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Cardiovascular Prevention
Samia Mora, MD, MHS
Associate PhysicianDirector, Center for Lipid Metabolomics
Divisions of Preventive and Cardiovascular MedicineDepartment of Medicine
Brigham and Women’s HospitalAssociate Professor, Harvard Medical School
Samia Mora, MD, MHS
• Harvard Medical School
• Internal Medicine Residency: Mass General Hospital
• Cardiovascular Medicine Fellowship: Johns Hopkins
• Associate Professor of Medicine: Harvard Medical School
• Clinical focus: General Cardiology, Echocardiography
• Research focus: Prevention
Disclosures
• Dr. Mora has served as a consultant for Pfizer and Quest Diagnostics
Objectives
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Sonia Y. Angell. Circulation. 2020 141:e120-e138,
DOI: (10.1161/CIR.0000000000000758)
Global Burden of Disease Collaborative Network.
http://ghdx.healthdata.org/record/ihme-data/gbd-
2017-dalys-and-hale-1990-2017.
Leading Causes of Death in the US 2007-2017, by causes and risk factors
• Lifestyle interventions should begin early and underlie all preventive efforts
• Risk stratification is the key to prevention
• The intensity of preventive interventions should match the level of cardiovascular risk
Take-home messages
Recommendations for Patient-Centered Approaches to Comprehensive
ASCVD Prevention
COR LOE Recommendations
I A
1. A team-based care approach is recommended for thecontrol of risk factors associated with ASCVD.
I B-R
2. Shared decision-making should guide discussions
about the best strategies to reduce ASCVD risk.
I B-NR
3. Social determinants of health should inform optimal
implementation of treatment recommendations for
the prevention of ASCVD.
2019 ACC/AHA Guidelines
Arnett et al JACC 2019;74:e177
White-Williams et al. Circulation 2020; 141: e841
Social Determinants of Health
Stress is a risk factor and prognostic factor for future cardiovascular disease events
Kivimäki & Steptoe. Nat. Rev. Cardiol. 2017: doi:10.1038/nrcardio.2017.189
Objectives
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Case 157 year old woman Ht 5’3”, 180 lbs, BMI 32, WC 36 inBP 128/82 mmHg, HR 88/minLDL-c 108, HDL-c 45, Trig 198
In order to decrease her cardiovascular risk, what lifestyle advice would you not recommend? [check one]
A – Mediterranean dietary pattern
B – Replace saturated fat with polyunsaturated fat
C – Advise weight loss and increased activity
D – Reduce sodium to <2400 mg/d
E – Reduce total dietary fat
Case 157 year old woman Ht 5’3”, 180 lbs, BMI 32, WC 36 inBP 128/82 mmHg, HR 88/minLDL-c 108, HDL-c 45, Trig 198
In order to decrease her cardiovascular risk, what lifestyle advice would you not recommend? [check one]
A – Mediterranean dietary pattern
B – Replace saturated fat with polyunsaturated fat
C – Advise weight loss and increased activity
D – Reduce sodium to <2400 mg/d
E – Reduce total dietary fat
1. ≥150 minutes moderate activity /week or ≥75 minutes vigorous activity/week
2. Eat a healthy diet (4-5 components of healthy diet score*)
2. Have a normal body weight (BMI < 25) 3. Never smoked or quit >1 year ago4. Total cholesterol <200 mg/dL5. Blood pressure <120/80 mm Hg6. Fasting blood glucose <100 mg/dL
AHA Life’s Simple 7
Lloyd-Jones et al. Circulation 2010; 121:586-613
* 1) 4.5 cups or more of fruits and vegetables per day 2) two or more 3.5-oz servings of fish per week 3) three servings per day of whole grains 4) less than 1500 mg of sodium per day 5) 36 ounces or less of sugar-sweetened beverages per week
Shiffman et al. JAMA Network Open 2020; 3(10): e2022119
Couples share heart disease risk factors and health habits
Concordance of AHA Life’s Simple 7 in US couples (N=10,728 individuals)
2020 US Dietary Guidelines Advisory Committee
Three beneficial dietary patterns
1. Healthy US-style pattern2. Healthy Mediterranean-style pattern3. Healthy Vegetarian pattern
https://www.dietaryguidelines.gov/2020-advisory-committee-report
PREDIMED STUDY
Estruch et al NEJM 2013;368:1279; corrected 2018
RRR of Mediterranean diet (EVVO or raw nuts) reduced CVD by 30% compared with control diet
N=744757% womenHigh CVD riskNo prior CVD
Dinu M et al Eur J Clin Nutr 2018 Jan;72(1):30-43. doi: 10.1038/ejcn.2017.58.
