Which lifestyle modifications are associated with a reduction in recurrent myocardial infarction (MI, heart attack) and prevention of further progression of cardiovascular disease?

Updated: May 07, 2019
  • Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang, MD  more...
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Much emphasis has been placed on postdischarge care for patients after MI.

Several lifestyle modifications have been strongly linked to a reduction in recurrent MI and prevention of further progression of cardiovascular disease. These modification include dietary changes that adopt a low-fat and low-salt diet with dietary counseling, smoking cessation, up-to-date vaccination, and an increase in physical activity and exercise.

2019 ACC/AHA primary CVD prevention recommendations

The American College of Cardiology (ACC) and the American Heart Association (AHA) published recommendations on the primary prevention of cardiovascular disease (CVD) in March 2019. [119, 120] Ten key messages and a few recommendations from the guidelines are summarized below, including an emphasis on lifestyle choices/modifications and a major shift away from the broad use of aspirin in primary prevention.

Key messages

A healthy lifestyle over a lifetime is the most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation.

A team-based care approach is an effective strategy for CVD prevention. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions.

Adults aged 40-75 years being evaluated for CVD prevention should undergo 10-year atherosclerotic CVD (ASCVD) risk estimation and have a clinician–patient risk discussion before being started on pharmacotherapy (eg, antihypertensive therapy, a statin, or aspirin). The presence or absence of additional risk factors and/or the use of coronary artery calcium (CAC) scanning can help guide decisions about preventive interventions in select individuals.

All adults should consume a healthy diet that emphasizes consumption of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish, and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. In the setting of overweight and obesity, counseling and caloric restriction are recommended to achieve and maintain weight loss.

Adults, including those with type 2 diabetes mellitus (T2DM), should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

For adults with T2DM, lifestyle changes (eg, improving dietary habits, achieving exercise recommendations) are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor (SGLT2) or a glucagon-like peptide-1 receptor agonist (GLP-1).

At every healthcare visit, assess all adults for tobacco use. Assist tobacco users and strongly advise them to quit.

Aspirin should be used infrequently in the routine primary prevention of ASCVD because of a lack of net benefit.

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

Nonpharmacologic interventions are recommended for all adults with elevated blood pressure or hypertension. When pharmacologic therapy is required, target the blood pressure to generally be below 130/80 mmHg.

Select recommendations

For adults aged 40-75 years, routinely assess traditional CV risk factors and calculate their 10-year ASCVD risk with the pooled cohort equations (PCE). For those aged 20-39 years, it is reasonable to assess traditional ASCVD risk factors at least every 4-6 years.

In adults at borderline risk (5% to < 7.5% 10-year ASCVD risk) or intermediate risk (≥7.5% to < 20% 10-year ASCVD risk), using additional risk-enhancing factors is reasonable to guide decisions about preventive interventions (eg, statin therapy).

In adults at intermediate risk (≥7.5% to < 20% 10-year ASCVD risk) or selected adults at borderline risk (5% to < 7.5% 10-year ASCVD risk), if risk-based decisions for preventive interventions (eg, statin therapy) remain uncertain, measuring a CAC score to guide the clinician-patient risk discussion is reasonable, as follows:

  • CAC = 0: Withholding statin therapy is reasonable; reassess in 5-10 years if higher risk conditions are absent (eg, diabetes, family history of premature coronary heart disease, tobacco use).

  • CAC = 1-99: Initiating statin therapy is reasonable for those aged 55 years or older.

  • CAC is ≥100, or is in ≥75th percentile: Initiating statin therapy is reasonable.

For adults aged 20-39 years and for those aged 40-59 years whose 10-year ASCVD risk is below 7.5%, consider estimating their lifetime or 30-year ASCVD risk.

In adults at intermediate risk (≥7.5% to < 20% 10-year ASCVD risk):

  • If statin therapy is decided upon, use a moderate-intensity agent.

  • Reduce LDL-C levels by ≥30%; for optimal ASCVD risk reduction, particularly in high-risk patients (≥20% 10-year ASCVD risk), reduce LDL-C levels by ≥50%.

  • In the setting of risk-enhancing factors, initiating or intensifying statin therapy is favored.

In diabetic adults aged 40-75 years, regardless of the estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated. High-intensity statin therapy is reasonable for diabetic adults with multiple ASCVD risk factors to reduce LDL-C levels by 50% or more.

The maximally tolerated statin therapy is recommended in patients aged 20-75 years with LDL-C levels of 190 mg/dL (≥4.9 mmol/L) or higher.

Blood pressure (BP)-lowering agents are recommended for the following patients:

  • Adults with an estimated 10-year ASCVD risk of ≥10% and an average BP of ≥130/80 mmHg (for primary CVD prevention)

  • Adults with an estimated 10-year ASCVD risk < 10% and a BP of ≥140/90 mmHg

Low-dose aspirin (75-100 mg orally daily) guidance includes the following:

  • Consider for primary ASCVD prevention in select adults aged 40-70 years who have higher ASCVD risk but not an increased bleeding risk.

  • Do not routinely administer for primary ASCVD prevention in adults >70 years as well as in adults of any age who have a higher bleeding risk.

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