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Author: Kristin Watson, PharmD, BCPS-AQ Cardiology
Looking for a one stop shop on recommendations for primary prevention of cardiovascular (CV) disease? Look no further than the 2019 American College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Primary Prevention of Cardiovascular Disease1 which was released on March 17, 2019.
Be sure to check out the American College of Cardiology’s Hub for resources for all things primary prevention: https://www.acc.org/guidelines/hubs/prevention There are some excellent tools posted here including the guideline recommendations in a PowerPoint format and Patient Resources.
Here are some key points from the Primary Prevention guidelines:
Patient-centered care is necessary.
Shared decision-making should be at the forefront of determining the approach(es) to lower one’s CV risk. Social determinants of health (e.g., psychological stressors, access to nutritious meals, mental illness) need to be considered as each treatment and implementation plan is developed.
For example, those on a fixed income are not likely to be able to afford an array of fresh fruits and vegetables. Instead, we can talk to our patients about low-sodium, frozen produce options which may be more affordable for some. Unfortunately, many of our patients do not live in a neighborhood where it is safe enough to walk outside. Alternatively, we can suggest taking a walk inside a local mall.
Evaluate your patient’s CV risk.
Determine each patient’s 10-year risk of ASCVD (atherosclerotic cardiovascular disease) before you engage in a discussion about risk reduction strategies. It is recommended that a patient’s risk is assessed routinely in those aged 40-75 and it is reasonable to assess traditional ASCVD risk factors every 4 to 6 years in those aged 20-39. However, it is important to remember that the ASCVD risk may be an over- or underestimated in some as pooled cohort equations are utilized in this calculation. Therefore, it may be reasonable for clinicians to assess for “risk-enhancing factors” or to measure a calcium artery score to further classify a patient’s risk (up or down).
Assessing and explaining a patient’s risk of ASCVD is essential when determining, with the patient, which risk reduction strategies will be employed.
A healthy lifestyle is paramount.
An array of studies evaluating different diets have been published in the past few years. These studies have all described the importance of eating a balanced diet. Diets that include fruit, vegetables, nuts, legumes, and lean animal or vegetable proteins have been shown to improve outcomes. Additionally, dietary recommendations continue to stress the importance of consuming the correct types of fats (monounsaturated and polyunsaturated versus saturated and trans fats). The recommendation to avoid trans fats was given a Class of Recommendation III (Harm) as consumption has been shown to increase the risk of ASCVD. Patients should also be encouraged to avoid sweetened beverages (sugar or artificial).
The importance of exercise is also discussed. At least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity is recommended. It is important to work with patients to develop an exercise routine that will work for them rather than just telling them a specific number of days and/or minutes that they should exercise each week.
Ask about tobacco use at every visit.
The primary prevention guideline reminds us of the importance of identifying patients who use tobacco and helping them to stop. Tobacco cessation is critical to lower one’s CV risk. Health care providers need to ensure that at each patient encounter we employ the 5 A’s – Ask, Advise, Assess, Assist and Arrange. If you missed it, be sure to check out the 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment.
Controlling diabetes is key.
Patients with type 2 diabetes should continue to receive metformin as part of their initial treatment regimen. The use of a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide 1 (GLP-1) agonist should be considered, after metformin, for those with additional ASCVD risk factors. These medications classes have been shown to reduce the risk of CV disease in addition to improving in glycemic control.
What to learn more about the CV benefits of antihyperglyemic medications? Check out Antihyperglycemic medications and impact on cardiovascular outcomes: a review of current evidence that was published by ATRIUM members.
Limited role of aspirin for primary prevention.
No surprises here given the results of studies evaluating the role of aspirin for primary prevention.2–6 The guideline states that the use of aspirin might be considered for some patients aged 40-70 who are at an increased ASCVD risk but not at an increased bleeding risk. A specific ASCVD risk score is not provided. Providers are encouraged to “consider the totality of available evidence for ASCVD” before recommending aspirin. Clinicians may consider use for those at increased ASCVD risk in whom ASCVD risk factors cannot be controlled. If aspirin is used, the dose should be 75-100 mg daily.
The use of aspirin is not recommended, for primary prevention, in those over the age of 70. Additionally, aspirin use in not recommended in those with an increased risk of bleeding (e.g., prior gastrointestinal bleed, peptic ulcer disease and use of other medications that increase the risk of bleeding). The lingering question is – should we discontinue aspirin therapy in those who no longer qualify for use for primary prevention? Concern exists over the risk of rebound CV events for those in whom therapy is discontinued. More data is needed to weigh the risks and benefits of discontinuing aspirin therapy.
Bottom Line
We need to consider each patient’s risk of ASCVD before developing a primary prevention strategy. Patients need help developing the best approach to lowering their CV risk. It is important to ensure that our treatment plan is realistic and feasible given varying socioeconomic factors. Aspirin should no longer be routinely recommended to lower a patient’s risk of ASCVD. We should focus on primary prevention strategies such as a healthy lifestyle as well as cholesterol and blood pressure management, all of which have been shown to have a significant impact on CV outcomes. And always remember to ask about tobacco use at every visit. You never know when you will make the difference in helping someone to quit.
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Kristin Watson, PharmD, BCPS-AQ Cardiology
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References:
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Journal of the American College of Cardiology. March 2019. doi:10.1016/j.jacc.2019.03.010
- Zheng SL, Roddick AJ. Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis. JAMA. 2019;321(3):277-287. doi:10.1001/jama.2018.20578
- Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. The Lancet. August 2018. doi:10.1016/S0140-6736(18)31924-X
- McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. New England Journal of Medicine. 2018;379(16):1519-1528. doi:10.1056/NEJMoa1803955
- Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly | NEJM. https://www.nejm.org/doi/full/10.1056/NEJMoa1805819. Accessed March 18, 2019.
- Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. New England Journal of Medicine. 2018;0(0):null. doi:10.1056/NEJMoa1804988
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