The LDL target in primary prevention depends upon the patient's risk factors. If the patient has CHD or its equivalent, then the LDL goal is under 100 mg/dl. If the patient has 2 risk factors, the LDL goal is 130 mg/dl. If the patient has < 2 risk factors, the LDL goal is < 160 mg/dl. Attempts should be made to reduce triglyceride levels and to increase HDL levels. The underlying causes for existing dyslipidemias should be identified and appropriately managed. Drugs that cause dyslipidemias should be avoided. Patients should be evaluated reguarly for the presence of risk factors for coronary heart disease, and those with increased risk should be counseled on the beneficial effects of daily aspirin therapy. Patients should also regularly be counseled about modifying risk factors such as obesity, hypertension, smoking, and the benefits of an exercise plan.
Risk Equivalents in Primary Prevention
If CHD or a risk equivalent is present, the LDL goal is < 100 mg/dl. You are essentially considered to have the equivalent of coronary heart disease if you have any of the following "risk equivalents":
Avoid Drug Interactions with the LDL-Lowering Agents Simvastatin, Atorvastatin or Lovastatin
While LDL-lowering agents are widely prescribed in primary prevention, care should be taken to select the appropriate statin based upon concommittant medications. As a result of the metabolism via the CYP 3A4 pathway, simvastatin, atorvastatin and lovastatin interact with the following agents and should be avoided. The patient should be switched to pravastatin.
Triglyceride lowering is a secondary target of primary prevention.
The independent and causal relationship of elevated triglycerides to CHD outcomes is not clear, although hypertriglyceridemia is a stronger risk factor for women than men.
The United States Preventive Services Task Force (USPSTF) concluded that aspirin, in doses of less than 75 to 81 mg/d, can reduce the incidence of cardiovascular events, but without change in mortality, and with an increase in major bleeding.[4]
The 2022 USPSTF recommendation was a "C" for aspirin for 'Adults aged 40 to 59 years with a 10% or greater 10-year cardiovascular disease (CVD) risk".[5] A risk calculator is available.[6] The USPSTF states, "decisions about initiating aspirin use should be based on shared decision-making between clinicians and patients about the potential benefits and harms" and "decisions about initiating aspirin use should be based on shared decision-making between clinicians and patients about the potential benefits and harms"[4].
The USPSTF Evidence Summary and Report states, "decisions about initiating aspirin use should be based on shared decision-making between clinicians and patients about the potential benefits and harms" and "decisions about initiating aspirin use should be based on shared decision-making between clinicians and patients about the potential benefits and harms"[4][7]. The USPSTF calculated:
No difference in mortality
"Significant decrease in major cardiovascular disease events (odds ratio [OR], 0.90 [95% CI, 0.85-0.95]"
ASCEND studied only diabetics and showed benefit but "The absolute benefits were largely counterbalanced by the bleeding hazard"[9]. In the ASCEND trial, the absolute changes were:
ASCVD outcomes: - 1.1% (there was no variation based on baseline ASCVD risk score per per Appendix 1, Table S4
ASPREE showed no benefit, including among diabetics[10]
Stopping aspirin, even if originally not indicated, may increase cardiac events[11].
The U.S. Preventive Services Task Force previously 'strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease'.
Modification of Risk Factors that do not have a Robust Evidence Base
Just because something has been identified as a risk factor, that does not mean that lowering the risk factor improves outcomes. This is because the risk factor may not lie in the causal pathway for CHD. Risk factors that when modified may not improve outcomes include the following:
There is little evidence that aggressive blood sugar control actually improves cardiac risk.
The World Health Organization (WHO) recommends "low to moderate alcohol intake" to reduce risk of coronary heart disease.[15]
Avoidance of fats that are readily oxidized (e.g., saturated fats and trans-fats). The consumption of trans fat (commonly found in hydrogenated products such as margarine) has been shown to cause the development of endothelial dysfunction, a precursor to atherosclerosis.[16]
It has been suggested that coronary heart disease is partially reversible using an intense dietary regimen coupled with regular cardio exercise.[17]
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Overarching recommendations for Atherosclerotic Cardiovascular Disease (ASCVD) prevention efforts (Please do not edit).
Patient-Centered Approaches to Comprehensive ASCVD Prevention
"1. A team-based care approach is recommended for the control of risk factors associated with ASCVD(Level of Evidence: A) "
"2. Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk (Level of Evidence: B-R) "
"3. Social determinants of health should inform the optimal implementation of treatment recommendations for the prevention of ASCVD(Level of Evidence: B-NR) "
"1. For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate the 10-year risk of ASCVD by using the pooled cohort equations (PCE).(Level of Evidence: B-NR)"
" 2. For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years (Level of Evidence B-NR)".
'' 3. 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 (eg, statin therapy)(Level of Evidence B-NR)''
''4. 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 (eg, statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician-patient risk discussion (Level of Evidence C B-NR)''
" 5. 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 (Level of Evidence B-NR)".
"1. For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate the 10-year risk of ASCVD by using the pooled cohort equations (PCE).(Level of Evidence: B-NR)"
" 2. Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD risk (Level of Evidence B-NR)".
'' 3. A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk (eg, statin therapy)(Level of Evidence B-NR)''
''4. 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.(Level of Evidence B-NR)''
"1. Adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle (Level of Evidence: B-R "
"2. 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(Level of Evidence: B-NR) "
" 3. 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 (Level of Evidence B-NR)".
