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Understanding the New 2019 ACC/AHA Guideline on the Prevention of Cardiovascular Disease

Apr 29, 2019 4:23:52 PM

Worldwide headlines read: “Aspirin no longer useful for stroke and heart attack prevention”

Source of this buzz was the new guidelines issued from a joint American College of Cardiology and American Heart Association (ACC/AHA) guideline published in early March, 2019. The new guideline is meant solely for primary prevention. Anyone with known clinically significant atherosclerotic vascular disease (ASCVD) is excluded from this guideline as their care is categorized as “secondary prevention”. One may suppose that the only topic in the guideline was aspirin use for the primary prevention of heart attack and stroke. In fact, the recommendations involved other key topics that are summed up here in text and pictures. But first, let’s discuss aspirin.

Aspirin Use for Primary Prevention

As stated above, aspirin therapy is strongly recommended for secondary prevention in patients with a history of heart disease like a prior stenting, heart attack, bypass procedure, carotid procedure, peripheral procedure such as an aneurysm repair, or identified significant narrowing in arteries. On the whole, in patients with a history of the abovementioned conditions, the benefits of aspirin in reducing cardiovascular crises outweigh the risks. Foremost among these risks is an especially small risk of bleeding in the brain, and a minor risk of life-threatening bleeding from the stomach.

The ACC/AHA guidelines suggest that most adults without a history of heart disease should not take low-dose daily aspirin to prevent a first stroke or heart attack, mainly if over 70 years old (chart 4.6 below). Based on 3 new studies, the ASPREE, ARRIVE, and ASCEND trials, the ACC/AHA guidelines concluded that the risk of side effects from aspirin, particularly bleeding, outweighed the potential benefit.

Aspirin Use1

Recommendations for Aspirin Use

Referenced studies that support recommendations are summarized in Online Data Supplements 17 & 18.

COR

LOE

Recommendations

IIb

A

1. Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk (S4.6-1–S4.6-8).

III:

Harm

B-R

2. Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age (S4.6-9).

III:

Harm

C-LD

3. Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding (S4.6-10).

 

A vague group are patients with evidence of silent atherosclerosis such as an elevated coronary artery calcium score (CACS) by CT Heart Scan. As exhibited below on the fourth bullet point, this is often will be individualized for each patient.

dsaf

The role of CACS was specified in the guidelines as of merit for many patients as indicated in the table below. The recommendation to take into account a CACS before starting a statin medication to ascertain if a zero score is present (and avoid the statin) would effect tens of millions of people if fully implemented.

Table 6. Selected Examples of Candidates for Coronary Artery Calcium Measurement Who Might Benefit From Knowing Their Coronary Artery Calcium Score Is Zero

Coronary Artery Calcium Measurement Candidates Who Might Benefit from Knowing Their Coronary Artery Calcium Score Is Zero
  • Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely
  • Patients concerned about need to re-institute statin therapy after discontinuation for statin- associated symptoms
  • Older patients (men 55–80 y of age; women 60–80 y of age) with low burden of risk factors (S4.3-53) who question whether they would benefit from statin therapy
  • Middle-aged adults (40–55 y of age) with PCE-calculated 10-year risk of ASCVD 5% to <7.5% with factors that increase their ASCVD risk, although they are in a borderline risk group.

 

Top 10 Take-Away Lessons for Primary Prevention of Cardiovascular Disease

  1. The foremost principal to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to encourage a healthy lifestyle throughout lifetime.

  2. A team-based care tactic is an effectual strategy for the prevention of cardiovascular disease. Clinicians should assess the social factors of health that affect patients to informed treatment decisions.

  3. Adults between 40 to 75 years of age and are being assessed for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk dialogue before starting on pharmacological therapy, such as antihypertensive therapy, statins, or aspirin. Additionally, evaluating for other risk-enhancing factors can help navigate decisions about preventive measures in select individuals, as can coronary artery calcium scanning.

  4. All adults should consume a healthy diet that emphasizes the consumption of vegetables, fruits, nuts, whole grains, lean vegetable and/or animal protein, and fish and minimizes the consumption of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For overweight or obese adults, counseling and caloric restriction are recommended for realizing and maintaining weight loss.

  5. Adults should participate in at least 150 minutesper week of accumulated moderate-intensity physical activity or 75 minutesper week of vigorous-intensity physical activity.

  6. For adults with type 2 diabetes mellitus, lifestyle modifications, such as improving dietary habits and reaching exercise recommendations, are critical. If medication is indicated, metforminis first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.

  7. All adults should be evaluated at every healthcare visit for tobacco use, and those who use tobacco should be aided and strongly counselled to quit.

  8. Aspirinshould be utilized infrequently in routine primary prevention of ASCVD due to lack of overall benefit.

  9. Statin therapyis first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein (LDL) cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician risk analysis.

  10. Nonpharmacological interventionsare recommended for all adults with hypertension. For those needing pharmacological therapy, the target blood pressure should generally be <130/80.

Physical Fitness

The news headlines overlooked the glaring evidence for the role of physical fitness in ASCVD prevention. Also overlooked, as little as 11 minutes a day or 75 minutes a week of vigorous-intensity aerobic physical activity satisfied the guidelines.

 

3.2. Exercise and Physical Activity1

Recommendations for Exercise and Physical Activity

Referenced studies that support recommendations are summarized in Online Data Supplements 6 and 7.

COR

LOE

Recommendations

I

B-R

1. Adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle (S3.2-1, S3.2-2).

I

B-NR

2. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) to reduce ASCVD risk (S3.2-3–S3.2-8).

IIa

B-NR

3. For adults unable to meet the minimum physical activity recommendations (at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity), engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial to reduce ASCVD risk (S3.2-5, S3.2-6).

IIb

C-LD

4. Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD-9–S3.2-11).

 

Nutrition

As recommended below by the ACC/AHA guidelines, the main foods for the prevention of ASCVD are modeled after the Mediterranean diet and are low/absent in saturated fat sources such as meat, cheese, butter, full fat dairy, and coconut oil and are rich in vegetables, fruits, legumes, nuts, whole grains, and fish. Processed meats, refined carbs, added sugars and trans-fats all should be avoided.

3.1. Nutrition and Diet1

Recommendations for Nutrition and Diet

Referenced studies that support recommendations are summarized in Online Data Supplements 4 and 5.

COR

LOE

Recommendations

I

B-R

1. A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors (S3.1-1–S3.1-11).

 

IIa

 

B-NR

2. Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD risk (S3.1-12, S3.1- 13).

 

IIa

 

B-NR

3. A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk (S3.1-9, S3.1-14–S3.1-16).

 

IIa

 

B-NR

4. As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk (S3.1-17–S3.1-24).

III: Harm

B-NR

5. As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk (S3.1-12, S3.1-17, S3.1-25–S3.1-27).

 

Conclusions

Our daily choices can have a lasting effect on our heart and vascular health. Embracing a heart healthy diet plan early in life, getting more exercise, avoiding tobacco and managing known risk factors are amongst the key recommendations in the 2019 Primary Prevention of Cardiovascular Disease guideline from the ACC/AHA. Moreover, it is recommended that aspirin should only be rarely used to help prevent heart attacks and stroke in patients without known cardiovascular disease.

 

References

Bittner, V. A. (2019). The New 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. doi:10.1161/circulationaha.119.040625

Orville Caval
Written by Orville Caval

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