The Living Guidelines: Summary of the Current Recommendations for Percutaneous Coronary Interventions (PCI)

# Initial Conservative versus Initial Invasive Strategies in patients with Unstable Angina / Non ST Elevation MI)

## Class I
1. An early invasive PCI strategy is indicated for patients with UA/NSTEMI who have no serious comorbidity and who have coronary lesions amenable to PCI and who have characteristics for invasive therapy (Class I Level of Evidence: A)
a. Apply Invasive therapy if;
- Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy (Class I Level of Evidence: A)
- Elevated cardiac biomarkers (cTnT or cTnI) (Class I Level of Evidence: A)
- New or presumably new ST-segment depression (Class I Level of Evidence: A)
- Signs or symptoms of HF or new or worsening mitral regurgitation (Class I Level of Evidence: A)
- High-risk findings from noninvasive testing (Class I Level of Evidence: A)
- Hemodynamic instability (Class I Level of Evidence: A)
- Sustained ventricular tachycardia (Class I Level of Evidence: A)
- PCI within 6 months (Class I Level of Evidence: A)
- Prior CABG (Class I Level of Evidence: A)
- High-risk score (e.g., TIMI, GRACE) (Class I Level of Evidence: A)
- Reduced Left Ventricular function (LVEF less than 40%) (Class I Level of Evidence: A)
b. Apply Conservative Therapy if;
- Low-risk score (e.g., TIMI, GRACE) (Class I Level of Evidence: A)
- Patient or physician preference in absence of high-risk features (Class I Level of Evidence: A)
2. Percutaneous coronary intervention (or CABG) is recommended for UA/NSTEMI patients with 1-or 2-vessel CAD with or without significant proximal left anterior descending CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Class I Level of Evidence: B)
3. Percutaneous coronary intervention (or CABG) is recommended for UA/NSTEMI patients with multi vessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes mellitus. (Class I Level of Evidence: A)
4. An intravenous platelet GP IIb/IIIa inhibitor is useful in UA/ NSTEMI patients undergoing PCI. (Class I Level of Evidence: A)
5. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Class I Level of Evidence: B)

## Class IIa
1. Percutaneous coronary intervention is reasonable for focal saphenous vein graft lesions or multiple stenoses in UA/NSTEMI patients who are undergoing medical therapy and who are poor candidates for reoperative surgery. (Class IIa Level of Evidence: C)
2. Percutaneous coronary intervention (or CABG) is reasonable for UA/NSTEMI patients with one or  two vessel CAD with or without significant proximal left anterior descending CAD but with a moderate area of viable myocardium and ischemia on noninvasive testing. (Class IIa Level of Evidence: B)
3. Percutaneous coronary intervention (or CABG) can be beneficial compared with medical therapy for UA/NSTEMI patients with 1-vessel disease with significant proximal left anterior descending CAD. (Class IIa Level of Evidence: B)
4. Use of PCI is reasonable in patients with UA/NSTEMI with significant left main CAD (greater than 50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG or who require emergency intervention at angiography for hemodynamic instability. (Class IIa Level of Evidence: B)

## Class IIb
1. In the absence of high-risk features associated with UA/NSTEMI, PCI may be considered in patients with single-vessel or multi vessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Class IIb Level of Evidence: B)
2. PCI may be considered in patients with UA/NSTEMI who are undergoing medical therapy who have two or three vessel disease, significant proximal left anterior descending CAD, and treated diabetes or abnormal Left Ventricular function, with anatomy suitable for catheter-based therapy. (Class IIb Level of Evidence: B)
3. In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events, including those who are troponin positive. (Class IIb Level of Evidence: B).  
The decision to implement an initial conservative (versus initial invasive) strategy in these patients may be made by considering physician and patient preference. (Class IIb Level of Evidence: C)
4. An invasive strategy may be reasonable in patients with chronic renal insufficiency. (Class IIb Level of Evidence: C)

## Class III
1. Percutaneous coronary intervention (or CABG) is not recommended for patients with one or two vessel coronary artery disease (CAD) without significant proximal left anterior descending CAD with no current symptoms or symptoms that are unlikely to be due to myocardial ischemia and who have no ischemia on noninvasive testing. (Class III Level of Evidence: C)
2. In the absence of high-risk features associated with UA/NSTEMI, PCI is not recommended for patients with UA/ NSTEMI who have single vessel or multi vessel CAD and no trial of medical therapy, or who have one or more of the following:
a. Only a small area of myocardium at risk. (Class III Level of Evidence: C)
b. All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. (Class III Level of Evidence: C)
c. A high risk of procedure-related morbidity or mortality. (Class III Level of Evidence: C)
d. Insignificant disease (less than 50% coronary stenosis). (Class III Level of Evidence: C)
e. Significant left main CAD and candidacy for CABG. (Class III Level of Evidence: B)
3. A PCI strategy in stable patients with persistently occluded infarct related coronary arteries after STEMI/NSTEMI is not indicated. (Class III Level of Evidence: B)

