the
research design and statistical results of relevant studies, and grading
of the sufficiency (quantity, quality, consistency, and relevancy) of
the evidence for drawing conclusions.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

To develop the coronary artery disease (CAD) guidelines, released in
March 2006, a multidisciplinary, interregional Guideline Development
Team first met in September 2005 to define the scope of the guideline.
Clin-eGuide (Wolters Kluwer), an outside vendor, then performed
systematic reviews of the medical literature on each of the clinical
questions identified by the Guideline Development Team, assembled the
evidence, and developed draft recommendations for review by the
Guideline Development Team. All of the recommendations and supporting
evidence were reviewed by the Guideline Development Team in depth during
two conference calls in January and March, 2006.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Recommendations are classified as either \"evidence-based (A-D, I)\" or
\"consensus.\" Refer to the table below for full definitions.

-   Evidence-based: sufficient number of high-quality studies from which
    to draw a conclusion, and the recommended practice is consistent
    with the findings of the evidence. A recommendation can also be
    considered \"evidence-based\" if there is insufficient evidence and
    no practice is recommended.

-   Consensus: insufficient evidence and a practice is recommended based
    on the consensus or expert opinion of the Guideline Development
    Team.

**Label and Language of Recommendations\***

  --------------------------------------------------------------------------------
  **Label**             **Evidence-Based Recommendations**
  --------------------- ----------------------------------------------------------
  **Evidence-based      **Language**: ^a^ The intervention is strongly recommended
  (A)**                 for eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on good evidence, and the Guideline
                        Development Team (GDT) concludes that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good.

  **Evidence-based      **Language**: ^a^ The intervention is recommended for
  (B)**                 eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on 1) good evidence that benefits outweigh
                        harms and costs; or 2) fair evidence that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ No recommendation for or against routine
  (C)**                 provision of the intervention. (At the discretion of the
                        GDT, the recommendation may use the language \"option,\"
                        but must list all the equivalent options.)\
                        \
                        **Evidence**: Evidence is sufficient to determine the
                        benefits, harms, and costs of an intervention, and there
                        is at least fair evidence that the intervention improves
                        important health outcomes.  But the GDT concludes that the
                        balance of the benefits, harms, and costs is too close to
                        justify a general recommendation.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ Recommendation against routinely
  (D)**                 providing the intervention to eligible patients.\
                        \
                        **Evidence**: The GDT found at least fair evidence that
                        the intervention is ineffective, or that harms or costs
                        outweigh benefits.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ The evidence is insufficient to
  (I)**                 recommend for or against routinely providing the
                        intervention.= (At the discretion of the GDT, the
                        recommendation may use the language \"option,\" but must
                        list all the equivalent options.)\
                        \
                        **Evidence**: Evidence that the intervention is effective
                        is lacking, of poor quality, or conflicting and the
                        balance of benefits, harms, and costs cannot be
                        determined.\
                        \
                        **Evidence Grade**: Insufficient.

  **Consensus-based**   **Language**: ^a^ The language of the recommendation is at
                        the discretion of the GDT, subject to approval by the
                        National Guideline Directors.\
                        \
                        **Evidence**: The level of evidence is assumed to be
                        \"Insufficient\" unless otherwise stated. However, do not
                        use the A, B, C, D, or I labels which are only intended to
                        be used for evidence-based recommendations.\
                        \
                        **Evidence Grade**: Insufficient, unless otherwise stated.

  For the rare          
  consensus-based       
  recommendations which 
  have \"Good\" or      
  \"Fair\" evidence,    
  the evidence must     
  support a different   
  recommendation,       
  because if the        
  evidence were good or 
  fair, the             
  recommendation would  
  usually be            
  evidence-based. In    
  this kind of          
  consensus-based       
  recommendation, the   
  evidence grade should 
  point this out, e.g., 
  \"Evidence Grade:     
  Good, supporting a    
  different             
  recommendation.\"     
  --------------------------------------------------------------------------------

^\[a\]^ All statements specify the population for which the
recommendation is intended.

\* Recommendations should be labeled and given an evidence grade. The
evidence grade should appear in the rationale. Evidence is graded with
respect to the degree it supports the specific clinical recommendation.
For example, there may be good evidence that Drugs 1 and 2 are effective
for Condition A, but no evidence that Drug 1 is more effective than Drug
2. If the recommendation is to use either Drug 1 or 2, the evidence is
good. If the recommendation is to use Drug 1 in preference to Drug 2,
the evidence is insufficient.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The National Guideline Directors\' Guideline Quality Committee reviewed
and approved the guidelines in March 2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations are identified as either \"evidence-based (A-D, I)\" or
\"consensus-based.\" For definitions of the levels of recommendations
see the end of the \"Major Recommendations\" field.

