Coronary heart disease primary prevention: Difference between revisions

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The most recent [[randomized controlled trial]]s include:
The most recent [[randomized controlled trial]]s include:
* ARRIVE<ref name="pmid30158069">{{cite journal| author=Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB | display-authors=etal| title=Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2018 | volume= 392 | issue= 10152 | pages= 1036-1046 | pmid=30158069 | doi=10.1016/S0140-6736(18)31924-X | pmc=7255888 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30158069  }} </ref>
* ARRIVE excluded diabetics and shoed no benefit<ref name="pmid30158069">{{cite journal| author=Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB | display-authors=etal| title=Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. | journal=Lancet | year= 2018 | volume= 392 | issue= 10152 | pages= 1036-1046 | pmid=30158069 | doi=10.1016/S0140-6736(18)31924-X | pmc=7255888 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30158069  }} </ref>
* ASCEND showed benefit<ref name="pmid30146931">{{cite journal| author=ASCEND Study Collaborative Group. Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G | display-authors=etal| title=Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 16 | pages= 1529-1539 | pmid=30146931 | doi=10.1056/NEJMoa1804988 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30146931  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=30557420 Review in: Ann Intern Med. 2018 Dec 18;169(12):JC67] </ref>
* ASCEND studied only diabetics and showed benefit<ref name="pmid30146931">{{cite journal| author=ASCEND Study Collaborative Group. Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G | display-authors=etal| title=Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 16 | pages= 1529-1539 | pmid=30146931 | doi=10.1056/NEJMoa1804988 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30146931  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=30557420 Review in: Ann Intern Med. 2018 Dec 18;169(12):JC67] </ref>
 
* ASPREE showed no benefit, including among diabetics<ref name="pmid30221597">{{cite journal| author=McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR | display-authors=etal| title=Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 16 | pages= 1509-1518 | pmid=30221597 | doi=10.1056/NEJMoa1805819 | pmc=6289056 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30221597  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=31154354 Review in: Evid Based Nurs. 2019 Oct;22(4):115]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=32289133 Review in: J Fam Pract. 2020 Apr;69(3):E16-E18] </ref>
* ASPREE showed no benefit<ref name="pmid30221597">{{cite journal| author=McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR | display-authors=etal| title=Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 16 | pages= 1509-1518 | pmid=30221597 | doi=10.1056/NEJMoa1805819 | pmc=6289056 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30221597  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=31154354 Review in: Evid Based Nurs. 2019 Oct;22(4):115]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=32289133 Review in: J Fam Pract. 2020 Apr;69(3):E16-E18] </ref>


Stopping aspirin, even if originally not indicated, may increase cardiac events<ref name="pmid35286146">{{cite journal| author=Nelson MR, Polekhina G, Woods RL, Reid CM, Tonkin AM, Wolfe R | display-authors=etal| title=Safety of Ceasing Aspirin Used Without a Clinical Indication After Age 70 Years: A Subgroup Analysis of the ASPREE Randomized Trial. | journal=Ann Intern Med | year= 2022 | volume= 175 | issue= 5 | pages= 761-764 | pmid=35286146 | doi=10.7326/M21-3823 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286146  }} </ref>.
Stopping aspirin, even if originally not indicated, may increase cardiac events<ref name="pmid35286146">{{cite journal| author=Nelson MR, Polekhina G, Woods RL, Reid CM, Tonkin AM, Wolfe R | display-authors=etal| title=Safety of Ceasing Aspirin Used Without a Clinical Indication After Age 70 Years: A Subgroup Analysis of the ASPREE Randomized Trial. | journal=Ann Intern Med | year= 2022 | volume= 175 | issue= 5 | pages= 761-764 | pmid=35286146 | doi=10.7326/M21-3823 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286146  }} </ref>.

Revision as of 20:26, 7 June 2022

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Risk calculators and risk factors for Coronary heart disease primary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

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":

CV Risk Factors in the Setting of Primary Prevention

If you have two or more of the following risk factors, the LDL goal is < 130 mg/dl:

  • Cigarette smoking
  • Family history of premature coronary artery disease (CAD)
  • High LDL (defined as LDL > 130 mg /dl)
  • Hypertension (defined as a BP ≥140/90 mm Hg or if the patient is on antihypertensive drugs)
  • Low HDL (defined as HDL < 40 mg/dL males, < 50 mg/dL in females)
  • Older Age (men ≥45 years old; women ≥55 years old)

If you have < two risk factors, the goal is an LDL < 160 mg/dl.

