Most cardiovascular diseases and mortality come down to 4 years of unhealthy habits (smoking, poor diet, obesity and sedentarism) and 3 major risk factors (cholesterol, hypertension, and diabetes).
Ideal cardiovascular health, defined as absence or control of these 7 factors, is far less frequent than we might believe. It is estimated that 87% of the middle-aged adult population and 95% of people over 60, present at least 4 of these factors.
Recommendations on the calculated risk for decision making when it comes to hypertension and hypercholesterolemia have not seen changes recently.
In other points, new evidence has been incorporated to the new guidelines.
- Aspirin: the prophylactic use of aspirin has been put into question. The new guidelines explicitly warn against the risk in patients over 70 and in patients with increased bleeding risk (prior bleeding, coagulopathy, thrombocytopenia, kidney failure or concomitant use of drugs that will increase bleeding).
Read also: New Valvular Heart Disease Guidelines with Key TAVI and Mitral Regurgitation Updates.
Aspirin indication as primary prevention in middle aged adults is now a IIB recommendation.
- Smoking: though significantly reduced, it is estimated 35% of men and 20% of women still smoke. Guidelines insist on the importance of routine questions about smoking habits and strongly advice against it (including vaping).
- Nutrition, diet, overweight, and obesity: guidelines recommend higher consumption of vegetables, fruit, legumes, nuts, whole grains, and fish. They also advice against processed meats, refined carbohydrates, and sweet drinks.
- Exercise and physical activity: asking about the level of physical activity and advising on optimal levels should be routine. Guidelines recommend 150 minutes a week of intense to moderate activity, 75 minutes of intense activity or a combination of both. For sedentary patients, any kind of physical activity is better than nothing.
- Diabetes: one in every three adults meets the criteria for a prediabetic condition and approximately 10% has been diagnosed with type 2 diabetes. Diet, physical activity and weight control are critical to the development and progress of diabetes.
Read also: Optimal Medical Treatment Under-used in Vascular Peripheral Disease.
For patients who have been diagnosed, metformin is the first line of treatment, with a IIa indication. Sodium/glucose 2 cotransporter Inhibitors and glucagon antagonists are reserved for diabetic patients and additional risk factors. (class IIb).
Conclusion
The new primary prevention guidelines summarize recommendations for the correct identification and modification of risk factors. Creating multidisciplinary teams to implement these guidelines and committing patients to become our life-long allies in this process depends entirely on us.
Original Title: The New 2019 AHA/ACC Guideline on the Primary Prevention of Cardiovascular Disease.
Reference: Vera Bittner. Circulation. 2020;142:2402–2404. DOI: 10.1161/CIRCULATIONAHA.119.040625.
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