ACC/AHA 2019 Guideline on the Primary Prevention of Cardiovascular Disease
New ACC and the American Heart Association (AHA) 2019 Guidelines for primary prevention of heart disease, stroke have been released. The guideline was presented at ACC's 68th Annual Scientific Session. The new guidelines offer comprehensive but practical recommendations for preventing cardiovascular disease, which remains the leading cause of death for both men and women in the United States. The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease was simultaneously published in the Journal of the American College of Cardiology and Circulation.
Nearly 1 out of 3 deaths in the U.S. is due to cardiovascular disease.The new ACC and American Heart Association (AHA) primary prevention guideline provide a comprehensive roadmap of strategies that can be used and tailored to help prevent or slow the development of atherosclerotic cardiovascular disease (ASCVD).
“The most important way to prevent cardiovascular disease … is by adopting heart healthy habits and to do so over one’s lifetime,” said Roger S. Blumenthal, MD, FACC, co-chair of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. “More than 80 percent of all cardiovascular events are preventable through lifestyle changes, yet we often fall short in terms of implementing these strategies and controlling other risk factors.”
The guideline consolidates existing recommendations and new research, expert consensus documents, and clinical practice guidelines into a single source of guidance on the primary prevention of ASCVD. It underscores healthy lifestyle changes and risk assessment as the cornerstone of preventing cardiovascular disease and goes a step further by providing practical advice based on the latest research and proven interventions for improving diet and exercise, tobacco cessation and optimally controlling other risk factors like obesity, diabetes, high cholesterol and high blood pressure.
Recommendations for Lifestyle Change
The guideline underscores healthy lifestyle changes as the cornerstone of preventing heart disease and goes a step further by providing practical advice based on the latest research.
"We can all do better with our dietary and exercise habits, and that's so important when we think about wanting to live longer and healthier lives, whether it's to see our grandchildren grow up or to stay as active as possible in older age," Blumenthal said.
Some of the key lifestyle recommendations include:
- Eating heart healthier – choosing more vegetables, fruits, legumes, nuts, whole grains, and fish, and limiting salt, saturated fats, fried foods, processed meats, and sweetened beverages; specific eating plans like the Mediterranean, DASH and vegetarian diets are reviewed.
- Engaging in regular exercise – experts advise aiming for at least 150 minutes of moderate-intensity exercises such as brisk walking, swimming, dancing or cycling each week. For people who are inactive, some activity is better than none and small 10-minute bursts of activity throughout the day can add up for those with hectic schedules. Currently, only half of the American adults are getting enough exercise and prolonged periods of sitting can counteract the benefits of exercise.
- Aiming for and keeping a healthy weight – for people who are overweight or obese, losing just 5 to 10 percent of their body weight (that would be 10-20 pounds for someone who weighs 200 pounds) can markedly cut their risk of heart disease, stroke and other health issues.
- Avoiding tobacco by not smoking, vaping or breathing in smoke – 1 in 3 deaths from heart disease is attributable to smoking or exposure to secondhand smoke, so every effort to try to quit through counseling and/or approved cessation medications should be supported and tailored to each individual.
Recommendations for Aspirin Use
For people who've had a heart attack, stroke, open heart surgery or stents placed to open clogged arteries, aspirin can be lifesaving. But regular use of aspirin to prevent heart attacks and stroke in healthy people isn't as clear-cut.
In this guideline, ACC/ AHA experts offer science-based guidance that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. Recent research suggests that the chance of bleeding, given the blood-thinning effect of aspirin, may be too high and the evidence of benefit—the number of heart attacks or strokes that are actually prevented—is not sufficient enough to make a daily aspirin worth taking for most adults in this setting.
"Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease," Blumenthal said. "It's much more important to optimize lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin. Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding."
Recommendations for Diabetes control
For people with Type 2 diabetes, which is one of the strongest risk factors for cardiovascular disease, there are new data that two classes of diabetes medications, which work to lower blood sugar levels, can also cut the risk of heart attack, stroke and related deaths.
Recommendations for Cholesterol management and statins Use
The new guideline suggests statins be recommended with lifestyle changes to prevent cardiovascular disease among people with elevated low density lipoprotein cholesterol levels (≥ 190 mg/dl), type 2 diabetes, and anyone who is deemed to have a high likelihood of having a stroke or heart attack upon reviewing their medical history and risk factors and having a detailed discussion with their clinician.
Recommendations related to team-based care shared decision-making, and assessment of social determinants of health are also included. “Social determinants of ASCVD risk – and their impact on the patient’s ability to prevent or treat risk factors – must be taken into account,” the authors said. “Clinicians need to consider patients’ health literacy and education levels and assess patients’ motivation to improve their lifestyle habits.”
However, the authors note: “Even if a blood pressure–reducing medication, lipid-lowering medication, or diabetes medication is ultimately prescribed, lifestyle goals should be emphasized on a regular basis. Only when a person’s risk is sufficiently high should medications to reduce ASCVD risk be considered as part of a shared decision-making process for optimal treatment.”
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