Abc’s Of Dietary Guidelines – March 21, 2019 |Abdulhamied Alfaddagh, MD, F; Kelly Arps, MD; Roger S. Blumenthal, MD, F; Seth Shay Martin, MD, MHS, F Expert Analysis
Editor’s Note: Commentary based on Arnett DK, Blumenthal RS, Albert MA, et al. 2019 /AHA Guideline on Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019. [Epub ahead of print].
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Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality and morbidity in the United States. Despite significant improvements in ASCVD outcomes over the past 4 decades, the burden of ASCVD risk factors remains high. Consequently, CVD death rates increased by 1% in 2015, the first increase since 1999.
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To control ASCVD risk factors and promote cardiovascular health, the American Heart Association (AHA) has provided a definition of ideal cardiovascular health using 7 metrics collectively known as “Life’s Simple 7”. The simple 7 include not smoking, a healthy weight, adequate physical activity and a balanced healthy diet, as well as reaching target values for cholesterol, blood pressure and blood sugar. A recent AHA report shows that only 17% of US adults have ≥5 of these metrics at ideal levels, however highlighting a significant health gap in primary prevention. The goal of the new AHA/prevention guidelines is to summarize previous recommendations, expert consensus documents, and clinical practice guidelines into one document to address this prevention gap.
In this review, we summarize the highlights of the 2019 AHA/Primary Prevention Guidelines using a simple, structured “
” Checklist (Figure 1). The goal is to help clinicians implement best practices for primary prevention using a simple framework.
Figure 1 was modified from the original version: Arnett DK, Blumenthal RS, Albert MA, et al. 2019 /AHA Guideline for the Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019.DOI:10.1016/j.j.2019.03.010.
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Control, we must highlight three general central recommendations. These recommendations, which apply to all ASCVD prevention efforts, adopt a team-based care approach to control ASCVD risk factors, engage patients in shared decision-making, and address social determinants of health to inform optimal implementation of treatment options. Team-based care improves the quality and consistency of care. It meets the needs of patients and achieves a greater reduction in ASCVD risk and better outcomes compared to usual care. This is especially true in low-resource settings or vulnerable population groups. Shared decision making engages patients in a discussion about their ASCVD risk and is more likely to identify and address potential barriers to treatment options.
Choosing the best risk reduction strategy for asymptomatic patients begins with an early assessment of ASCVD risk. Risk assessment initiates a clinician-patient discussion that continues during primary prevention and enables appropriate identification of patients who may benefit from pharmacotherapy in addition to lifestyle changes. For adults aged 40 to 75 years, the new guidelines continue to recommend routine assessment of traditional ASCVD risk factors as well as estimation of 10-year ASCVD risk using race- and sex-specific pooled cohort equations (PCE) (I, B- NR). ).
Given the limitations of population-based risk estimates, estimated ASCVD risk should be interpreted in light of the patient’s individual circumstances. PCE either significantly overestimates or underestimates ASCVD in approximately half of individuals within the 5–20% 10-year ASCVD risk range. For example, ASCVD risk is often underestimated in individuals with low socioeconomic status or other risk-increasing factors not included in PCE. For individuals with borderline (5% to <7.5%) or intermediate (≥ 7.5% to <20%) 10-year ASCVD risk requiring additional risk stratification, a reasonable approach is to determine whether additional risk-increasing factors exist (IIa , B). -NR). Table 1 lists the ASCVD risk-increasing factors described in the new guidelines; if present, they should lead to reclassification to a higher ASCVD risk group.
If uncertainty about the reliability of risk assessment for an individual remains, the new guidelines encourage the use of coronary artery calcium (CAC) measurement to guide preventive strategies in adults at intermediate risk or selected patients at borderline risk (IIa, B-NR). CAC is far superior to other subclinical imaging markers or blood-based biomarkers and has established properties for discrimination and risk reclassification. The CAC reliably reclassifies ASCVD risk upwards when the score is ≥100 Agatston units and reclassifies risk downwards with a score equal to zero. CAC measurement is particularly useful for refining estimates of ASCVD risk in lower-risk women, adults <45 years or ≥75 years, and people with a strong family history but low estimated ASCVD risk.
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Prescription of aspirin for primary ASCVD prevention is no longer based solely on a threshold of estimated ASCVD risk. Rather, an individualized decision to start aspirin should be based on the overall assessment of ASCVD risk (including PCE risk assessment and risk-increasing factors) weighted against the risk of bleeding. It is reasonable to start aspirin in adults aged 40 to 70 years with a high overall estimate of ASCVD risk (including risk-increasing factors) or at least moderate coronary calcium and low bleeding risk (IIb, A). However, acetylsalicylic acid is not recommended for primary ASCVD prevention if the risk of bleeding is moderately high (III, C-LD). Similarly, aspirin should not be routinely administered for primary ASCVD prevention to individuals >70 years of age with a bleeding risk that exceeds the protective benefit in this age group (III, B-R).
Hypertension contributes significantly to ASCVD morbidity and mortality. The blood pressure management recommendations are adapted from the 2017 high blood pressure guideline. The current guidelines for primary prevention re-emphasize the importance of lifestyle changes as an initial intervention for people with elevated blood pressure and a necessary addition to pharmacological treatment when indicated. Nonpharmacologic therapy in the form of weight loss, a heart-healthy diet, sodium reduction, dietary potassium supplementation, and increased physical activity with a structured exercise program and limited alcohol is recommended for all adults with elevated blood pressure or hypertension.
For adults with mean blood pressure ≥130/80 mmHg who either have an estimated 10-year risk of ASCVD ≥10%, diabetes, or chronic kidney disease, antihypertensive medications are recommended to achieve a blood pressure goal of <130/80 mmHg. . Adults with an estimated 10-year ASCVD risk of <10% and a mean blood pressure ≥140/90 mmHg are also recommended antihypertensive medications to reduce blood pressure to <130/80 mmHg. For individuals with a 10-year ASCVD risk of <10% and mean blood pressure 130-139/80-89 mmHg, nonpharmacologic treatment should be emphasized.
Increased serum cholesterol is a modifiable leading cause of ASCVD. Cholesterol Management Recommendations for primary ASCVD prevention were adapted from the 2018 AHA/Multi-Society Guidelines for Blood Cholesterol Management. In the majority of adults between 40 and 70 years of age, estimation of 10-year ASCVD risk using PCE is the first step in guiding the physician-patient discussion about statin therapy. The exceptions are in adults with diabetes (I, A) or low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL (I, B-R), for whom statin therapy is recommended regardless of estimated ASCVD risk.
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For adults with intermediate (≥7.5% to <20%) or high (≥20%) 10-year ASCVD risk, a moderate-intensity statin is recommended after physician-patient risk discussion (I, A). For those with intermediate ASCVD risk where the value of statin therapy remains uncertain, it is reasonable to identify risk-increasing factors (Table 1; IIa, B-R) or CAC measurement (IIa, B-NR) to guide shared decision-making. A CAC score ≥100 Agatston units (or ≥75th percentile for age and sex) reliably reclassifies risk upwards and favors initiation of moderate-intensity statin therapy. A CAC score of zero lowers risk and favors withholding statins and delaying risk assessment for 5–10 years in people without high-risk conditions such as diabetes, family history of premature coronary artery disease, or cigarette smoking (IIa, B-NR).
For adults with a borderline 10-year ASCVD risk (5% to <7.5%), the presence of risk-increasing factors would favor initiation of moderate-intensity statins (IIb, B-R). In young adults aged 20-39 years, measuring risk factors facilitates the calculation of lifetime risk and can help prioritize a healthy lifestyle. Statins in young adults are only strongly recommended for those with LDL-C ≥190 mg/dL or for selected patients with persistent LDL-C ≥160 mg/dL.
Tobo use is the largest modifiable risk factor for morbidity and mortality in the United States. Tobo use status should be assessed at each care visit (I, A) and all adults using tobo should be strongly advised to stop (I, A). Clinicians should recommend a combination of behavioral therapy and pharmacotherapy to aid cessation (I, A). Seven pharmacological options are now FDA-approved to facilitate tobo withdrawal: 5 types of nicotine replacement, as well as bupropion and vareniline (see Figure 2).
The guidelines emphasize the fact that neuropsychiatric side effects are no longer listed as a black box warning for bupropion and varenicline. The benefits of behavioral therapy and/or pharmacotherapy are well established in nonpregnant adults. In pregnant women, the benefit of stopping tobo is considerable. However, data on the results and safety of pharmacotherapy are still lacking in pregnant women.
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Electronic nicotine delivery systems (eg, e-cigarettes) are not recommended because the safety profile and evidence of benefit are not yet clear. Tobo use addiction is a chronic disease that requires
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