# PCI Indications for Chronic Kidney Disease

## Class I
1. Creatinine clearance should be estimated in UA/NSTEMI patients and the doses of drugs (with renal clearance) should be adjusted appropriately. (Class I Level of Evidence: B)
2. In chronic kidney disease patients undergoing angiography, iso osmolar contrast agents are indicated and are preferred. (Class I Level of Evidence: A)

# PCI for STEMI in Conjunction with Concomitant Fibrinolytic Therapy

## Class IIb
1. Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present: a. Patients are at high risk, b. PCI is not immediately available within 90 minutes, and c. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight). (Class IIb Level of Evidence: C)

## Class III
1. A planned reperfusion strategy using full dose fibrinolytic therapy followed by immediate PCI may be harmful. (Class III Level of Evidence: B)

# PCI After Failed Fibrinolysis

## Class I
1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is recommended for patients who have received fibrinolytic therapy and have any of the following:
a. Cardiogenic shock in patients less than 75 years who are suitable candidates for revascularization. (Class I Level of Evidence: B)
b. Severe congestive heart failure and/or pulmonary edema (Killip class III). (Class I Level of Evidence: B)
c. Hemodynamically compromising ventricular arrhythmias. (Class I Level of Evidence: C)

## Class IIa
1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is reasonable in patients 75 years of age or older who have received fibrinolytic therapy and are in cardiogenic shock, provided that they are suitable candidates for revascularization. (Class IIa Level of Evidence: B)
2. It is reasonable to perform rescue PCI for patients with 1 or more of the following:
a. Hemodynamic or electrical instability. (Class IIa Level of Evidence: C)
b. Persistent ischemic symptoms. (Class IIa Level of Evidence: C)
3. A strategy of coronary angiography with intent to perform rescue PCI is reasonable for patients in whom fibrinolytic therapy has failed (ST-segment elevation less than 50% resolved after 90 minutes following initiation of fibrinolytic therapy in the lead showing the worst initial elevation) and a moderate or large area of myocardium at risk (anterior MI, inferior MI with right ventricular involvement or precordial ST-segment depression). (Class IIa Level of Evidence: B)

## Class IIb
1. A strategy of coronary angiography with intent to perform PCI in the absence of 1 or more of the above Class I or IIa indications might be reasonable in moderate-and high-risk patients, but its benefits and risks are not well established. The benefits of rescue PCI are greater the earlier it is initiated after the onset of ischemic discomfort. (Class IIb Level of Evidence: C)

## Class III
1. A strategy of coronary angiography with intent to perform PCI (or emergency CABG) is not recommended in patients who have received fibrinolytic therapy if further invasive management is contraindicated or the patient or designee does not wish further invasive care. (Class III Level of Evidence: C)

# PCI after Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion

## Class I
1. In patients whose anatomy is suitable, PCI should be performed when there is objective evidence of recurrent MI. (Class I Level of Evidence: C)
2. In patients whose anatomy is suitable, PCI should be performed for moderate or severe spontaneous or provocable myocardial ischemia during recovery from STEMI. (Class I Level of Evidence: B)
3. In patients whose anatomy is suitable, PCI should be performed for cardiogenic shock or hemodynamic instability. (Class I Level of Evidence: B)

## Class IIa
1. It is reasonable to perform routine PCI in patients with Left Ventricular ejection fraction 40%, Heart Failure, or serious ventricular arrhythmias. (Class IIa Level of Evidence: C)
2. It is reasonable to perform PCI when there is documented clinical heart failure during the acute episode, even though subsequent evaluation shows preserved Left Ventricular function (Left Ventricular ejection fraction >40%). (Class IIa Level of Evidence: C)

## Class IIb
1. PCI of a hemodynamically significant stenosis in a patent infarct artery longer than 24 hours after STEMI may be considered as part of an invasive strategy. (Level of Evidence: B)

