Primary Prevention of Cardiovascular Disease

Publication Date: March 17, 2019

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)
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Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk. (I, B-R)
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Social determinants of health should inform optimal implementation of treatment recommendations for the prevention of ASCVD. (I, B-NR)
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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)
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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)
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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)
573
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)
573
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)
573

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)
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Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD risk. (IIa, B-NR)
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A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk. (IIa, B-NR)
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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)
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As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk. (III - Harm, B-NR)
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Exercise and Physical Activity

Adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle. (I, B-R)
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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)
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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)
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Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD. (IIb, C-LD)
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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)
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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)
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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)
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It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk. (IIa, B-NR)
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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)
573
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)
573
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)
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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)
573

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)
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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)
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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)
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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)
573
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)
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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)
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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)
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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)
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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)
573
In adults with an estimated 10-year ASCVDb risk of 10% or higher and
an average systolic BP (SBP) of 130 mm Hg or higher (I, A)
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an average diastolic BP (DBP) of 80 mm Hg or higher, (I, C-EO)
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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)
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an average diastolic BP (DBP) of 80 mm Hg or less (I, C-EO)
573
is recommended.
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)
573
an average diastolic BP (DBP) of 80 mm Hg or less (I, C-EO)
573
is recommended.
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)
573
an average diastolic BP (DBP) of 80 mm Hg or less (I, C-EO)
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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)
573
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)
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an average diastolic BP (DBP) of 80 mm Hg or less (IIb, C-EO)
573
may be reasonable.
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)
573
To achieve tobacco abstinence, all adults who use tobacco should be firmly advised to quit. (I, A)
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In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates. (I, A)
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In adults who use tobacco, tobacco abstinence is recommended to reduce ASCVD risk. (I, B-NR)
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To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system. (IIa, B-R)
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All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk. (III - Harm, B-NR)
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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)
573
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)
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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)
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Recommendation Grading

Disclaimer

Overview

Title

Primary Prevention of Cardiovascular Disease

Authoring Organizations

Publication Month/Year

March 17, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline is intended to be a resource for the clinical and public health practice communities. It addresses the primary prevention of CVD in adults (≥18 years of age), focused on outcomes of ASCVD (ie, acute coronary syndromes, MI, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of atherosclerotic origin), as well as heart failure and atrial fibrillation.

Target Patient Population

Adults 18 years of age and older

Target Provider Population

All healthcare providers

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention

Diseases/Conditions (MeSH)

D009765 - Obesity, D050171 - Dyslipidemias, D003920 - Diabetes Mellitus, D006973 - Hypertension

Keywords

atherosclerosis, cardiovascular disease, dyslipidemia, diabetes mellitus, primary prevention, coronary artery disease

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
24
Literature Search Start Date
January 1, 1993
Literature Search End Date
July 31, 2018
Specialties Involved
Cardiology, Endocrinology, Family Medicine, Internal Medicine General