"1. In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile . (Level of Evidence: B-R)"
"2. Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity(Level of Evidence: B)"
"3. Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations. (Level of Evidence: C-EO)"
"1. 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 (Level of Evidence: A)"
"2. 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 (Level of Evidence: A)"
" 3. 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.(Level of Evidence B-R)".
" 4. 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 (Level of Evidence B-NR)".
Treatment of T2DM for primary prevention of cardiovascular disease. Adapted from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.
"1. In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk), statin therapy reduces the 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. Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines(Level of Evidence: A)"
"2. 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.Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines(Level of Evidence: A)"
"3. In adults 40 to 75 years of age with diabetes, regardless of the estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated. Included from recommendations in the 2018 Cholesterol Clinical Practice Guideline (Level of Evidence: A)"
"4. 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. Included from recommendations in the 2018 Cholesterol Clinical Practice Guideline (Level of Evidence: B-R)''
" 5. 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. Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (Level of Evidence B-R)".
'' 6. In intermediate-risk (≥7.5% to <20% 10-year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of statin therapy.S4.3-7,S4.3-26–S4.3-33Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S (eg, statin therapy). (Level of Evidence B-R)''
''7. 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 (eg, diabetes, family history of premature CHD, cigarette smoking).
If the coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients ≥55 years of age.
If the coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy. Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guideline(Level of Evidence B-NR)''
" 8. 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 from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (Level of Evidence B-R)".
"1. 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.
Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines(Level of Evidence: A)"
"2. 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 or an average diastolic BP (DBP) of 80 mm Hg or higher, use of BP-lowering medications is recommended for primary prevention of CVD. Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines (Level of Evidence: A;DBP:C-EO)"
"3. In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended. Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines(Level of Evidence: SBP:B-R; DBP:C-EO)"
"4. In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than 130/80 mm Hg is recommended. Adapted from recommendations in the 2017 Hypertension Clinical Practice Guideline (Level of Evidence: SBP: B-R; DBP: C-EO)''
''5. 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 less than 130/80 mm Hg.Adapted from recommendations in the 2017 Hypertension Clinical Practice Guideline (Level of Evidence: SBP:B-R; DBP:C-EO )''
''6. 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. Adapted from recommendations in the 2017 Hypertension Clinical Practice Guideline (Level of Evidence: C-LD )''
"1. 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(Level of Evidence: A)"
"2. To achieve tobacco abstinence, all adults who use tobacco should be firmly advised to quit.(Level of Evidence: A)"
"3. In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rate(Level of Evidence: B-NR)"
"4. In adults who use tobacco, tobacco abstinence is recommended to reduce ASCVD risk (Level of Evidence: B-R)''
" 5. To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system (Level of Evidence B-R)".
" 1. 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 (Level of Evidence: A)".
"2. 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 (Level of Evidence: B-NR) "
"3. 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 (Level of evidence C-LD)''
2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[19]
Identification of Patients at Risk (DO NOT EDIT)[19]
"1. Primary care providers should evaluate the presence and status of control of major risk factors for CHD for all patients at regular intervals (approximately every 3 to 5 years). (Level of Evidence: C)"
"2. Ten-year risk (National Cholesterol Education Program [NCEP] global risk) of developing symptomatic CHD should be calculated for all patients who have 2 or more major risk factors to assess the need for primary prevention strategies.[20][21](Level of Evidence: B)"
"3. Patients with established CHD should be identified for secondary prevention efforts, and patients with a CHD risk equivalent (e.g., atherosclerosis in other vascular beds, diabetes mellitus, chronic kidney disease, or 10-year risk greater than 20% as calculated by Framingham equations) should receive equally intensive risk factor intervention as those with clinically apparent CHD. (Level of Evidence: A)"
References
↑Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-2497
↑Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-2497
↑Thompson PD, Buchner D, Pina IL; et al. (2003). "Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity)". Circulation. 107 (24): 3109–16. doi:10.1161/01.CIR.0000075572.40158.77. PMID12821592.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link) http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=5360&string=#s23
↑Hooper L, Thompson RL, Harrison RA, Summerbell CD, Ness AR, Moore HJ, Worthington HV, Durrington PN, Higgins JP, Capps NE, Riemersma RA, Ebrahim SB, Davey Smith G (2006). "Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review". BMJ. 332 (7544): 752–60. doi:10.1136/bmj.38755.366331.2F. PMID16565093.CS1 maint: Multiple names: authors list (link)
↑Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B, Jordan HS, Lau J (2006). "n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review". Am. J. Clin. Nutr. 84 (1): 5–17. PMID16825676.CS1 maint: Multiple names: authors list (link) http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.38290
↑Yokoyama M, Origasa H, Matsuzaki M; et al. (2007). "Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis". Lancet. 369 (9567): 1090–8. doi:10.1016/S0140-6736(07)60527-3. PMID17398308.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
↑Lopez-Garcia E, Schulze MB, Meigs JB, Manson JE, Rifai N, Stampfer MJ, Willett WC, Hu FB. (2005). "Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction". J Nutr. 135 (3): 562–6. PMID 15735094.CS1 maint: Multiple names: authors list (link)
↑Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA, McLanahan SM, Kirkeeide RL, Brand RJ, Gould KL. (1990). "Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial". Lancet. 336 (8708): 129–33. PMID 1973470.CS1 maint: Multiple names: authors list (link)
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