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Journal of Cardiovascular Nursing:
doi: 10.1097/JCN.0000000000000135
DEPARTMENTS: Progress in Prevention

New Cardiovascular Prevention Guidelines Offer a New Approach and Effective Strategies

Dennison Himmelfarb, Cheryl R. RN, ANP, PhD, FAHA, FPCNA, FAAN; Commodore-Mensah, Yvonne BSN, RN; Hayman, Laura L. PhD, RN, FAAN, FAHA

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Cheryl R. Dennison Himmelfarb, RN, ANP, PhD, FAHA, FPCNA, FAAN Associate Professor, School of Nursing, Department of Acute and Chronic Care, and Division of Health Sciences Informatics, School of Medicine, Johns Hopkins University, Baltimore, Maryland.

Yvonne Commodore-Mensah, BSN, RN PhD Candidate, Johns Hopkins University School of Nursing, Baltimore, Maryland.

Laura Hayman, PhD, RN, FAAN, FAHAAssociate Dean for Research and Professor of Nursing, College of Nursing and Health Sciences, and Associate Vice-Provost for Research, University of Massachusetts Boston.

The authors have no funding or conflicts of interest to disclose.

Correspondence Cheryl R. Dennison Himmelfarb, RN, ANP, PhD, FAHA, FPCNA, FAAN, School of Nursing, Acute and Chronic Care Department, Johns Hopkins University, 525 N Wolfe Street, Rm 527, Baltimore, MD 21205-2110 (cdennis4@jhu.edu).

One in 4 Americans will die of heart disease or stroke, and 60% will have a major vascular event before they die.1 Recognizing this burden on public health, the American College of Cardiology and American Heart Association jointly released 4 new prevention guidelines in November 2013. These guidelines focused on lifestyle management to reduce cardiovascular risk,2 management of overweight and obesity,3 assessment of cardiovascular risk,4 and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk.5

These evidence-based guidelines were developed through a rigorous process involving careful consideration of an extensive body of high-quality evidence derived from randomized controlled trials and systematic reviews and meta-analyses of randomized controlled trials in answering critical questions in clinical decision making. Key recommendations from each of the prevention guidelines are listed in the Table. Please refer to the published guidelines for details and comprehensive recommendations.

TABLE Key Recommenda...
TABLE Key Recommenda...
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The new guidelines recommend new risk assessment and treatment strategies. The Assessment of Cardiovascular Risk guideline recommends a new model for estimating risk for atherosclerotic cardiovascular disease (ASCVD).4 Risk estimation is based on group averages that are then applied to individual patients in practice. The approach balances an understanding of an individual’s absolute risk for ASCVD and potential treatment benefits against the potential risks for harm from therapy. The Treatment of Blood Cholesterol guideline recommends a new strategy involving focus on reducing ASCVD risk in 4 major statin benefit groups, a new perspective on low-density lipoprotein cholesterol and/or non–high-density lipoprotein cholesterol treatment goals, and use of global risk assessment to guide primary prevention.5 These approaches are consistent with the existing and widely used paradigm of matching the intensity of preventive efforts with an individual’s absolute risk.

Among the tools provided to support clinicians in implementing the new guidelines is a risk calculator to be used to determine 10-year risk for myocardial infarction and stroke among adults aged 40 to 79 years. It uses an updated equation developed from large, racially and geographically diverse community-based populations and includes race, gender, age, total cholesterol, high-density lipoprotein cholesterol, blood pressure, use of blood pressure medication, diabetes status, and smoking status. A downloadable spreadsheet enabling estimation of 10-year and lifetime risk for ASCVD and a Web-based calculator are available at http://my.americanheart.org/cvriskcalculator.6 If after quantitative risk assessment, a risk-based treatment decision is uncertain, additional risk measures that support revising risk assessment upward may be considered to inform treatment decision making: family history of premature cardiovascular disease (first degree male relative <55 years or female relative <65 years), high-sensitivity C-reactive protein (≥2 mg/L), coronary artery calcium score (≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity), or ankle-brachial index (<0.9).4 The goal of this risk-based framework is to target treatment to those most likely to benefit without undue risk for harm, in the context of a risk discussion. A risk discussion could include the assessment of the individual’s risk for ASCVD and potential benefits, negative aspects, risks, and patient preferences regarding initiation of relevant preventive therapies.

Guideline development is a dynamic process; as new evidence becomes available, guidelines will be revised and promulgated. Research in process and future research suggested by the Expert Panels is designed to address gaps in our existing evidence with the ultimate goal of promoting optimal cardiovascular health and quality of life for all individuals. To incorporate the clinical practice changes indicated in the 2013 evidence-based guidelines for cardiovascular prevention, we must become familiar with the new clinical recommendations and identify effective implementation strategies. It is likely that professional education materials, paper- and computer-based treatment algorithms, protocols, and other clinical tools, as well as patient-facing materials, will be revised to reflect new approaches for reducing cardiovascular risk. Cardiovascular nurses are well prepared and positioned to assume leadership roles in these processes.

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REFERENCES

1. Center for Disease Control and Prevention. Heart Disease Facts. http://www.cdc.gov/heartdisease/facts.htm. Accessed November 30, 2013.

2. Eckel RH, Jakicic JM, Ard JD, et al. 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 [published online ahead of print]. Circulation. 2013. doi:10.1161/01.cir.0000437740.48606.d1.

3. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society [published online ahead of print]. Circulation. 2013. doi:10.1161/01.cir.0000437739.71477.ee.

4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print]. Circulation. 2013. doi:10.1161/01.cir.0000437741.48606.98PMID:24222018.

5. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print]. Circulation. 2013. doi:10.1161/01.cir.0000437738.63853.7a.

6. American Heart Association. 2013 prevention guidelines tools. CV risk calculator. http://my.americanheart.org/cvriskcalculator. Accessed November 30, 2013.

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