2013+AHA+ACC+管理生活方式降低心血管风险指南

Accepted Manuscript 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk Robert H. Eckel, MD, FAHA John M. Jakicic, PhD Jamy D. Ard, MD Nancy Houston Miller, RN, BSN, FAHA Van S. Hubbard, MD, PhD Cathy A. Nonas, MS, RD Janet M. de Jesus, MS, RD Frank M. Sacks, MD, FAHA I-Min Lee, MD, ScD Sidney C. Smith, Alice H. Lichtenstein, DSc, FAHA Laura P. Svetkey, MD, MHS Catherine M. Loria, PhD, FAHA Thomas W. Wadden, PhD Barbara E. Millen, DrPH, RD, FADA Susan Z. Yanovski, MD PII: S0735-1097(13)06029-4 DOI: 10.1016/j.jacc.2013.11.003 Reference: JAC 19597 To appear in: Journal of the American College of Cardiology Please cite this article as: Eckel RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA, de Jesus JM, Sacks FM, Lee I-M, Smith Jr SC, Lichtenstein AH, Svetkey LP, Loria CM, Wadden TW, Millen BE, Yanovski SZ, 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk, Journal of the American College of Cardiology (2013), doi: 10.1016/j.jacc.2013.11.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 1 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease EXPERT WORK GROUP MEMBERS Robert H. Eckel, MD, FAHA, Co-Chair John M. Jakicic, PhD, Co-Chair Jamy D. Ard, MD Nancy Houston Miller, RN, BSN, FAHA Van S. Hubbard, MD, PhD* Cathy A. Nonas, MS, RD Janet M. de Jesus, MS, RD* Frank M. Sacks, MD, FAHA I-Min Lee, MD, ScD Sidney C. Smith, Jr, MD, FACC, FAHA Alice H. Lichtenstein, DSc, FAHA Laura P. Svetkey, MD, MHS Catherine M. Loria, PhD, FAHA* Thomas W. Wadden, PhD Barbara E. Millen, DrPH, RD, FADA Susan Z. Yanovski, MD* Methodology Members Laura C. Morgan, MA Michael G. Trisolini, PhD, MBA Karima A. Kendall, PhD George Velasco Janusz Wnek, PhD ACC/AHA TASK FORCE MEMBERS Jeffrey L. Anderson, MD, FACC, FAHA, Chair Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect Nancy M. Albert, PhD, CCNS, CCRN, FAHA Judith S. Hochman, MD, FACC, FAHA Biykem Bozkurt, MD, PhD, FACC, FAHA Richard J. Kovacs, MD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC E. Magnus Ohman, MD, FACC Lesley H. Curtis, PhD, FAHA Susan J. Pressler, PhD, RN, FAAN, FAHA David DeMets, PhD Frank W. Sellke, MD, FACC, FAHA Robert A. Guyton, MD, FACC Win-Kuang Shen, MD, FACC, FAHA Subcommittee on Prevention Guidelines Sidney C. Smith, Jr, MD, FACC, FAHA, Chair Gordon F. Tomaselli, MD, FACC, FAHA, Co-Chair *Ex-Officio Members. This document was approved by the American College of Cardiology Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in November 2013. Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 2 The American College of Cardiology requests that this document be cited as follows: Eckel RH, Jakicic JM, Ard, JD, Hubbard VS, de Jesus JM, Lee IM, Lichtenstein AH, Loria CM, Millen BE, Houston Miller N, Nonas CA, Sacks FM, Smith SC Jr, Svetkey LP, Wadden TW, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; ��:����–����. This article is copublished in Circulation. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. For copies of this document, please contact the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact healthpermissions@elsevier.com. ©2013 The Expert Work Group Members. Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer; the Journal of the American College of Cardiology is published on behalf of the American College of Cardiology Foundation by Elsevier Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDervis License, which permits use, distribution, and reproduction in any medium, provided that the Contribution is properly cited, the use is non-commercial, and no modifications or adaptations are made. Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 3 Table of Contents Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk................................................................... 4 1. Introduction ............................................................................................................................................................................. 8 1.1. Scope of Guideline........................................................................................................................................................... 8 1.2. Methodology and Evidence Review ................................................................................................................................ 9 1.2.1. Scope of the Evidence Review................................................................................................................................. 9 1.2.2. CQ-Based Approach .............................................................................................................................................. 11 1.3. Organization of Panel .................................................................................................................................................... 12 1.4. Document Reviews and Approval ................................................................................................................................. 12 2. Lifestyle Management Recommendations............................................................................................................................. 12 3. CQ1—Dietary Patterns and Macronutrients: BP and Lipids ................................................................................................. 14 3.1. Introduction/Rationale ................................................................................................................................................... 14 3.2. Inclusion/Exclusion Criteria .......................................................................................................................................... 15 3.3. Literature Search Yield .................................................................................................................................................. 15 3.3.1. Dietary Pattern/Macronutrient Composition Evidence .......................................................................................... 15 3.4. CQ1 Evidence Statements.............................................................................................................................................. 15 3.4.1. Dietary Patterns...................................................................................................................................................... 15 3.4.1.1. MED Pattern.................................................................................................................................................... 15 3.4.1.2. DASH Dietary Pattern ..................................................................................................................................... 16 3.4.1.3. DASH Variations............................................................................................................................................. 17 3.4.2. Dietary Fat and Cholesterol.................................................................................................................................... 