**[Summary]{.underline}**

**Definition of Coronary Artery Disease (CAD)**

These guidelines describe secondary prevention measures for patients
with a diagnosis of ischemic heart disease based upon a history of
angina, myocardial infarction (MI), coronary artery bypass surgery graft
(CABG), percutaneous coronary intervention (PCI), or evidence of
coronary artery disease on angiography or non-invasive testing. For
treatment decisions involving patients with acute coronary syndromes,
cardiology consultation is recommended.

**Angiotensin-Converting Enzyme (ACE) Inhibitor Therapy**

For most patients with CAD,\* angiotensin-converting enzyme (ACE)
inhibitor therapy is recommended for long term use,\*\* unless
contraindicated.

\* In the PEACE Trial, patients with stable coronary artery disease and
preserved left ventricular systolic function had no benefit on the
composite endpoint of cardiovascular death, MI, and coronary
revascularization with the addition of an ACE-inhibitor to standard
medical therapy. ACE-inhibition is, therefore, not required in such
patients.

\*\* For patients on concomitant aspirin, low-dose aspirin is
recommended.

***Evidence-based***

**Angiotensin II Receptor Blocker (ARB) Therapy**

A.  Angiotensin II receptor blocker (ARB) therapy is recommended for the
    following patients with CAD who are intolerant to ACE inhibitors:

    -   Patients with CAD and diabetes with hypertension and
        microalbuminuria (or albuminuria)

    -   Patients with CAD and left ventricular systolic dysfunction
        (LVSD)

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B.  For patients who are intolerant to ACE inhibitors, with CAD and
    hypertension (without either LVSD or diabetes), ARB therapy is an
    option equal to other antihypertensive medications.

C.  For all other patients with CAD who are intolerant to ACE
    inhibitors, there is insufficient evidence to recommend for or
    against ARB therapy.

A: ***Consensus-based***\
B, C: ***Evidence-based***

**ACE Inhibitor + Aspirin**

For all patients with CAD taking low-dose aspirin, ACE inhibitor therapy
may be safely recommended for long term use.

***Evidence-based***

**ACE Inhibitor Plus ARB Therapy**

A.  For CAD patients, the routine addition of ARB therapy to ACE
    inhibitor therapy is not recommended.

B.  If ARBs are added to ACE inhibitors it should be done for clinical
    reasons, such as uncontrolled hypertension or insufficient
    vasodilation.

C.  This recommendation applies whether or not a patient is treated with
    a beta blocker.

A, B, C: ***Consensus-based***

**Antiplatelet Therapy: Aspirin**

A.  For all patients with CAD, daily aspirin (75 to 325 mg) is
    recommended indefinitely, unless there is clear contraindication
    such as active bleeding, major coagulopathy, or true aspirin
    allergy.

B.  For CAD patients on concomitant ACE Inhibitors, low-dose aspirin is
    recommended.

> (NOTE: The lowest dose commercially available acetylsalicylic acid
> (ASA) in the United States is 81 mg.)

A: ***Evidence-based***\
B: ***Consensus-based***

**Antiplatelet Therapy: Clopidogrel Use in Stable Patients**

A.  In stable CAD patients who tolerate aspirin well (and who are not
    post-procedure), clopidogrel is not recommended as either a
    substitute for or in addition to aspirin.

B.  In stable CAD patients with contraindications to aspirin,
    clopidogrel is recommended as the antiplatelet of choice.

A, B: ***Consensus-based***

**Antiplatelet Therapy: Post-Procedure**

A.  Following coronary artery bare metal stent placement clopidogrel
    plus aspirin is recommended to be given for at least four weeks.

B.  Following coronary artery drug-eluting stent placement, clopidogrel
    plus aspirin is recommended to be given for at least three months
    and up to one year post-procedure to reduce the risk of thrombotic
    events.

C.  If there is presence of a rash after clopidogrel use, patients may
    be switched to ticlopidine.

A: ***Evidence-based***\
B, C: ***Consensus-based***

**Beta Blocker Therapy**

Beta blocker therapy is recommended for CAD patients unless
contraindicated; specifically:

A.  For post-MI patients non-intrinsic sympathomimetic activity
    (non-ISA) beta blocker therapy is recommended.

B.  For post-MI patients non-ISA beta blocker therapy is recommended to
    be initiated within hours after MI and continued long term.

C.  For CAD patients with unstable angina, long term non-ISA beta
    blocker therapy is recommended.

D.  For CAD patients with chronic stable angina, long term non-ISA beta
    blocker therapy is recommended for treatment of symptoms.

E.  For CAD patients with silent ischemia, non-ISA beta blocker therapy
    is recommended.

F.  For patients with CAD, beta blocker therapy is recommended
    peri-operatively for vascular surgery or noncardiac surgery with
    general anesthesia.

G.  For patients at risk for CAD,\* beta blocker therapy is recommended
    peri-operatively for vascular surgery.

> \* At risk for CAD is defined as having at least two of the following
> cardiac risk factors: age [\>]{.underline}65 years, hypertension,
> current smoking, serum cholesterol [\>]{.underline}240 mg/dL (6.2
> mmol/L), diabetes mellitus.
>
> (NOTE: Drugs [without]{.underline} ISA are atenolol, betaxolol,
> bisoprolol, carvedilol, labetalol, nadolol, metoprolol, propranolol,
> and timolol.  Drugs [with]{.underline} ISA are acebutolol, and
> pindolol.)

A, D, F, G: ***Evidence-based***\
B, C, E: ***Consensus-based***

**CAD Plus Mild to Moderate Reversible Airway Disease or Chronic
Obstructive Pulmonary Disease (COPD): Beta Blocker Therapy**

A.  For CAD patients with concomitant mild to moderate reversible airway
    disease or chronic obstructive pulmonary disease (COPD)
    cardioselective beta blockers are recommended.

B.  Discuss the risks and benefits of treatment with the patient and
    instruct the patient to report any increase in airway symptoms.

C.  Initiating beta blocker therapy is NOT recommended:

    -   For patients with severe airway disease requiring frequent
        hospitalization or intubation

    -   During acute exacerbation of airway disease

    -   When airway disease is unstable or poorly controlled

A: ***Evidence-based***\
B, C: ***Consensus-based***

**CAD Plus Heart Failure: Beta Blocker Therapy**

A.  For CAD patients with either left ventricular systolic dysfunction
    (LVSD) (New York Heart Associations (NYHA) Class II-IV) or
    asymptomatic LVSD (NYHA Class I), beta blockers are strongly
    recommended.

B.  For CAD patients with LVSD carvedilol, metoprolol CR/XL, or
    bisoprolol is the recommended choice of beta blocker therapy.

C.  Metoprolol tartrate (short-acting formulation) titrated to maximum
    tolerated dosage, is an acceptable but less well-established
    alternative to carvedilol, metoprolol CR/XL, or bisoprolol.

A, B: ***Evidence-based***\
C: ***Consensus-based***

**Lipid Management**

Treatment with statins is recommended for all adults with established
atherosclerosis, even if baseline low density lipoprotein (LDL)-C is
\<100 mg/dL.

***Evidence-based***

**Diet Therapy**

For all patients with CAD a diet rich in fruits, vegetables, legumes,
nuts, whole grains, and n-3- (omega-3) polyunsaturated fat is
recommended.

***Evidence-based***

**Dietary Fat Modification**

For all patients with CAD consuming a usual Western diet the following
modifications in dietary fat are recommended:

-   Increase intake of n-3 (omega-3) polyunsaturated fatty acids to a
    level of approximately 1 g/day from a variety of sources (flaxseed,
    canola, and soybean oils, nuts, fish, and fish oil supplements).\*

-   Replace saturated fatty acids with polyunsaturated and
    monounsaturated fatty acids.

-   Reduce or eliminate intake of trans-fatty acids.

\* To limit the bioaccumulation of methylmercury, polychlorinated
biphenyls (PCBs), dioxins, and other environmental contaminants, intake
of certain fish (e.g., swordfish, tuna, and farmed salmon) is
recommended not to exceed two servings per week.

***Consensus-based***

**Dietary Supplement Therapy**

A.  For patients with CAD, supplemental vitamins C, E and beta carotene
    are not recommended for prevention of cardiovascular mortality or
    subsequent coronary events.

B.  For CAD patients who are current or former smokers, supplemental
    beta carotene is not recommended due to a small but significant
    excess in all cause mortality reported in this group.

C.  For patients with CAD supplemental folic acid, vitamin B6, and
    vitamin B12 are not recommended.

A, B: ***Evidence-based***\
C: ***Evidence-based (D)***\*

\* Please note that only recommendations approved since the adoption in
2006 of evidence grading will use letters (A, B, C, etc.) to specify the
grade of the evidence. Recommendations approved prior to 2006 will not
include a letter grade following the statement \"evidence-based.\"

**[Definitions]{.underline}**:

Recommendations are classified as either \"evidence-based (A-D, I)\" or
\"consensus.\" Refer to the table below for full definitions.

-   Evidence-based: sufficient number of high-quality studies from which
    to draw a conclusion, and the recommended practice is consistent
    with the findings of the evidence. A recommendation can also be
    considered \"evidence-based\" if there is insufficient evidence and
    no practice is recommended.

-   Consensus: insufficient evidence and a practice is recommended based
    on the consensus or expert opinion of the Guideline Development
    Team.

**Label and Language of Recommendations\***

  --------------------------------------------------------------------------------
  **Label**             **Evidence-Based Recommendations**
  --------------------- ----------------------------------------------------------
  **Evidence-based      **Language**: ^a^ The intervention is strongly recommended
  (A)**                 for eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on good evidence, and the Guideline
                        Development Team (GDT) concludes that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good.

  **Evidence-based      **Language**: ^a^ The intervention is recommended for
  (B)**                 eligible patients.\
                        \
                        **Evidence**: The intervention improves important health
                        outcomes, based on 1) good evidence that benefits outweigh
                        harms and costs; or 2) fair evidence that benefits
                        substantially outweigh harms and costs.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ No recommendation for or against routine
  (C)**                 provision of the intervention. (At the discretion of the
                        GDT, the recommendation may use the language \"option,\"
                        but must list all the equivalent options.)\
                        \
                        **Evidence**: Evidence is sufficient to determine the
                        benefits, harms, and costs of an intervention, and there
                        is at least fair evidence that the intervention improves
                        important health outcomes.  But the GDT concludes that the
                        balance of the benefits, harms, and costs is too close to
                        justify a general recommendation.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ Recommendation against routinely
  (D)**                 providing the intervention to eligible patients.\
                        \
                        **Evidence**: The GDT found at least fair evidence that
                        the intervention is ineffective, or that harms or costs
                        outweigh benefits.\
                        \
                        **Evidence Grade**: Good or Fair.

  **Evidence-based      **Language**: ^a^ The evidence is insufficient to
  (I)**                 recommend for or against routinely providing the
                        intervention.= (At the discretion of the GDT, the
                        recommendation may use the language \"option,\" but must
                        list all the equivalent options.)\
                        \
                        **Evidence**: Evidence that the intervention is effective
                        is lacking, of poor quality, or conflicting and the
                        balance of benefits, harms, and costs cannot be
                        determined.\
                        \
                        **Evidence Grade**: Insufficient.

  **Consensus-based**   **Language**: ^a^ The language of the recommendation is at
                        the discretion of the GDT, subject to approval by the
                        National Guideline Directors.\
                        \
                        **Evidence**: The level of evidence is assumed to be
                        \"Insufficient\" unless otherwise stated. However, do not
                        use the A, B, C, D, or I labels which are only intended to
                        be used for evidence-based recommendations.\
                        \
                        **Evidence Grade**: Insufficient, unless otherwise stated.

  For the rare          
  consensus-based       
  recommendations which 
  have \"Good\" or      
  \"Fair\" evidence,    
  the evidence must     
  support a different   
  recommendation,       
  because if the        
  evidence were good or 
  fair, the             
  recommendation would  
  usually be            
  evidence-based. In    
  this kind of          
  consensus-based       
  recommendation, the   
  evidence grade should 
  point this out, e.g., 
  \"Evidence Grade:     
  Good, supporting a    
  different             
  recommendation.\"     
  --------------------------------------------------------------------------------

^\[a\]^ All statements specify the population for which the
recommendation is intended.

\* Recommendations should be labeled and given an evidence grade. The
evidence grade should appear in the rationale. Evidence is graded with
respect to the degree it supports the specific clinical recommendation.
For example, there may be good evidence that Drugs 1 and 2 are effective
for Condition A, but no evidence that Drug 1 is more effective than Drug
2. If the recommendation is to use either Drug 1 or 2, the evidence is
good. If the recommendation is to use Drug 1 in preference to Drug 2,
the evidence is insufficient.

#### CLINICAL ALGORITHM(S)

An algorithm on Statin Management in Secondary Prevention is provided in
the original guideline document.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation, but the evidence underlying the recommendations are
drawn from randomized controlled trials, meta-analyses, and existing
systematic reviews. In cases where the data was inconclusive,
inconsistent, or non-existent, recommendations were based on the
consensus opinion of the group.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate treatment and management of adult patients with coronary
heart disease to decrease morbidity and mortality and improve patient
outcomes

#### POTENTIAL HARMS

Side effects of medication

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Aspirin therapy is contraindicated in patients with active bleeding,
major coagulopathy or aspirin allergy

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are informational only. They are not intended or
    designed as a substitute for the reasonable exercise of independent
    clinical judgment by practitioners, considering each patient\'s
    needs on an individual basis.

-   Guideline recommendations apply to populations of patients. Clinical
    judgment is necessary to design treatment plans for individual
    patients.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Pocket Guide/Reference Cards

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kaiser Permanente Care Management Institute. Secondary prevention of
coronary artery disease clinical practice guideline. Oakland (CA):
Kaiser Permanente Care Management Institute; 2006 Mar. 117 p. \[51
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Mar

#### GUIDELINE DEVELOPER(S)

Kaiser Permanente Care Management Institute - Managed Care Organization

#### SOURCE(S) OF FUNDING

Kaiser Permanente Care Management Institute

#### GUIDELINE COMMITTEE

Kaiser Permanente CAD Guidelines Project Management Team\
Kaiser Permanente CAD Guidelines Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Kaiser Permanente CAD Guidelines Project Management Team Members*: John
Golden, MD, Clinical Lead, Care Management Institute; Donna M. Schaffer,
RD, MPH, Project Manager, Care Management Institute; Paul Barrett, MD,
Evidence-Based Medicine Methodologist, Care Management Institute;
Tabitha Pousson, Staff Assistant, Care Management Institute

*Kaiser Permanente CAD Guidelines Development Team Members*: John H.
Merenich, MD, Cardiology, KP Colorado; George Kawamura, MD, Cardiology,
KP Georgia; Alan Golston, MD, Cardiology, Group Health Cooperative; Art
Resnick, MD, Cardiology, Group Health Cooperative; Steven Hong, MD,
Internal Medicine, KP Hawaii; Patricia E. Casey, MSN, RN, Chronic
Disease Management, KP Mid-Atlantic States; John Golden, MD, Cardiology,
KP Mid-Atlantic States; Gerald Bourne, MD, Cardiology, KP Northern
California; Carlos Iribarren, MD, CVD Research, KP Northern California;
Marc Jaffe, MD, Endocrinology, KP Northern California; Eleanor Levin,
MD, Cardiology, KP Northern California; Anita Strohmeier, Chronic
Disease Management, KP Northern California; Wiley V. Chan, MD, Internal
Medicine, KP Northwest; Alison Fulmer, MD, Cardiology, KP Northwest;
Shobana Rajagopal, MD, Family Practice, KP Northwest; Maan Fares, MD,
Cardiology, KP Ohio; Carol Bartolotto, MPH, RD, Health Education, KP
Southern California; Victor M. Benson, MD, Internal Medicine, KP
Southern California; Gary M Besinque, PharmD, Pharmacy, KP Southern
California; Kathleen Ryman, MD, Cardiology, KP Southern California

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from the Kaiser Permanente Care Management
Institute, One Kaiser Plaza, 16L, Oakland, CA 94612

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Kaiser Permanente Care Management Institute. Summary of secondary
    prevention of coronary artery disease clinical practice guidelines.
    Oakland (CA): Kaiser Permanente Care Management Institute; 2006 Mar.
    10 p.

Electronic copies: None available

Print copies: Available from the Kaiser Permanente Care Management
Institute, One Kaiser Plaza, 16L, Oakland, CA 94612

The following is also available:

-   Pocket card: coronary artery disease in primary care. Oakland (CA):
    Kaiser Permanente Care Management Institute; 2006. 2 p.

Electronic copies: None available

Print copies: Contact the CMI Product Line at (510) 271-6426 or
<CMIProducts@kp.org>.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on November 17, 2006. The
information was verified by the guideline developer on December 19,
2006.

#### COPYRIGHT STATEMENT

For any questions regarding the content of this Kaiser Permanente
National Clinical Practice Guideline, please contact Donna M. Schaffer,
RD, MPH, CMI at <Donna.M.Schaffer@kp.org> or (510) 271-5678.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008