New AHA/ACC CVD Primary Prevention Guideline

Susan Jeffrey

March 17, 2019

NEW ORLEANS — The American College of Cardiology (ACC) and the American Heart Association (AHA) have released new guidance on the primary prevention of cardiovascular disease.

As expected, one of the major changes is a recommendation against the broad use of aspirin in primary prevention, after recently reported results of the ARRIVEASCEND, and ASPREE trials called the balance of risk and benefit with treatment into question in a variety of populations.

The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease is published online March 17 in the Journal of the American College of Cardiology and Circulation and presented here at the American College of Cardiology 68th Annual Scientific Session 2019 (ACC.19).

The document is also endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association.

Co-chairs of the writing committee are Donna K. Arnett, PhD, dean and professor of epidemiology at the University of Kentucky College for Public Health, and past president of the American Heart Association, and Roger Blumenthal, MD, professor of medicine at the Johns Hopkins School of Medicine and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland.

During a press conference here, presidents of the both the ACC and AHA discussed the goals of the new guideline.

"What we're here to talk about today is the fact is that through lifestyle choices and modifications, nearly 80% of all cardiovascular disease can be prevented," John J. Warner, MD, immediate past president of the American Heart Association and executive vice president for Health System Affairs, UT Southwestern Medical Center, Dallas. "These 2019 prevention guidelines look at the whole person and how individuals, working hand in hand with their clinicians and physicians, can manage their vulnerabilities."

The document emphasizes healthy lifestyle as "the most important part of prevention throughout the entire lifespan, but these guidelines also look at prevention from a new lens of social determinants of health," Warner noted. "Based on scientific evidence, we now know that only 10% to 20% of our health is actually determined by the healthcare that we receive, and 70% to 80% is impacted by social determinants of health. Underserved and low-income populations have a higher risk of heart disease and life expectancy can vary by more than 20 years in people living only 5 miles apart."

Richard Kovacs, MD, professor of clinical medicine and clinical director of the Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, is vice president of the American College of Cardiology and takes on the role of ACC president during this meeting. He congratulated the writing committee for completing this task in 1 year, through 33 peer reviews.  

"This is going to be a comprehensive resource for both clinical and public health practices in terms of the prevention of cardiovascular disease, and it dovetails quite nicely with other guidelines," Kovacs said, updating the 2013 CV Risk and 2013 Lifestyle guidelines, and the 2013 overweight and obesity guidelines, but also "includes and replicates" portions of the 2017 blood pressure guidelines and the 2018 cholesterol guideline.

During the press conference, Arnett and writing committee member Amit Khera, MD, professor of medicine at the University of Texas, Southwestern Medical School in Dallas, and president of the American Society of Preventive Cardiology, discussed some of the main changes in the new guidelines.

"One different part about this guideline is that we decided that there are three overarching themes that have to underline all prevention," Arnett said. "The first is that we really need a team-based approach to care for risk factors for ASCVD (atherosclerotic cardiovascular disease). The second recommendation is that all decisions should be shared between the clinician and the patient as they're discussing the best strategies to reduce risk, and finally, we adopted the recommendation that social determinants of health should inform optimal implementation of treatment recommendations for the prevention of ASCVD."

For busy clinicians, Khera said, "This is a one-stop shop. This is one central resource for clinicians, putting it all together with prior work as well as new and evolving components that you're going to hear about, and hopefully that will help in the effectiveness of implementation."

Among some of the main recommendations are the following:

  • Risk estimation: "One can't do prevention without understanding one's risk factors," Khera noted. The recommendation therefore is for adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year ASCVD risk estimation. For those age 20 to 39 years, "every 4 to 6 years it's reasonable to assess risk factors, even though you can't formally calculate that 10-year risk." There should be a clinician–patient risk discussion before initiation of pharmacologic therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning, the executive summary document notes.

  • Diet: Adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, legumes, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of processed meats, refined carbohydrates, sodium, and sweetened beverages. The document recommends replacing saturated fat with poly- and monounsaturated fats, and, for the first time, gives a harm recommendation to avoid consumption of trans fats, Arnett noted.

Diet is an area, for example, where social determinants of health come into play, Arnett noted. "We need to assess barriers to adopting a heart-healthy diet," such as inner-city or rural environments where there may be scarce access to fresh fruits and vegetables, or those with socioeconomic disadvantage or advanced age. 