Higher adherence to Med diet pattern is associated with 30-40% reductions in MI, stroke, DM, and CVD death
Umbrella meta-analysis
>12.8 million individuals
Ahmad S et al.
JAMA Net Open 2018; 1:e185708
Mediterranean Diet Lowers Chronic Inflammation% of CVD Benefit Explained by Various Risk Factors
Inflammation
Insulin Resistance/
Glucose Metabolism
Blood Pressure / Hypertension
Body Mass Index
Traditional Lipids
HDL Measures
VLDL Measures
LDL Measures
Branched Chain Amino Acids
Apolipoproteins
Small Molecule Metabolites
% Risk Reduction
29%
28%
27 %
26.6%
26%
Hu et al. JAHA: 8, Issue: 19, DOI: (10.1161/JAHA.119.013543)
Omega-3 supplements Meta‐Analysis of 13 Randomized Controlled Trials Involving 127 477 Participants
Recommendations for Nutrition and Diet
CO
R
LOE Recommendations
I B-R
1. A diet emphasizing intake of vegetables,
fruits, legumes, nuts, whole grains, and
fish is recommended to decrease ASCVD
risk factors.
IIaB-
NR
2. Replacement of saturated fat with
dietary monounsaturated and
polyunsaturated fats can be beneficial to
reduce ASCVD risk.
IIaB-
NR
3. A diet containing reduced amounts of
cholesterol and sodium can be beneficial
to decrease ASCVD risk.
2019 AHA/ACC Prevention Guidelines
Arnett et al JACC 2019;74:e177 Sacks et al Circulation 2017;136:e1-23.
DOI: 10.1161/CIR.0000000000000510
2017 AHA Dietary Fats Statement
Meta-analysis of 4 RCTs replacing saturated with polyunsaturated fat
Ward et al, NEJM 2019;381:2440-50.
Obesity is a major risk factor for premature death with rising prevalence
1990
2030
2020
BMI ≥30
2010
2000
BMI ≥35
For a BMI of 30 kg/m2
Outcome Relative Risk
• Diabetes 27.6
• HTN 3.9
• CHD 3.5
• Endometrial cancer >3.0
• Total mortality 2.1
• Stroke 1.5
• Breast cancer 1.4Nurses’ Health Study, multiple publications.
Leisure-Time Physical Activity and Mortality
Arem H, et al. JAMA Intern Med 2015;175:959
Individuals meeting the recommended min ≥150 min (2.5 hours, ~ 7.5 to <15 MET-hr) per week had ~30% lower risk of all-cause and CVD death
Lesser but significant 20% lower mortality even among those performing less than the recommended minimum.
Ekelund U et al. BMJ. 2019;366:l4570. doi: 10.1136/bmj.l4570.
Sedentary Behavior, Physical Activity, and CVD Mortality
Meta-analysis >850,000
individuals
Moderate PA5 min/d
25-30 min/d
50--60 min/d
>65 min/d
U.S. adults spend >7 h/d on average insedentary activities.
Arnett et al JACC 2019;74:e177
2018 Physical Activity Guidelines for Americans
• 150-300 minutes (2.5-5 hrs) per week of moderate-intensity or 75-150 minutes per week of vigorous-intensity activity, or combination
plus Muscle strengthening activities, 2 d/week [added benefit]
• Sit less [no quantitative parameters specified]
• Medically supervised programs for high-risk [ACS, heart failure]
US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, DC; 2018.
• Lifestyle improvement should begin early and underlie all preventive efforts
• Most cardiovascular events preventable with lifestyle
• Some is better than none, more is even better
Take-home messages:
Lifestyle
Objectives
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Case 1 37 year old, African American woman comes in for a PAP smear
• Rare alcohol, no tobacco, no drugs• Father had MI at age 49, was a heavy smoker; mother is 61
years old, has DM and HTN. • Height 5’3”, 256 lbs, BMI 45.4, Waist 42”• BP 128/82 mmHg, HR 88/min
What is the most appropriate next step in the evaluation of this patient?
A. Measurement of high-sensitivity C-reactive protein
B. Measurement of coronary artery calcium (CAC) by noncontrast CT scan
C. Measurement of serum homocysteine
D. Exercise electrocardiographic stress test
E. Measurement of a lipid panel
Case 1 37 year old, African American woman comes in for a PAP smear
• Rare alcohol, no tobacco, no drugs• Father had MI at age 49, was a heavy smoker; mother is 61
years old, has DM and HTN. • Height 5’3”, 256 lbs, BMI 45.4, Waist 42”• BP 128/82 mmHg, HR 88/min
What is the most appropriate next step in the evaluation of this patient?
A. Measurement of high-sensitivity C-reactive protein
B. Measurement of coronary artery calcium (CAC) by noncontrast CT scan
C. Measurement of serum homocysteine
D. Exercise electrocardiographic stress test
E. Measurement of a lipid panel
Lipid Tests
Fasting vs. Nonfasting Lipid Profiles
COR LOE Recommendations
I B-NR
Adults >20 y/o not on drug Rx: measurement of either
fasting or nonfasting lipid profile is useful for
estimating risk & documenting baseline LDL-C
I B-NR
Adults >20 yrs & in whom an initial nonfasting lipid
profile reveals TG > 400 → repeat lipid profile fasting
for assessment of TG levels & baseline LDL-C
Grundy et al JACC 2019;73: e285 Mora et al. JAMA Intern Med 2019 May 28.
Estimating Cardiovascular Risk
PCE
30-year ASCVD risk
Lifetime risk (Class IIb)
Risk-Enhancing Factors
(Class IIa)
Coronary artery calcium
(Class IIa)
Arnett et al JACC 2019;74:e177 Grundy et al JACC 2019;73: e285
2019 ACC/AHA Primary Prevention GuidelineAssessment of ASCVD Risk: Conclusions
1. Adults 40-75 years of age should undergo 10-year ASCVD risk estimation by PCE
2. Engage in Clinician–Patient Risk Discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin.
3. Presence or absence of additional risk-enhancing factors can help guide decisions about preventive interventions
4. If clinical uncertainty or patient indecision remain, consider CACmeasurement in intermediate (7.5% - 19.9%) and selected borderline (5 - 7.4%) risk patients
Arnett et al JACC 2019;74:e177 Grundy et al JACC 2019;73: e285
2019 ACC/AHA Primary Prevention GuidelineRefining Risk Estimates for Individual Patients
Arnett et al JACC 2019;74:e177 Grundy et al JACC 2019;73: e285
Who Should Be Considered for Statin?
