NEW ORLEANS — The American College of Cardiology (ACC) and American Heart Association (AHA) have released a new evidence-based guideline detailing the primary prevention of cardiovascular disease (CVD), including recommendations on patient-centered care, aspirin use, nutrition and body weight, smoking cessation, as well as diabetes management. The guideline was presented and discussed at the 2019 American College of Cardiology annual meeting held in New Orleans, March 16-18.
Strategies for CVD Prevention
According to the ACC/AHA, the majority of CVD burden and mortality are linked to smoking, poor diet, sedentary lifestyle, elevated body mass index (adverse health behaviors) as well as hypercholesterolemia, hypertension, and diabetes (major risk factors).
The ACC/AHA guidelines reflect the current consensus that targeting lifestyle, behavioral, and underlying medical conditions that contribute to heart disease is the cornerstone of disease prevention.
The guideline emphasizes the importance of a team-based care coordinated by professionals from multiple disciplines. Multidisciplinary care should channel its efforts into a shared-decision making approach which involves the patient as well as the patient’s family. A team-based approach can be facilitated in an outpatient setting to further help reduce disease risk among previously hospitalized patients at risk for heart disease.
Screening patient for social determinants of health, including food and housing insecurity and poor health literacy, can also be implemented in patient-centered care to identify health-related barriers.
Based on the level of current data, the guideline recommends against aspirin use among patients aged >70 years as well as adults who are at risk of bleeding. The use of prophylactic aspirin in middle-aged adults is now considered a Class IIb recommendation, the guideline states. “The complexity of assessing risk and benefit related to prophylactic aspirin use in individual patients mandates thorough assessment of cardiovascular risk and bleeding risk and re-emphasizes the importance of shared decision making,” the researchers wrote.
Although the use of cigarettes in the US have declined in recent years, tobacco use is still somewhat prevalent among men (34.8%) and women (20.8%). Clinicians are asked to reaffirm the importance of tobacco assessment during clinic visits, and tobacco cessation continues to be recommended.
Behavioral intervention combined with pharmacotherapy can optimize cessation rates, the guideline wrote. The guideline also advises clinicians to urge patients to reduce e-cigarette use.
Nutrition and Obesity
In line with previous research, the guideline also recommends a diet high in vegetables and fruits, nuts, fish, legumes, and whole grains. Trans fats and saturated fat should be replaced with unsaturated fats (ie, mono- and polyunsaturated fats), and cholesterol and sodium should be reduced. Dietitians may be helpful for creating individualized and realistic meal plans for patients, especially if these patients do not have access to healthy foods. Caloric restriction, counseling, and a comprehensive lifestyle intervention plan for >6 months is recommended for weight loss in obesity/overweight patients.
In addition to dietary intervention, exercise combined with counseling may be necessary for maximizing positive cardiovascular-related outcomes. The guideline continues to recommend 150 minutes/week of moderate intensity activity, 75 minutes/week of vigorous activity, or a combination of the 2 regimens. Sedentary behavior, another cardiovascular risk factor, should also be targeted in a CVD prevention program.
Reduction in screen time can help reduce sedentary behavior in adults. Any activity is better than no activity, the guideline wrote, including brief bouts of activity throughout the day.
Diabetes continues to be a prevalent CVD risk factor in the US, with prediabetes diagnosed in >1 out of 3 adults, and 11% of adults have type II diabetes. Diet, exercise, and body weight contribute to diabetes risk, making these 3 factors an important target for CVD prevention. First-line therapy for type II diabetes, according to the ACC/AHA guideline, is metformin (Class IIa). Individuals with type II diabetes as well as additional cardiovascular risk factors are recommended to take sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor antagonists.
“The new primary prevention guideline concisely summarizes recommendations for comprehensive risk factor modification in the healthcare setting,” the guideline authors wrote. “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.”
The author has multiple disclosures. Please refer to the original text for a full list.
Bittner, V. The new 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Presented at: American College of Cardiology 68th Annual Scientific Session & Expo; March 16-18, 2019; New Orleans, LA.