Primary Prevention: LDL Goals for Various Categories of Risk[1]

Risk Category LDL-C Goal Consider Drug Therapy
CHD or CHD risk equivalent <100 mg/dl >130 mg/dl*
> 2 Risk Factors
10 yr risk 10-20% <130 mg/dl >130 mg/dl
10 yr risk < 10% <130 mg/dl > 160 mg/dl
< 2 Risk Factors <160 mg/dl >190 mg/dl

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.

Reduce Simvastatin Dosing in the Following Scenarios

Simvastatin drug interactions include the following:

  • Simvastatin 10 mg should be the maximum dose when prescribed with:
  • Simvastatin 20 mg should be the maximum dose when prescribed with:

Treat Underlying Causes of Hyperlipidemia

Treatment of Triglycerides

  • 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.
  • Triglyceride levels > 500 mg/dl are associated with acute pancreatitis.
  • Hypertriglyceridemia is associated with the following conditions:

Class IB

  • If the triglycerides are 200-499 mg/dL, then the non-HDL-C should be < 130 mg/dL

Class IIa

  • Further reduction of non-HDL to < 100 mg/dL is reasonable

Class IC

  • If TG are > 500 mg/dL, treat to prevent, pancreatitis before LDL-lowering therapy.

Avoid Drugs that Cause Dyslipidemia

Lifestyle Modification Goals

Aspirin in Primary Prevention

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 increase in major bleeding.[4] The U.S. Preventive Services Task Force 'strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease'.[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 most recent randomized controlled trials include:

  • ARRIVE excluded diabetics and shoed no benefit[7]
  • ASCEND studied only diabetics and showed benefit[8]
  • ASPREE showed no benefit, including among diabetics[9]

Stopping aspirin, even if originally not indicated, may increase cardiac events[10].

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:

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)[17]

Identification of Patients at Risk (DO NOT EDIT)[17]

Class I
"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.[18][19] (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

  1. Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-2497
  2. Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-2497
  3. 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. PMID 12821592. http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=5360&string=#s23
  4. 4.0 4.1 Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA (2022). "Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force". JAMA. 327 (16): 1585–1597. doi:10.1001/jama.2022.3337. PMID 35471507 Check |pmid= value (help).
  5. USPSTF. Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication. Available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication
  6. http://openrules.github.io/
  7. Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB; et al. (2018). "Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial". Lancet. 392 (10152): 1036–1046. doi:10.1016/S0140-6736(18)31924-X. PMC 7255888 Check |pmc= value (help). PMID 30158069.
  8. ASCEND Study Collaborative Group. Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G; et al. (2018). "Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus". N Engl J Med. 379 (16): 1529–1539. doi:10.1056/NEJMoa1804988. PMID 30146931. Review in: Ann Intern Med. 2018 Dec 18;169(12):JC67
  9. McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR; et al. (2018). "Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly". N Engl J Med. 379 (16): 1509–1518. doi:10.1056/NEJMoa1805819. PMC 6289056. PMID 30221597. Review in: Evid Based Nurs. 2019 Oct;22(4):115 Review in: J Fam Pract. 2020 Apr;69(3):E16-E18
  10. Nelson MR, Polekhina G, Woods RL, Reid CM, Tonkin AM, Wolfe R; et al. (2022). "Safety of Ceasing Aspirin Used Without a Clinical Indication After Age 70 Years: A Subgroup Analysis of the ASPREE Randomized Trial". Ann Intern Med. 175 (5): 761–764. doi:10.7326/M21-3823. PMID 35286146 Check |pmid= value (help).
  11. 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. PMID 16565093.
  12. 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. PMID 16825676. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.38290
  13. 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. PMID 17398308.
  14. http://www.who.int/nutrition/topics/5_population_nutrient/en/index12.html
  15. 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.
  16. 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.
  17. 17.0 17.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "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: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.
  18. Grundy SM, Cleeman JI, Merz CN, Brewer HB, Clark LT, Hunninghake DB; et al. (2004). "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines". Circulation. 110 (2): 227–39. doi:10.1161/01.CIR.0000133317.49796.0E. PMID 15249516.
  19. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (2002). "Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report". Circulation. 106 (25): 3143–421. PMID 12485966.

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