( 1-3) High Risk:
1. Clinical ASCVD*
2. LDL–c >190 mg/dL, Age >21 years
3. Primary prevention – Diabetes:
Age 40-75 years, LDL–c 70-189 mg/dL
(4) Primary prevention† 4. No Diabetes & ASCVD risk >20%
5. ASCVD risk 7.5-20% & risk enhancers/CAC
* ACS, MI, angina, coronary or other arterial revascularization, stroke, TIA, PAD† Risk discussion between clinician and patient
Arnett et al JACC 2019;74:e177 Grundy et al JACC 2019;73: e285
2019 AHA/ACC Cardiovascular Risk Assessment: Summary
* using the Pooled Cohort Equations in adults 40-79 y (ASCVD Risk Estimator)
No Clinical ASCVD, primary preventionCalculate 10-year ASCVD risk*
Clinical ASCVD, orLDL-C≥190 mg/dL, orDiabetes, age 40-75, LDL-C 70-189 mg/dL
Statin & Lifestyle Therapy
Lifetime RiskRisk Enhancing Factors
Coronary artery calcification (CAC)
Low Borderline Intermediate High
Lifestyle Therapy
Statin
If above threshold for statin benefit
Arnett et al JACC 2019;74:e177 Grundy et al JACC 2019;73: e285
Risk Enhancing Factors
Risk
Enhancers
Family
History
Pregnancy/
MenopauseBiomarkers
CKD
Chronic
Inflammation
Ethnicity
hs-CRP ≥ 2 mg/L
Metabolic
Syndrome
Lp(a) ≥ 50 mg/dL or≥ 125 nmol/L
ApoB ≥ 130 mg/dL
Grundy et al JACC 2019;73: e285
TGs ≥ 175 mg/dL
ABI <0.9
premature ASCVD (men <55 y, women <65 y)
preeclampsiapremature menopause
eGFR 15-59
RA, lupus, psoriasis, HIV
LDL-C ≥ 160 mg/dLNon-HDL-C ≥ 190 mg/dL
ARS Question
A. Patient who is reluctant to initiate statin and wishes to understand their risk & potential for benefit more precisely
B. Patient who is concerned about need to reinstitute statin after discontinuation for ? statin-associated symptoms
C. Men, 55-80 y/o; women, 60-80 y/o with low burden of risk factors who question whether they would benefit Rx
D. 40-55 y/o with 10-yr risk of ASCVD 5% - 7.4% with risk-enhancing factors
E. All of the above
Which of the following patients are candidates for CAC measurement
who might benefit from knowing their CAC Score = Zero?
ARS Question
A. Patient who is reluctant to initiate statin and wishes to understand their risk & potential for benefit more precisely
B. Patient who is concerned about need to reinstitute statin after discontinuation for ? statin-associated symptoms
C. Men, 55-80 y/o; women, 60-80 y/o with low burden of risk factors who question whether they would benefit Rx
D. 40-55 y/o with 10-yr risk of ASCVD 5% - 7.4% with risk-enhancing factors
E. All of the above
Which of the following patients are candidates for CAC measurement
who might benefit from knowing their CAC Score = Zero?
Use of Risk-Enhancing Factors or CAC
CO
R
LO
ERecommendations
IIa B-R
If intermediate-risk: risk-enhancing
factors favor initiation or
intensification of statin Rx
IIaB-
NR
In intermediate-risk or selected
borderline-risk adults, if decision about
statin remains uncertain → reasonable
to use CAC score to withhold,
postpone, or initiate Rx
Primary Prevention Adults 40 to 75 y, LDL-C 70-189
Grundy et al JACC 2019;73: e285
Use of Risk-Enhancing Factors or CAC
CO
R
LO
ERecommendations
IIa B-R
If intermediate-risk: risk-enhancing
factors favor initiation or
intensification of statin Rx
IIaB-
NR
In intermediate-risk or selected
borderline-risk adults, if decision about
statin remains uncertain → reasonable
to use CAC score to withhold,
postpone, or initiate Rx
Primary Prevention Adults 40 to 75 y, LDL-C 70-189
Impact of CAC Results
CO
R
LO
ERecommendations
IIaB-
NR
In intermediate-risk adults or
selected borderline-risk adults &
CAC measured for making Rx
decision:
• If CAC=0 → reasonable to
withhold statin & reassess in 5 -