  • Physical activity: Adults should be routinely counseled on healthcare visits to engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity. "Notice we're not saying exercise, we're saying physically active," Arnett said. Recent research suggested that just advising physical activity to sedentary individuals can improve their effectiveness for becoming physically active, with a number needed to treat of about 12 for 1 person to improve their activity, she noted. "So that's a pretty powerful intervention, just counselling our patients." Engaging in some moderate or vigorous activity, even if it doesn't meet the recommendation, is still beneficial, she added.

  • Obesity: For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. Calculating body mass index is recommended annually or more frequently to identify obesity and overweight, and it is "reasonable" to measure waist circumference to identify those at higher metabolic risk. Lifestyle counseling for weight loss should include assessment of psychosocial stressors and sleep hygiene, and individualized barriers, Arnett noted. "These can be particularly pronounced in vulnerable populations."

  • Diabetes: To lower cardiovascular disease risk in patients with diabetes, it's become clear that "it's not just about the blood sugar, it's comprehensive cardiovascular disease prevention — nutrition, exercise, weight, blood pressure, cholesterol, and of course medications as well," Khera said. For adults with type 2 diabetes mellitus, lifestyle changes, including a tailored nutrition plan, and achieving exercise recommendations, are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. These later agents, he said, "have really revolutionized diabeto-cardiology, if you will, in that not only do they lower blood glucose," they've also been shown to reduce ASCVD events and death.

  • Tobacco: All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. In adults who use tobacco, the recommendation is for a combination of behavioral and one of seven approved pharmacologic treatments, Arnett said. "We know from the evidence that using two different types of nicotine replacement therapy moderately improves cessation over just one type," she added, and the addition of varenicline or bupropion provides added benefit.

  • Aspirin: One of the major changes in the guidelines is the recommendation on aspirin, Khera said. Results of the ARRIVE, ASCEND, and ASPREE studies have shifted the balance between benefit from aspirin therapy and bleeding risk, "which really have shown us that the place for aspirin is diminished in terms of primary prevention and that bleeding may be outweighing the benefit in the modern era with all of our preventive therapies."

Low-dose aspirin now has a IIb recommendation, he said, "meaning general no, occasionally yes." Aspirin might be considered for primary prevention among select adults 40 to 70, who are at higher ASCVD risk but not at increased bleeding risk. There is a "harm" recommendation that low-dose aspirin should not be used routinely for those over 70, or those at any age with an increased risk of bleeding. "We don't pay enough attention to that risk of bleeding component, but this is a call to arms to make sure we do," Khera noted. 

  • Statins: Cholesterol recommendations in this document reflect those for primary prevention in the 2018 cholesterol guideline, Khera noted. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, those who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk, after a clinician–patient risk discussion. Coronary calcium testing may be useful here in helping patients make a decision on whether or not to seek therapy, Khera said.

  • Blood pressure: Blood pressure recommendations also align with the 2017 guideline recommendations, starting with the recommendation for nonpharmacologic interventions in all adults with elevated blood pressure or hypertension. "The cornerstone for blood pressure management is lifestyle," Khera said, including the DASH diet. For those requiring pharmacologic therapy, the target blood pressure should generally be less than 130/80 mm Hg.

"For more than 150 years the American Heart Association and the American College of Cardiology have been fighting against cardiovascular disease and trying to limit the impact of stroke and heart disease, not only on residents of the United States but of the world as well," Warner said. The new guideline "is a comprehensive document that we think will dramatically change the trajectory of the prevention of cardiovascular disease not only in the United States but across the globe."

In an editorial accompanying the Circulation publication of the guidelines, Vera Bittner, MD, professor of medicine at the University of Alabama at Birmingham, concludes that "the new primary prevention guideline concisely summarizes recommendations for comprehensive risk factor modification in the healthcare setting. It is up to us to develop multidisciplinary models of care to implement these guidelines in our individual practices, and to engage our patients to become our partners in this lifelong process." 

J Am Coll Cardiol. Published online March 17, 2019. Guideline, Executive Summary

Circulation. Published online March 17, 2019. Guideline,  Executive Summary, Editorial

American College of Cardiology 68th Annual Scientific Session 2019 (ACC.19). Presented March 17, 2019.

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