Almost 18 million deaths were attributed to cardiovascular disease (CVD) globally in 2016; this was an increase of 14.5% during the previous decade.1 In the United States, although there has been substantial improvement in CVD outcomes during the past decade, CVD remains the leading cause of death for women and men and for most racial or ethnic groups.1 The economic burden of CVD exceeds $200 billion dollars in annual healthcare costs, medications, and lost work productivity. In 2015, a primary diagnosis of CVD was identified for more than 88 million physician office visits and 4.7 million emergency department visits.2 The excessive burden of CVD among Americans can be attributed in large part to suboptimal prevention and management of CVD risk factors. Effective strategies for primary prevention and partnering with our patients to promote better cardiovascular health are essential to disrupt the status quo.
Recently, the American Heart Association, in partnership with the American College of Cardiology, released the “Guideline on the Primary Prevention of CVD.”3 This evidence-based guideline consolidates recent scientific statements and clinical practice guidelines and includes newly generated recommendations for exercise and physical activity, tobacco use, and aspirin use, in addition to recommendations related to team-based care, shared decision making, and assessment of social determinants of health, to provide comprehensive recommendations for the prevention of CVD.
Developing a Patient-Centered, Team-Based Approach
A strong and important message from this new guideline is that CVD prevention is optimized through promotion of a healthy lifestyle across the lifespan. Three overarching recommendations for patient-centered approaches to CVD prevention are (1) a team-based care approach for the control of risk factors, (2) shared decision making to guide discussion about the best strategies to reduce CVD risk, and (3) social determinants of health that should inform implementation of treatment recommendations. A team-based care approach is an effective strategy for the prevention of CVD. Shared decision making occurs when clinicians engage patients in discussions about personalized CVD risk estimates and their implications for the perceived benefits of preventive strategies, including lifestyle and medical therapies. Because socioeconomic inequalities are strong determinants of CVD risk, clinicians should tailor their advice and treatment plans to patients' culture, work, and home environments as well as socioeconomic and educational statuses. The Centers for Medicare & Medicaid Services offer a screening instrument to assess 5 domains of nonhealth factors (housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety) that can affect prevention efforts and health outcomes.4 For each CVD risk factor, the social determinants of health should be integrated in the discussion. For example, for diet and obesity, body size perception and its social and cultural influences should be assessed. Barriers to healthy food and adhering to a healthy diet should be assessed including where the patient resides, financial resources, and cultural factors. Sleep hygiene and psychological factors can have a significant impact on obesity and blood pressure and should be assessed.
Assessment of Atherosclerotic Cardiovascular Disease Risk
Assessment of atherosclerotic CVD (ASCVD) risk to determine a patient's 10-year absolute risk is used to match appropriate interventions to an individual's level of risk. All adults, aged 40 to 75 years, should have their ASCVD risk estimated. This allows for optimization of the treatment plan while minimizing the potential for overtreatment. The ASCVD risk score is used to guide decisions in lipid and hypertension management. The ASCVD risk estimator can be found at http://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calculate/estimator/.5 Risk enhancing factors, which are not considered in the ASCVD risk score, can also help guide the patient's risk discussion (see Table 1).
Lifestyle Factors Affecting Cardiovascular Disease Risk
The guideline clearly outlines the specific recommendations for lifestyle factors affecting CVD including nutrition, diet, physical activity, and exercise (see Table 2). The guideline provides a comprehensive algorithm to help healthcare providers work with their patients to emphasize adherence to healthy lifestyle.3
Other Factors Affecting Cardiovascular Disease Risk
Calculating body mass index (BMI) is recommended annually or more frequently to identify individuals with overweight (BMI of 25–29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) for weight loss considerations. In individuals with overweight and obesity, weight loss is recommended to improve their ASCVD risk factor profile. The nutritional aspects of obesity revolve around the principle of balancing caloric intake and expenditure. Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss.
For adults with type 2 diabetes mellitus (DM), it is important to provide a tailored nutrition plan that improves glycemic control and other ASCVD risk factors. Patients with diabetes should follow the recommended physical activity recommendations as previously discussed. There are other identified risk enhancers in patients with diabetes that the clinician should assess and monitor including presence of retinopathy, neuropathy, Ankle-Brachial Index less than 0.9, or duration of type 2 DM of 10 years longer or type 1 DM of 20 years or longer. Renal function is also important to monitor and includes albuminuria and glomerular filtration rate. Metformin continues to be the first-line medication therapy along with lifestyle modification. For diabetic patients with high ASCVD risk, there are 2 classes of glucose-lowering medications that have demonstrated a reduction in CVD events that may be considered as second-line therapy: sodium-glucose cotransporter 2 inhibitor or a glucagonlike peptide-1 receptor agonist. A treatment algorithm is provided to guide shared decision-making discussions.