10 yrs, as long as higher risk
conditions are absent (diabetes,
Family h/o premature CHD,
smoking)
• If CAC = 1 – 99 or > 75%→
reasonable to initiate statin
• If CAC >100 → initiate statin Grundy et al JACC 2019;73: e285
Coronary Events Cardiovascular Events
Coronary Artery Calcium (CAC) for Risk Stratification, by Pooled Cohorts risk score
Mahabadi AA, et al. JACC Cardiovasc Imaging. 2017;10:143
Statins reduce vascular events in women and men, with or without CVD
Cholesterol Treatment Trialists Collaborators. Lancet. 2015;385: 1397
High: Lowers LDL-C by ≥50%
Moderate:Lowers LDL-C 30 to <50%
Low: Lowers LDL-C <30%
Atorvastatin 40, 80 Atorvastatin 10, 20
Rosuvastatin 20, 40 Rosuvastatin 5, 10
Simvastatin 20, 40 Simvastatin 10
Pravastatin 40, 80 Pravastatin 10, 20
Lovastatin 40 Lovastatin 20
Fluvastatin XL 40 BID Fluvastatin 20, 40
Pitavastatin 2, 4 Pitavastatin 1
Statin Intensity
Stone et al JACC 2014;63:2889-934
Moderate vs. High Intensity Statin Rx
COR LOE Recommendations
I A
If intermediate-risk, statin Rx reduces ASCVD risk, &
if decision is made for Rx, start moderate-intensity
statin
I A
If intermediate-risk, LDL-C should be reduced >30%;
for optimal risk reduction, especially if high-risk,
goal is >50%
Grundy et al JACC 2019;73: e285
Primary Prevention Adults 40 to 75 y, LDL-C 70-189
Top 10Very high-risk ASCVD: use LDL-C threshold of 70 mg/dL to consider nonstatin
• Very high-risk: multiple major ASCVD events or 1 major event + high-risk conditions
• Reasonable to add ezetimibe to maximally tolerated statin when LDL-C remains ≥70
• If LDL-C remains ≥70 on max. tolerated statin + ezetimibe → adding PCSK9i is reasonable
* long-term safety (>3 years) & cost-effectiveness uncertain
How about adding nonstatin?
Grundy et al JACC 2019;73: e285
CVD risk estimation
• Risk estimation (eg SCORE) is recommended for asymptomatic adults aged >40 years without evidence of
CVD, DM, CKD, FH, or LDL> 4.9 mmol/L (>190 mg/dL). IC
• High- and very-high-risk individuals (CVD, DM, moderate-to-severe renal disease, very high risk factors, FH,
or a high SCORE risk) are a priority for advice and management of all risk factors. IC
Lipid analyses for CVD risk estimation
• Total cholesterol is to be used for the estimation of total CV risk. IC
• HDL-C for further refining risk estimation. IC
• LDL-C is the primary lipid analysis method for screening, diagnosis, and management. IC
• Triglycerides (TGs) are recommended in routine lipid analysis. IC
• Non-HDL-C is recommended for risk assessment, particularly if high TGs, DM, obesity, or very low LDL-C.IC
• Apolipoprotein B is recommended for risk assessment, particularly in people with high TGs, DM, obesity,
MetS, or very low LDL-C. Can be used as an alternative to LDL-C, if available, as the primary measurement
for screening, diagnosis, and management, and may be preferred over non-HDL-C in people with high TGs,
DM, obesity, or very low LDL-C. IC
Treatment goals for LDL-C in primary prevention
In individuals at very-high risk, LDL-C reduction ≥ 50% and an LDL-C goal of <1.4 mmol/L (<55 mg/dL). IC
In individuals at high risk, LDL-C reduction ≥ 50% and LDL-C goal of <1.8 mmol/L (<70 mg/dL). IA
Mach et al Eur Heart J 2020; 41:111
2019 European dyslipidemia guidelines
26 yo Hispanic M, smoker, multiple borderline risk factors, BMI 33, Lp(a) 70 (uln 30 mg/dL)
One day prior to his myocardial infarction:
• Does he have any of the other risk enhancing factors that the 2018/2019 ACC/AHA guidelines recommend can be considered if a risk decision is not certain?
