Treatment
Overarching Recommendations for ASCVD Prevention Efforts
Patient-Centered Approaches to Comprehensive ASCVD Prevention
A team-based care approach is recommended for the control of risk factors associated with ASCVD. ( I, A )
Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk. ( I, B-R )
Social determinants of health should inform optimal implementation of treatment recommendations for the prevention of ASCVD. ( I, B-NR )
Assessment of Cardiovascular Risk
For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the pooled cohort equations (PCE). ( I, B-NR )
For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years. ( IIa, B-NR )
In adults at borderline risk (5% to <7.5% 10-year
ASCVD risk) or intermediate risk (≥7.5% to <20% 10-year
ASCVD risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions (e.g.,
statin therapy).
( IIa, B-NR ) 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 (e.g.,
statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician–patient risk discussion.
( IIa, B-NR ) For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be considered. ( IIb, B-NR )
Lifestyle Factors Affecting Cardiovascular Risk
Nutrition and Diet
A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors. ( I, B-R )
Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD risk. ( IIa, B-NR )
A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk. ( IIa, B-NR )
As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk. ( IIa, B-NR )
As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk. ( III - Harm, B-NR )
Exercise and Physical Activity
Adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle. ( I, B-R )
Adults should engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) to reduce ASCVD risk. ( I, B-NR )
For adults unable to meet the minimum physical activity recommendations (at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity), engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial to reduce ASCVD risk. ( IIa, B-NR )
Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD. ( IIb, C-LD )
Other Factors Affecting Cardiovascular Risk
Adults With Overweight and Obesity
In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile. ( I, B-R )
Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity. ( I, B-R )
Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations. ( I, C-EO )
It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk. ( IIa, B-NR )
Adults With Type 2 Diabetes Mellitus
For all adults with T2DM, a tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors. ( I, A )
Adults with T2DM should perform at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors. ( I, A )
For adults with
T2DM, it is reasonable to initiate
metformin as first-line therapy along with lifestyle therapies at the time of diagnosis to improve glycemic control and reduce
ASCVD risk.
( IIa, B-R ) For adults with
T2DM and additional
ASCVD risk factors who require glucose-lowering therapy despite initial lifestyle modifications and
metformin, it may be reasonable to initiate a sodium-
glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like
peptide-1 receptor (GLP-1R) agonist to improve glycemic control and reduce
CVD risk.
( IIb, B-R )
Adults With High Blood Cholesterol
In adults at intermediate risk (≥7.5% to <20% 10-year
ASCVD risk),
statin therapy reduces risk of
ASCVD, and in the context of a risk discussion, if a decision is made for
statin therapy, a moderate-intensity
statin should be recommended.
( I, A ) In intermediate risk (≥7.5% to <20% 10-year ASCVD risk) patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk (≥20% 10-year ASCVD risk), levels should be reduced by 50% or more. ( I, A )
In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year
ASCVD risk, moderate-intensity
statin therapy is indicated.
( I, A ) In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL (≥4.9 mmol/L) or higher, maximally tolerated
statin therapy is recommended.
( I, B-R ) In adults with diabetes mellitus who have multiple
ASCVD risk factors, it is reasonable to prescribe high-intensity
statin therapy with the aim to reduce LDL-C levels by 50% or more.
( IIa, B-R ) In intermediate-risk (≥7.5% to <20% 10-year
ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of
statin therapy.
( IIa, B-R ) In intermediate-risk (≥7.5% to <20% 10-year
ASCVD risk) adults or selected borderline-risk (5% to <7.5% 10-year
ASCVD risk) adults in whom a coronary artery calcium score is measured for the purpose of making a treatment decision, AND
- If the coronary artery calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (e.g., diabetes, family history of premature CHD, cigarette smoking);
- If coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients ≥55 years of age;
- If coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.
( IIa, B-NR ) In patients at borderline risk (5% to <7.5% 10-year
ASCVD risk), in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity
statin therapy.
( IIb, B-R )
Adults With High Blood Pressure or Hypertension
In adults with elevated blood pressure (
BP) or hypertension, including those requiring
antihypertensive medications nonpharmacological interventions are recommended to reduce
BP. These include:
- weight loss
- a heart-healthy dietary pattern
- sodium reduction
- dietary potassium supplementation
- increased physical activity with a structured exercise program and
- limited alcohol.
( I, A ) In adults with an estimated 10-year ASCVD risk of 10% or higher and
an average systolic BP (SBP) of 130 mm Hg or higher ( I, A )
an average diastolic BP (DBP) of 80 mm Hg or higher, ( I, C-EO )
use of BP-lowering medications is recommended for primary prevention of CVD.
In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher.
an average systolic BP (SBP) of 130 or less ( I, B-R )
an average diastolic BP (DBP) of 80 mm Hg or less ( I, C-EO )
In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than
an average systolic BP (SBP) of 130 or less ( I, B-R )
an average diastolic BP (DBP) of 80 mm Hg or less ( I, C-EO )
In adults with
T2DM and hypertension,
antihypertensive drug treatment should be initiated at a
BP of 130/80 mm Hg or higher, with a treatment goal of
an average systolic BP (SBP) of 130 or less ( I, B-R )
an average diastolic BP (DBP) of 80 mm Hg or less ( I, C-EO )
In adults with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher, initiation and use of BP-lowering medication are recommended. ( I, C-LD )
In adults with confirmed hypertension without additional markers of increased ASCVD risk, a BP target of
an average systolic BP (SBP) of 130 or less ( IIb, B-NR )
an average diastolic BP (DBP) of 80 mm Hg or less ( IIb, C-EO )
a Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.
b ACC/AHA pooled cohort equations to estimate 10-year risk of ASCVD
Treatment of Tobacco Use
All adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation. ( I, A )
To achieve tobacco abstinence, all adults who use tobacco should be firmly advised to quit. ( I, A )
In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates. ( I, A )
In adults who use tobacco, tobacco abstinence is recommended to reduce ASCVD risk. ( I, B-NR )
To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system. ( IIa, B-R )
All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk. ( III - Harm, B-NR )
Aspirin Use
Low-dose
aspirin (75–100 mg orally daily) might be considered for the primary prevention of
ASCVD among select adults 40 to 70 years of age who are at higher
ASCVD risk but not at increased bleeding risk.
( IIb, A ) Low-dose
aspirin (75–100 mg orally daily) should
NOT be administered on a routine basis for the primary prevention of
ASCVD among adults >70 years of age.
( III - Harm, B-R ) Low-dose
aspirin (75–100 mg orally daily) should
NOT be administered for the primary prevention of
ASCVD among adults of any age who are at increased risk of bleeding.
( III - Harm, C-LD ) Class of Recommendations and Level of Evidence
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.
COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; RCT, randomized controlled trial.