The American College of Cardiology/American Heart Association (ACC/AHA) have recently published primary prevention cardiovascular disease guidelines. They were originally considered very useful for general practitioners who had no choice but to review separately expert consensus or clinical practice guidelines for hypertension, cholesterol, diabetes, etc. Now, everything is concentrated in a single reference document. But is it enough for all patients?
These guidelines also take into account other risk factors such as diet, exercise, need for aspirin, and tobacco consumption.
The first part focuses on patient-oriented strategies aimed at achieving prevention objectives. The document emphasizes the need for teamwork to handle risk factors.
Then, there is a section on risk assessment, which includes an update of the 2013 definitions that controversially defined low (<5%), intermediate (5 to 7.5%), and high risk (>7.5%) at 10 years. With all the noise caused by the hypertension guidelines, we expected an update that further adjusted such thresholds. However, what we have is the exact opposite. The new thresholds are borderline (5-7.5%), intermediate (7.5 to 19.9%), and high (>20%!!!), always at 10 years.
A healthy lifestyle is one of the keys in these guidelines, which emphasize a diet focused on vegetables, fruits, legumes, nuts, whole grains, and fish (basically, a Mediterranean diet). They reduce the consumption of sodium, cholesterol, processed meat, refined carbohydrates, and sugary drinks. Exercise is the other key in lifestyle change, recommending at least 150 minutes of moderate activity or 75 minutes of vigorous-intensity aerobic activities per week.
Finally, these new guidelines focus on weight loss and obesity.
There is a special section on diabetes; class of recommendation I includes lifestyle optimization (nutrition, exercise, and weight loss plan) and the first-line therapy is metformin (class IIa).
For the first time, these guidelines incorporate calcium score as a tool to determine risk when other scores do not seem neither useful nor representative of a patient’s true risk. Starting statin therapy with a calcium score over 100 is a reasonable parameter.
The biggest change as regards aspirin in primary prevention is the fact that its category was lowered, from class I to class IIb.
In summary, the 2019 ACC/AHA primary prevention guidelines seem to be an excellent resource to guide the management and treatment of the main risk factors. They can be applied to the wide majority of patients, even though their implementation in real-world clinical practice may be disheartening.
Original Title: Prevention Guidelines: Does one size fit all? Discussion of the 2019 ACC/AHA Primary Prevention of Cardiovascular Disease Guidelines.
Reference: Sophia Larson et al. European Heart Journal, Volume 40, Issue 27, 14 July 2019, Pages 2181–2183.
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