## Class III
1. PCI of a totally occluded infarct artery greater than 24 hours after STEMI is not recommended in asymptomatic patients with 1-or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia. (Level of Evidence: B)

# Ancillary Therapy for Patients Undergoing PCI for STEMI

## Class I
1. For patients undergoing PCI after having received an anticoagulant regimen, the following dosing recommendations should be followed:
a. For prior treatment with UFH, administer additional boluses of UFH as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I Level of Evidence: C)
Bivalirudin may also be used in patients treated previously with UFH. (Class I Level of Evidence: C)
b. For prior treatment with enoxaparin, if the last subcutaneous dose was administered at least 8 to 12 hours earlier, an IV dose of 0.3 mg/kg of enoxaparin should be given; if the last subcutaneous dose was administered within the prior 8 hours, no additional enoxaparin should be given. (Class I Level of Evidence: B)
c. For prior treatment with fondaparinux, administer additional intravenous treatment with an anticoagulant possessing anti-IIa activity, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (Class I Level of Evidence: C)

## Class III
1. Because of the risk of catheter thrombosis, fondaparinux should not be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered. (Class III Level of Evidence: C)

# Oral Antiplatelet Therapy

## Class I
1. Patients already taking daily long-term aspirin therapy should take 75 mg to 325 mg of aspirin before PCI is performed. (Class I Level of Evidence: A)
2. Patients not already taking daily long-term aspirin therapy should be given 300 mg to 325 mg of aspirin at least 2 hours and preferably 24 hours before PCI is performed. (Class I Level of Evidence: C)
3. After PCI, in patients without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after bare metal stent implantation, 3 months after Sirolimus eluting stent implantation, and 6 months after Paclitaxel eluting stent implantation, after which daily long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg. (Class I Level of Evidence: B)
4. A loading dose of clopidogrel (some uncertainty exists about optimal loading dose of clopidogrel. Randomized trials establishing its efficacy and providing data on bleeding risks used a loading dose of 300 mg orally followed by a daily oral dose of 75 mg. Higher oral loading doses such as 600 mg or 900 mg of clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of inhibition of platelet aggregation, but the additive clinical efficacy and safety of higher oral loading doses have not been rigorously established) generally 600 mg, should be administered before or when PCI is performed. (Class I Level of Evidence: C)
In patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therapy, a clopidogrel oral loading dose of 300 mg may be considered. (Class I Level of Evidence: C)
5. For all post PCI stented patients receiving a drug eluting stent (DES), clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post PCI patients receiving a bare metal stent, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Class I Level of Evidence: B)

## Class IIa
1. If clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial. (Class IIa Level of Evidence: B)
2. For patients with an absolute contraindication to aspirin, it is reasonable to give a 300-mg to 600-mg loading dose of clopidogrel, administered at least 6 hours before PCI, and / or GP IIb/IIIa antagonists, administered at the time of PCI. (Class IIa Level of Evidence: C)
3. In patients for whom the physician is concerned about risk of bleeding, a lower dose of 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Class IIa Level of Evidence: C)

## Class IIb
1. Continuation of clopidogrel therapy beyond 1 year may be considered in patients undergoing DES placement. (Class IIb Level of Evidence: C)

# Drug Eluting and Bare Metal Stents

## Class I
1. A DES should be considered as an alternative to a BMS in those patients for whom clinical trials indicate a favorable effectiveness/safety profile. (Class I Level of Evidence: A)
2. Before implanting a DES, the interventional cardiologist should discuss with the patient the need for and duration of dual antiplatelet therapy and confirm the patients ability to comply with the recommended therapy for DES. (Class I Level of Evidence: B)
3. In patients who are undergoing preparation for PCI and are likely to require invasive or surgical procedures for which dual antiplatelet therapy must be interrupted during the next 12 months, consideration should be given to implantation of a BMS or performance of balloon angioplasty with a provisional stent implantation instead of the routine use of a DES. (Class I Level of Evidence: C)

## Class IIa
1. In patients for whom the physician is concerned about risk of bleeding, a lower dose of 75 mg to 162 mg of aspirin is reasonable. (Class IIa Level of Evidence: C)

## Class IIb
1. A DES may be considered for clinical and anatomic settings in which the effectiveness / safety profile appears favorable but has not been fully confirmed by clinical trials. (Class IIa Level of Evidence: C)