The guideline is consistent with the 2018 guideline on the management of blood cholesterol.6 Moderate-intensity statin therapy is recommended for patients at an intermediate ASCVD risk with a goal of 30% low-density lipoprotein cholesterol (LDL-C) level reduction and at a high ASCVD risk with a goal of 50% LDL-C reduction. In patients with diabetes aged 40 to 75 years, moderate-intensity statin therapy is indicated regardless of 10-year estimated ASCVD risk. To meet the 50% LDL-C level reduction, it is feasible that high-intensity statin therapy may be needed. The coronary artery calcium (CAC) score can be used in guiding treatment decisions and discussion with patients especially if they are reluctant to start statin therapy, have had statin-induced symptoms, or are older and really do not think statin therapy would be beneficial. If the CAC score is zero, it is reasonable to not start statin therapy and to reassess in 5 to 10 years in the absence of other high-risk conditions such as diabetes, premature coronary heart disease family history, or cigarette smoking. In any patient 55 years or older, if the CAC is 1 to 99, statin therapy may be initiated. Coronary artery calcium measurement is not intended as a “screening” test for all but rather may be used as a decision aid in select patients to facilitate the risk discussion.
In adults with high blood pressure or known hypertension, the 2017 guideline for hypertension clinical practice should be followed.7 Lifestyle modification is emphasized as a key recommendation for all adults with elevated blood pressure or hypertension and includes weight loss if overweight or obese, a heart-healthy diet following the DASH plan, sodium reduction (<1500 mg/d), dietary potassium supplementation (3500–5000 mg/d), and reduction of alcohol consumption. Physical activity should be increased using a structured exercise program including the addition of dynamic and isometric resistance exercises. The recommended target blood pressure is less than 130/80 mm Hg, and if there is an estimated ASCVD risk of 10% or higher, use of blood pressure–lowering medications is recommended as a primary prevention measure.
All individuals with CVD risk should be assessed at every health visit for current tobacco use including the use of vaping and “juul” methods. Cigarette smoking continues to be a strong, independent risk factor for CVD events and premature death. Tobacco use dependence is a chronic disease that requires highly skilled chronic disease management. If a patient uses any tobacco product, there should be shared decision making to develop a plan to quit. Tobacco users are more likely to quit after 6 months when the provider gives strong advice and support for cessation. A combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates. The guideline recommends behavioral and pharmacotherapy treatments to assist patients with tobacco cessation. Having dedicated trained staff to provide tobacco treatment in every healthcare system is recommended. Finally, all adults and adolescents should avoid secondhand smoke exposure to reduce their ASCVD risk.
Recommendations for the use of aspirin in primary prevention have been updated in this guideline, although aspirin continues to be indicated in secondary prevention. The current recommendations for use of aspirin in primary prevention are provided in Table 3.
The new guideline for the primary prevention of CVD recommends a comprehensive patient-centered approach. The benefit of a healthy lifestyle throughout the lifespan is emphasized. Addressing a patient's social determinants of health and lifestyle and estimating the risk of a future ASCVD event provide essential information to guide shared decision-making discussions between a patient and a clinician and provide a basis for determining whether pharmacotherapy may be indicated. Importantly, lifestyle goals should continue to be emphasized on a regular basis even among those on pharmacotherapy for risk reduction. Use of treatment algorithms provided in the guideline may be helpful in guiding treatment decisions and optimizing outcomes of the recommended evidence-based CVD risk reduction therapies.
1. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics—2019 Update: a report from the American Heart Association. Circulation
. 2019;139(10):e56–e528. doi:10.1161/CIR.0000000000000659.
3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Circulation
. 2019;CIR0000000000000678. doi:10.1161/CIR.0000000000000678.
6. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Circulation
. 2018;CIR0000000000000625. doi:10.1161/CIR.0000000000000625.
7. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation
. 2018;138(17):e426–e483. doi:10.1161/CIR.0000000000000597.