This article is an expert commentary from Andrew Freeman, MD, FACC, who attended the ACC Annual Scientific Sessions 2019. Dr. Freeman is the Director of Clinical Cardiology & Operations, Director of CVD Prevention & Wellness, and Associate Professor of Medicine at National Jewish Health in Denver, CO.
Andrew Freeman, MD: My name is Dr. Andrew Freeman, and I am here at the ACC Annual Scientific Sessions 2019 in New Orleans. Today I’ll be talking a little bit about the updated 2019 primary prevention guidelines and some of the key takeaways.
So, the bottom line is no major surprise, but, of course, it’s nice to see that there’s significant emphasis on healthy lifestyle, and this is really the key to preventing and even reversing disease, particularly cardiovascular disease.
Multidisciplinary care is truly critical to success
The guidelines are very careful in a number of places to really highlight the importance of team-based care with frequent touchpoints from different perspectives and different types of providers, which helps patients understand some of the cardiovascular prevention that we’re trying so hard to implement.
Shared decision-making is absolutely essential, and social determinants of health were all discussed in this guideline.
Treat CVD risk, not lipid targets
And, again, as the lipid guidelines have evolved from 2013 when the paradigm shifted significantly, these guidelines reiterate the most recent update from just a few months ago, and they really want you to treat the risk associated with the cholesterol that’s measured rather than the numbers themselves. And it’s important that one populates their 10-year ASCVD risk using the latest pooled risk calculator, which you can find on the ACC site or in the Google Play or Apple Stores, respectively.
And, in short, what they say is that once you calculate the risk, if someone’s borderline now, which is 5%-7.5%, or intermediate risk, it’s reasonable to use additional risk-enhancing factors to guide decisions about whether or not to use a statin, and there’s a very important caveat which is said both in the guidelines on lipids alone, but also in these prevention guidelines, that it needs to be a very patient-centered discussion so that risks and benefits can be carefully weighed.
Welcome back, coronary calcium score
Similar to the guidelines that came out just a few months ago, the writing committee has welcomed back in the coronary calcium score; so, believe it or not, the coronary calcium score, which was previously thought to be more of a tool that might be helpful, is now considered helpful when there is an unclear benefit perhaps for statins. So, an adult at intermediate risk, which is greater than 7.5% all the way up to 20%, or selected adults at borderline risk 5%-7.5%, if risk-based decisions for preventive interventions are uncertain, a coronary artery calcium score can be done.
Risk-enhancing factors can help guide decisions
I want to mention the risk-enhancing factors—and I recommend checking out the full guideline, so you can see them all—but, importantly, things like chronic kidney disease with metabolic syndrome are risk-enhancing. Chronic inflammatory conditions are specifically called out, such as RA and lupus, which in many cases can significantly elevate cardiovascular risk; even things like premature menopause are factors. And then, of course, if Lp(a) or apoB are measured, those are important as well.
Key dietary guidance
There were also some very important dietary recommendations in this set of guidelines. First, to decrease risk, a diet of predominantly vegetables, fruits, legumes, nuts, whole grains, and even some fish in some cases is recommended. Very importantly, saturated fat should be replaced with dietary monounsaturated and polyunsaturated fats, and reducing amounts of cholesterol and sodium can be beneficial. Processed meats, refined carbohydrates, sweetened beverages, in addition to trans fats, should all really be avoided for the most part.
There were also some specifics mentioned about the provegetarian cohort substudy of PREDIMED, and they really are pushing quite a bit harder for us to go to a much more plant-based diet. And, again, like the guidelines that came out from the US Preventive Task Force, in addition to the US Dietary Guidelines for Americans, eating a more plant-based, whole-food, unprocessed diet seems to be really underscored. There was also a specific discussion regarding dairy, and because the evidence was so mixed it was not specifically endorsed or called out, but the jury is certainly still out there.
What’s the deal with exercise?