18 3.5. Diet Recommendations for LDL–C Lowering .............................................................................................................. 19 4. CQ2—Sodium and Potassium: BP and CVD Outcomes ....................................................................................................... 21 4.1. Introduction and Rationale............................................................................................................................................. 21 4.2. Selection of Inclusion/Exclusion Criteria ...................................................................................................................... 22 4.3. Literature Search Yield .................................................................................................................................................. 22 4.4. CQ2 Evidence Statements.............................................................................................................................................. 22 4.4.1. Sodium and BP....................................................................................................................................................... 22 4.5. Diet Recommendations for BP Lowering ...................................................................................................................... 24 5. CQ3—Physical Activity: Lipids and BP ............................................................................................................................... 26 5.1. Introduction/Rationale ................................................................................................................................................... 27 5.2. Selection of Inclusion/Exclusion Criteria ...................................................................................................................... 27 5.3. Literature Search Yield .................................................................................................................................................. 27 5.4. CQ3 Evidence Statements.............................................................................................................................................. 28 5.4.1. Physical Activity and Lipids .................................................................................................................................. 28 5.4.2. Physical Activity and BP........................................................................................................................................ 29 5.4.2.1. Aerobic Exercise Training and BP .................................................................................................................. 29 5.4.2.2. Resistance Exercise Training and BP .............................................................................................................. 29 5.4.2.3. Combination of Aerobic and Resistance Exercise Training and BP................................................................ 29 5.5. Physical Activity Recommendations ............................................................................................................................. 30 5.6. Heart Healthy Nutrition and Physical Activity Behaviors ............................................................................................. 30 6. Gaps in Evidence and Future Research Needs ...................................................................................................................... 31 6.1. Diet ................................................................................................................................................................................ 31 6.2. Physical Activity............................................................................................................................................................ 32 Appendix 1. Author Relationships With Industry and Other Entities (Relevant)...................................................................... 34 Appendix 2. Expert Reviewer Relationships With Industry and Other Entities ........................................................................ 38 Appendix 3. Abbreviations........................................................................................................................................................ 39 References ................................................................................................................................................................................. 40 Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 4 Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular (CV) diseases, improve the management of people who have these diseases through professional education and research, and develop guidelines, standards and policies that promote optimal patient care and CV health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of CV risk, lifestyle modifications to reduce CV risk, and management of blood cholesterol, overweight and obesity in adults. In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence and craft recommendations. In response to the 2011 report of the Institute of Medicine on the development of trustworthy clinical guidelines (1), the NHLBI Advisory Council (NHLBAC) recommended that the NHLBI focus specifically on reviewing the highest quality evidence and partner with other organizations to develop recommendations (2,3). Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the expert panels did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA and collaborating societies plan to begin updating these guidelines starting in 2014. The joint ACC/AHA Task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBAC, key Federal agencies and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes as the bulk of the content was undisputed. Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs in each topic, based on the highest quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality, and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel Reports include more detailed information about the evidence statements (ESs) that serves as the basis for Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 5 recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Class of Recommendation/Level of Evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable. Table 1. Applying Classification of Recommendation and Level of Evidence 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 when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. Downloaded From: http://content.onlinejacc.org/ on 11/13/2013 guide.medlive.cn M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Eckel RH, et al. 2013 AHA/ACC Lifestyle Management Guideline Page 6 *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. In consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA