Who really needs to take a statin? What about an aspirin? Who needs further cardiac testing?
What do the governing bodies have to say? In March of 2019, the American College of Cardiology and the American Heart Association released a new guideline which made important recommendations for lifestyle modification, hypertension, cholesterol, and type 2 diabetes.
The task force created a comprehensive compilation of the most important studies and guidelines for atherosclerotic cardiovascular disease. The overarching theme of the guideline is that emphasis should be placed on prevention strategies using a shared decision model between the patient and physician. Furthermore, it must take into account potential barriers to care, such as limited health literacy.
The following excerpts are main points of the guidelines
written by Melvyn Rubenfire, MD, FACC. A guideline summary is also available.
Assessment and estimation of atherosclerotic cardiovascular disease (ASCVD) risk
Estimating Risk of ASCVD
- Assessment of ASCVD risk is the foundation of primary prevention.
- Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician-patient risk discussion before starting on pharmacological 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 guideline uses the race- and sex-specific Pooled Cohort Equation (PCE) (ASCVD Risk Estimator Plus
) to estimate 10-year ASCVD risk for asymptomatic adults aged 40-79 years. The PCE is best validated among non-Hispanic whites and non-Hispanic blacks living in the United States. In some race/ethnic groups and some non-US populations, the PCE may over or underestimate risk. Adults should be categorized into the following risk groups:
- Low (<5%)
- Borderline (5 to <7.5%)
- Intermediate (≥7.5 to <20%)
- High (≥20%)
There is benefit to using other risk prediction tools if validated in a population with similar characteristics. Examples are:
- Framingham CVD risk score
- Reynold’s risk score
- And QRISK/JBS3 tools
Among borderline and intermediate risk adults, “risk-enhancing” clinical factors can be used to revise the 10-year ASCVD risk estimate. These clinical factors include:
- Family history of premature ASCVD (men <55 years, women <65 years)
- Low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or non-high-density lipoprotein cholesterol (non-HDL-C) ≥190 mg/dL
- Chronic kidney disease (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2)
- Metabolic syndrome
- Pre-eclampsia and premature menopause (<40 years)
- Inflammatory diseases including rheumatoid arthritis, lupus, psoriasis, HIV
- South Asian ancestry
- Biomarkers, including fasting triglycerides ≥175 mg/dl, Lp(a) ≥50 mg/dl, high-sensitivity C-reactive protein ≥2 mg/L, apolipoprotein B >130 mg/dl, and ankle-brachial index (ABI) <0.9
If there is still uncertainty about the reliability of the risk estimate, further testing with computed tomography-derived coronary artery calcium score (CACs) will help to adjust the risk estimate upward or downward.
- The guidelines recognize that the obesity epidemic and the rise of associated comorbidities such as HTN and diabetes are a direct result of a more sedentary culture in addition to the greater availability of high calorie, low nutritional foods.
- The recommendation is that all adults should consume a healthy plant-based or Mediterranean-like diet high in vegetables, fruits, nuts, whole grains, lean vegetable or animal protein (preferably fish), and vegetable fiber, which has been shown to lower the risk of all-cause mortality compared to control or standard diet.
- Adults diagnosed as obese (body mass index [BMI] ≥30 kg/m2) or overweight (BMI 25-29.9 kg/m2) are at increased risk of ASCVD, heart failure, and atrial fibrillation compared with those of a normal weight.
- Clinically meaningful weight loss (≥5% initial weight) is associated with improvement in blood pressure (BP), LDL-C, triglycerides, and glucose levels among obese or overweight individuals, and delays the development of T2DM.
- Obese and overweight adults are advised to participate in comprehensive lifestyle programs for six months that assist participants in adhering to a low-calorie diet (decrease by 500 kcal or 800-1500 kcal/day) and high levels of physical activity (200-300 minutes/week).
- In addition to diet and exercise, FDA-approved pharmacologic therapies and bariatric surgery may have a role for weight loss in select patients.
- Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Smoking and smokeless tobacco (e.g., chewing tobacco) increases the risk for all-cause mortality and causal for ASCVD. Secondhand smoke is a cause of ASCVD and stroke, and almost one third of CHD deaths are attributable to smoking and exposure to secondhand smoke. Even low levels of smoking increase risks of acute myocardial infarction; thus, reducing the number of cigarettes per day does not totally eliminate risk.
- Electronic Nicotine Delivery Systems (ENDS), known as e-cigarettes and vaping, are a new class of tobacco products that emit aerosol containing fine and ultrafine particulates, nicotine, and toxic gases that may increase risk for CV and pulmonary diseases. Arrhythmias and hypertension with e-cigarette use have been reported. Chronic use is associated with persistent increases in oxidative stress and sympathetic stimulation in the healthy young.
- All adults should be assessed at every visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit on every visit. Referral to specialists is helpful for both behavioral modification, nicotine replacement, and drug treatments. Treatments include varieties of nicotine replacement; the nicotine receptor blocker varenicline; and bupropion, an antidepressant.
- Adults 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 type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits 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.
Statin treatment recommendations:
- Primary ASCVD prevention requires assessing risk factors beginning in childhood. For those <19 years of age with familial hypercholesterolemia, a statin is indicated.
- For young adults (ages 20-39 years), priority should be given to estimating lifetime risk and promoting a healthy lifestyle.
- Statin therapy should be considered in those with a family history of premature ASCVD and LDL-C ≥160 mg/dl.
- ASCVD risk-enhancing factors, (see risk estimate section above), should be considered in all patients.
- 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 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.
- For patients ages 20-75 years and LDL-C ≥190 mg/dl, use high-intensity statin without risk assessment.
- For patients with T2DM and age 40-75 years, use moderate-intensity statin and risk estimate to consider high-intensity statins.
- In those with multiple ASCVD risk factors, consider high-intensity statin with aim of lowering LDL-C by 50% or more.
- For patients older than 75 years, base decisions on clinical assessment and risk discussion.
- For patients age 40-75 years and LDL-C ≥70 mg/dl and <190 mg/dl without diabetes, use the risk estimator that best fits the patient and risk-enhancing factors to decide intensity of statin.
- Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension.
- For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.
- For adults with Stage I hypertension (BP 130-139/80-89 mm Hg) and estimated 10-year ASCVD risk of <10%, nonpharmacologic therapy is recommended.
- In those adults with a 10% or higher 10-year ASCVD risk (including persons with chronic kidney disease and diabetes), use of BP-lowering medication is recommended with a BP target of <130/80 mm Hg.
- For adults with Stage 2 hypertension (BP≥140/90 mm Hg), a target of <130/80 mm Hg is recommended and can be treated with nonpharmacological approaches and BP-lowering medication.
For decades, low-dose aspirin (81 mg/day) has been widely administered for ASCVD prevention. By irreversibly inhibiting platelet function, aspirin reduces risk of atherothrombosis but at the risk of bleeding, particularly in the gastrointestinal (GI) tract. Aspirin is well established for secondary prevention of ASCVD and is widely recommended for this indication, but recent studies have shown that in the modern era, aspirin should not be used in the routine primary prevention of ASCVD due to lack of net benefit. Most important is to avoid aspirin in persons with increased risk of bleeding including a history of GI bleeding or peptic ulcer disease, bleeding from other sites, age >70 years, thrombocytopenia, coagulopathy, chronic kidney disease, and concurrent use of nonsteroidal anti-inflammatory drugs, steroids, and anticoagulants. The following are recommendations based on meta-analysis and three recent trials:
Apply these recommendations to a real-life scenario in this case study.
- Low-dose aspirin might be considered for primary prevention of ASCVD in select higher ASCVD adults aged 40-70 years who are not at increased bleeding risk.
- Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years.
- Low-dose aspirin should not be administered for primary prevention among adults at any age who are at increased bleeding risk.
Arnett, D., Blumenthal, R., Albert, M., Buroker, A., Goldberger, Z., Hahn, E., Himmelfarb, C., Khera, A., Lloyd-Jones, D., McEvoy, W., Michos, E., Miedema, M., Muñoz, D., Smith, S., Virani, S., Williams, K., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 74 (10). doi: 10.1016/j.jacc.2019.03.010
Rubenfire, M. MD, FACC (2019, March 17). 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Retrieved 2/1/20 from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention