Coronary heart disease primary prevention

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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

Clinical Practice Guidelines

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]"

Evidence

The most recent randomized controlled trials include:

  • ARRIVE excluded diabetics and shoed no benefit[8]
  • 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:
  • 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:

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

Class I
"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) "

[18]

Assessment of Cardiovascular Risk

Class I
"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)"

[18]

Class IIa
" 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)''

[18]

Class IIb
" 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)".

[18]

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Life (Please do not edit).

Nutrition and Diet

Class I
"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)"

[18]

Class IIa
" 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)''

[18]

Class III (Harm)
"5. As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk (Level of Evidence: B-NR) "

[18]

Exercise and Physical Activity

Class I
"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) "

[18]

Class IIa
" 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)".

[18]

Class IIb
" 4.  Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD risk (Level of Evidence B-NR)".

[18]

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Other Cardiovascular Risk Factors

Adults With Overweight and Obesity

Class I
"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)"

[18]

Class IIa
" 4. It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk (Level of Evidence B-NR)".

Adults With Type 2 Diabetes Mellitus

Class I
"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)"

[18]

Class IIa
" 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)".

[18]

Class IIa
" 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)".

[18]

Adapted from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease [18]
Treatment of T2DM for primary prevention of cardiovascular disease. Adapted from 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.

Adults With High Blood Cholesterol

Class I
"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)''

[18]

Class IIa
" 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)''

[18]

Class IIb
" 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)".

[18]

Adults With High Blood Pressure or Hypertension

Class I
"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 )''

[18]

Adapted from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.
Adapted from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease.

Treatment of Tobacco Use

Class I
"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)''

[18]

Class IIa
" 5. To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare system (Level of Evidence B-R)".

[18]

Class III (Harm)
"6. All adults and adolescents should avoid secondhand smoke exposure to reduce ASCVD risk (Level of Evidence: B-NR) "

[18]

Aspirin Use

Class IIb
" 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)".

[18]

Class III (Harm)
"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)''

[18]

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]

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.[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

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  2. Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001; 285:2486-2497
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  6. OpenRules. http://openrules.github.io/
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  18. 18.00 18.01 18.02 18.03 18.04 18.05 18.06 18.07 18.08 18.09 18.10 18.11 18.12 18.13 18.14 18.15 18.16 18.17 18.18 18.19 18.20 18.21 18.22 Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ | display-authors=etal (2019) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 140 (11):e596-e646. DOI:10.1161/CIR.0000000000000678 PMID: 30879355
  19. 19.0 19.1 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.
  20. 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.
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