And then, of course, what’s the deal with exercise, this super-important concept? These guidelines are careful to say that you really should aim for 30 minutes of exercise most days a week, so adults should really aim for about 150 minutes per week of accumulated moderate-intensity physical activity, or 75 minutes of vigorous physical activity. What should we tell our patients? Well, we want to try to keep it simple, so I usually say 30 minutes per day and the guidelines would say that’s more or less correct. Of course, people can take a couple of days off on the weekend if they want, but 30 minutes every day seems to be very doable.
Getting rid of the sedentary behavior, right, so walking further in from a parking lot, not trying to get the first spot, say, at the gym right outside the door, or taking the stairs instead of the elevator, or standing if you have a standing desk at work. The guidelines are favorable toward any activity, although the patient should try to hit targets if they’re able.
How about for diabetes?
So, this is an interesting set of guidelines because it incorporates all the various components of prevention, including diabetes. And again they recommend lifestyle changes, including marked improvement in dietary habits and achieving exercise recommendations, which can have a significant impact on diabetes.
And if a medication is indicated, they recommend the old-fashioned, time-tested metformin as first-line therapy, but they’re also careful to incorporate the latest evidence on SGLT2s or GLP-1s, and this is in light of a lot of the recent evidence suggesting significant cardiovascular improvements in terms of risk.
Smoking: just quit it
They recommend in this set of guidelines that the status of tobacco use should be checked at every visit. Counseling patients on quitting at every opportunity is important, but using the team to help achieve abstinence is critical, and urging patients to proactively avoid secondhand smoke is specifically asked for.
Parting ways with ASA
Interestingly, this set of guidelines also talks about using aspirin for primary prevention, and finally there is enough of a consensus across the globe where aspirin may not be the ideal choice in primary prevention. One has to really assess cardiovascular risks, so in very select high-risk patients, aspirin may still be needed for primary prevention, but in general, the risk of bleeding often outweighs the risk of cardiovascular disease events reduction. So they recommend using it infrequently and avoiding it in older folks over 75 years old.
How about statins?
Again, they were very careful to recommend using them in the usual treatment groups that we’ve known since 2013, which is an LDL greater than 190, a prior cardiovascular event, clinical ASCVD, ACS, history of MI, TIA, PAD, aneurysm of atherosclerotic origin, diabetic patients aged 40-75, and overall elevated cardiovascular risk that one calculates using that risk calculator.
Statins are also recommended for very high-risk patients, so if you’ve had multiple major ASCVD events such as recent ACS, MI, ischemic stroke, PAD with symptoms, or one major ASCVD event with multiple high-risk conditions, they’re also recommended.
Ease the pressure
They very much recommend nonpharmacologic interventions to lower blood pressure. I usually tell patients that diet, exercise, stress relief, mindfulness, and connection are actually very powerful ways to lower blood pressure. And the guidelines are careful to mention that, too, in addition to sodium restriction and even alcohol reduction, and if meds are needed the target blood pressure should be about 130/80 in most individuals.
In addition, they tie the ASCVD risk estimate into the blood pressure, so they wrote that in adults with an estimated 10-year ASCVD risk of 10% or higher and an average systolic blood pressure of 130/80, use of blood pressure-lowering medications is recommended for primary prevention of cardiovascular disease. And I refer the audience to take a look at the prior hypertension guidelines which are exhaustive and encyclopedic in their reviews, but they are very handy to have for very specific conditions and very useful in determining which drug therapies should be used.
- Remember to assess cardiovascular disease risk ideally at every visit—it should almost be considered a vital sign. Look into lipid control, blood pressure control, smoking status, and the need for aspirin.
- The guidance around aspirin has definitely changed. Aspirin used to be one of the number one drugs that cardiologists gave out automatically and reflexively, but now it really should be avoided unless someone has already had a cardiovascular event. So, for primary prevention, aspirin should be very seldom used unless you have a very select high-risk patient.
- The team is critical in overcoming common hurdles when implementing behavioral and dietary changes. It’s really important to assess those barriers, those social determinants of health, and they recommend that the clinician should tailor advice to a patient’s socioeconomic and educational status as well as cultural, work, and home environments.
So, with that, I hope you have the latest and greatest on the prevention guidelines. Thank you!