Similar to our recommendations for other primary prevention trials, these studies should use CV risk scores to select patients for treatment. These studies need to be larger and have longer follow-up periods given the lower baseline absolute CVD risk than the secondary prevention trials conducted to date, which will also allow the subgroup analysis that has been performed with statins. b. Secondary Prevention Recommendation 11. For secondary prevention, we recommend using at least a moderate-dose statin. (Strong for | Reviewed, New-replaced) Discussion Secondary prevention is intended to prevent subsequent CVD events in patients with an established clinical diagnosis of CVD. This includes patients with ACS, MI, coronary arteries bypass graft (CABG), percutaneous coronary interventions (PCI), stable obstructive coronary artery disease (CAD) including angina and equivalents, cerebrovascular accident (CVA)/stroke, transient ischemic attack (TIA), and atherosclerotic PAD including claudication or abdominal aortic aneurysm (AAA). Secondary prevention does not include patients with asymptomatic arteriosclerosis, as detected by incidentally reported or measurements of CAC, exercise test, intima-media thickness ultrasound measurement, ABI, or brachial reactivity because there is little evidence on how to best manage the detection of subclinical atherosclerosis. These entities were not specified within the inclusion criteria of clinical trials and the management of subclinical atherosclerosis is beyond the scope of this CPG. The Work Group conceded that revascularizations were not a clear outcome because the indications for these interventions are not well defined, may have regional variation, and their impact on mortality or other important outcomes (e.g., congestive heart failure [CHF]) is uncertain. This recommendation is supported by three meta-analyses by the CTT Collaborators.[56,73,74] From the CTT meta-analyses, statin use led to a reduction in all-cause mortality, non-fatal MI, coronary death, and non-fatal stroke when compared to placebo control. 