# Comprehensive Risk Reduction for Patients with Coronary and Other Vascular Disease After PCI

## Smoking
Goal: Complete cessation, no exposure to environmental tobacco smoke

### Class I
1. Status of tobacco use should be asked about at every visit. (Class I Level of Evidence: B)
2. Every tobacco user and family members who smoke should be advised to quit at every visit. (Class I Level of Evidence: B)
3. The tobacco users willingness to quit should be assessed. (Class I Level of Evidence: B)
4. The tobacco user should be assisted by counseling and developing a plan for quitting. (Class I Level of Evidence: B)
5. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological treatment) should be arranged. (Class I Level of Evidence: B)
6. Exposure to environmental tobacco smoke at work and home should be avoided. (Class I Level of Evidence: B)

## Blood Pressure Control=
Goal: <140/90 mmHg or <130/80 mmHg if patient has diabetes or chronic kidney disease

### Class I
1. For patients with blood pressure 140/90 mmHg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), it is recommended to initiate or maintain lifestyle modification (weight control; increased physical activity; increased consumption of fresh fruits, vegetables, and low-fat dairy products). (Class I Level of Evidence: B)
2. For patients with blood pressure 140/90 mm Hg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), it is useful as tolerated, to add blood pressure medication, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure. (Class I Level of Evidence: A)

## Lipid Management
Goal: LDL-C substantially <100 mg/dL. (If triglycerides are 200 mg/dL, nonHDL-C should be <130 mg/dL)

### Class I
1. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid lowering medication is indicated as recommended below before discharge according to the following schedule:
- LDL-C should be < 100 mg/dL. (Class I Level of Evidence: A)
- Further reduction of LDL-C to <70 mg/dL is reasonable. (Class IIa Level of Evidence: A)
- If baseline LDL-C is 100 mg/dL, LDL-lowering drug therapy should be initiated. (Class I Level of Evidence: A)
- If on-treatment LDL-C is 100 mg/dL, intensify LDL lowering drug therapy (may require LDL lowering drug combination) is recommended. (Class I Level of Evidence: A)
- If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. (Class IIa Level of Evidence: B)
- If triglycerides are 150 mg/dL or HDL-C is <40 mg/dL, weight management, physical activity, and smoking cessation should be emphasized. (Class I Level of Evidence: B)
- If triglycerides are 200 to 499 mg/dL, nonHDL-C target should be less than 130 mg/dL. (Class I Level of Evidence: B)
- If triglycerides are 200 to 499 mg/dL, further reduction of nonHDL-C to <100 mg/dL is reasonable. (Class IIa Level of Evidence: B)
2. Therapeutic options to reduce nonHDL-C include:
- More intense LDL-Clowering therapy is indicated. (Class I Level of Evidence: B)
- Niacin (after LDL-Clowering therapy) can be beneficial. (Class IIa Level of Evidence: B)
- Fibrate therapy (after LDL-Clowering therapy) can be beneficial. (Class IIa Level of Evidence: B)
3. If triglycerides are 500 mg/dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL lowering therapy, and treat LDL-C to goal after triglyceride-lowering therapy. Achieving a nonHDL-C of <130 mg/dL is recommended. (Class I Level of Evidence: C)
4. Starting dietary therapy is recommended. Reduce intake of saturated fats (to <7% of total calories), trans fatty acids, and cholesterol (to <200 mg/day). (Class I Level of Evidence: B)
5. Promotion of daily physical activity and weight management is recommended. (Class I Level of Evidence: B)

### Class IIa
1. Adding plant stanol/sterols (2 g/day) and/or viscous fiber (>10 g/day) is reasonable to further lower LDL-C. (Class IIa Level of Evidence: A)

### Class IIb
1. It may be reasonable to encourage increased consumption of omega-3 fatty acids in the form of fish or in capsules (1 g/day) for risk reduction. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Class IIb Level of Evidence: B)

## Physical Activity
Goal: 30 minutes 5 days/week; but optimal one is 30 minutes daily physical activity
1. Advising medically supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, heart failure) is recommended. (Class I Level of Evidence: B)
2. For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. (Class I Level of Evidence: B)
3. For all patients, encouraging 30 to 60 minutes of moderate-intensity aerobic activity is recommended, such as brisk walking on mostpreferably alldays of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). (Class I Level of Evidence: B)
4. Encouraging resistance training 2 days per week may be reasonable. (Class IIb Level of Evidence: C)

## Weight Management
Goal: BMI: 18.5 to 24.9 kg/m2, Waist circumference: men <40 inches (102 cm), women <35 inches (89 cm)

### Class I
1. It is useful to assess BMI and/or waist circumference on each visit and consistently encourage weight maintenance / reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m2. (Class I Level of Evidence: B)
2. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. (Class I Level of Evidence: B)
3. If waist circumference (measured horizontally at the iliac crest) is 35 inches (89 cm) in women and 40 inches (102 cm), it is useful to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. (Class I Level of Evidence: B)

## Diabetes Management
Goal: HbA1c <7%

### Class I
1. It is recommended to initiate lifestyle and pharmacotherapy to achieve near normal HbA1c. (Class I Level of Evidence: B)
2. Beginning vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended above) is beneficial. (Class I Level of Evidence: B)
3. Coordination of diabetic care with the patients primary care physician or endocrinologist is beneficial. (Class I Level of Evidence: C)

## Antiplatelet Agents/Anticoagulants: Aspirin

### Class I
1. For all post PCI stented patients without allergy or increased risk of bleeding, aspirin 162 mg to 325 mg daily should be given for at least 1 month after BMS implantation, 3 months after Sirolimus eluting stent implantation, and 6 months after Paclitaxel eluting stent implantation, after which long-term aspirin use should be continued indefinitely at a dose of 75 mg to 162 mg daily. (Class I Level of Evidence: B)

### Class IIa
1. In patients for whom the physician is concerned about risk of bleeding, lower-dose 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation. (Class IIa Level of Evidence: C)

## Antiplatelet Agents/Anticoagulants: Clopidogrel

### Class I
1. For all post-PCI patients who receive a DES, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding. For post-PCI patients receiving a BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Class I Level of Evidence: B)
2. For all post-PCI non-stented STEMI patients, treatment with clopidogrel should continue for at least 14 days. (Class I Level of Evidence: B)

### Class IIa
1. Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) is reasonable in STEMI and non-STEMI patients who undergo PCI without reperfusion therapy.  (Class IIa Level of Evidence: C)

## Antiplatelet Agents/Anticoagulants: Warfarin

### Class I
1. Managing warfarin to an INR equal to 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter is recommended, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, left ventricular thrombus). (Class I Level of Evidence: A)
2. Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. (Class I Level of Evidence: B)
3. In patients requiring warfarin, clopidogrel, and aspirin therapy after PCI, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75-mg dose of clopidogrel. (Class I Level of Evidence: C)

## Renin-Angiotensin-Aldosterone System Blockers: ACE Inhibitors

### Class I
1. ACE inhibitors should be started and continued indefinitely in all patients with LVEF 40% and (changed text) for those with hypertension, diabetes, or chronic kidney disease, unless contraindicated. (Class I Level of Evidence: A)
2. ACE inhibitors should be started and continued indefinitely in patients who are not lower risk (lower risk defined as those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed), unless contraindicated. (Class I Level of Evidence: B)

### Class IIa
1. Among lower risk patients (i.e., those with normal LVEF in whom cardiovascular risk factors are well controlled and revascularization has been performed) use of ACE inhibitors is reasonable. (Class IIa Level of Evidence: B)

## Renin-Angiotensin-Aldosterone System Blockers: Angiotensin Receptor Blockers

### Class I
1. Use of angiotensin receptor blockers is recommended in patients who are intolerant of ACE inhibitors and have HF or have had an MI with LVEF 40%. (Class I Level of Evidence: A)
2. Angiotensin receptor blockers are useful in other patients who are ACE-inhibitor intolerant and have hypertension. (Class I Level of Evidence: B)

### Class IIb
1. Considering use in combination with ACE inhibitors in systolic dysfunction HF may be reasonable (Class IIb Level of Evidence: B)

## Renin-Angiotensin-Aldosterone System Blockers: Aldosterone Blockade

### Class I
1. Use of aldosterone blockade in post MI patients without significant renal dysfunction or hyperkalemia is recommended in patients who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF of less than or equal to 40%, and have either diabetes or HF. (Class I Level of Evidence: A)

## Beta Blockers

### Class I
1. It is beneficial to start and continue beta-blocker therapy indefinitely in all patients who have had MI, acute coronary syndrome, or LV dysfunction with or without HF symptoms, unless contraindicated. (Class I Level of Evidence: A)

### Class IIa
2. It is reasonable to consider long-term therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated. (Class IIa Level of Evidence: C)

## Influenza Vaccination

### Class I
1. Patients with cardiovascular disease should have an annual influenza vaccination. (Class I Level of Evidence: B)