A. SmokingB. Obesity (his BMI 33)C. High lifetime risk D. High Lp(a) (his Lp(a) 70 mg/dL)
Case 2
Case 2 Discussion
Discussion:
• High lifetime risk is a factor that the guidelines say can inform treatment decision regarding initiation or intensification of statin therapy
• High Lp(a) (≥ 50 mg/dL or ≥ 125 nmol/L) is a risk enhancing factor
• Obesity is not a risk enhancing factor (but metabolic syndrome is)
• Smoking is a major risk factor
26 yo Hispanic M, smoker, multiple borderline risk factors, BMI 33, Lp(a) 70 (uln 30 mg/dL) - one day prior to ACS:• Does he have any of the other risk enhancing factors that the 2018/2019 ACC/AHA
guidelines recommend can be considered if a risk decision is not certain? A. SmokingB. Obesity (his BMI 33)C. High lifetime risk D. High Lp(a)
• First assess ASCVD risk
(risk factors, global risk score, risk enhancing factors, lifetime risk, CAC)
• Statins added to lifestyle to reduce risk of ASCVD in higher risk individuals and at maximally tolerated dose highest risk (e.g. clinical ASCVD)
• PCSK9 inhibitors reduce the risk of events when added to statin therapy in very high risk secondary prevention patients with additional risk factors
• Lower is better
Take-home messages:
Cholesterol
1. Risk-based assessment*
2. For most patients, goal is <130/ <80 if tolerated
3. Use any of: thiazides, CCB, ACE/ ARB, BB, taking into account CKD, CAD, HF, aortopathy
*ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-
Risk-Estimator/) to estimate 10-year risk of atherosclerotic CVD.
Take-home messages:
BP
Objectives
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Zheng et al. JAMA 2019; 321:277
Low-dose aspirin in the primary prevention of ASCVD
2019 Meta-analysis
2019 ACC/AHA Prevention Guidelines
Recommendations for Aspirin Use
COR LOE Recommendations
IIb A
1. Low-dose aspirin (75-100 mg orally daily) might be considered for theprimary prevention of ASCVD among select adults 40 to 70 years of agewho are at higher ASCVD risk but not at increased bleeding risk.
III:
HarmB-R
2. Low-dose aspirin (75-100 mg orally daily) should not be administered ona routine basis for the primary prevention of ASCVD among adults >70years of age.
III:
HarmC-LD
3. Low-dose aspirin (75-100 mg orally daily) should not be administered forthe primary prevention of ASCVD among adults of any age who are atincreased risk of bleeding.
Arnett et al JACC 2019;74:e177
• Europe
• USPSTF
Bibbins-Domingo et al. Ann Intern Med 2016;164:836Piepoli et al. Eur Heart J 2016;37:2315
What do other guidelines recommend?
Other Guidelines
2020 ADA Recommendations for Patients with DM
• Aspirin 75 to 162 mg/day for secondary prevention (DM + ASCVD) • clopidogrel 75 mg/day if asa allergy
• ASA 75-162 mg/day may be considered for primary prevention in diabetic patients at increased ASCVD risk and not increased risk of bleeding– Those at risk for ASCVD (10-year risk >10%)— age >50 yrs, with >1
additional risk factor:– Family history of premature ASCVD– HTN– Smoking– Dyslipidemia– CKD/Albuminuria
• Generally not recommended to start in patients older than 70 years • Not recommended for primary prevention in low risk groups (<50 yrs, no other
risk factors)ADA Diabetes Care 2018;41:S86-S104
Diabetes Care 2020;43:S111-S134.
Yusuf et al, N Engl J Med. 2021; 384: 216-228
N=5,713Intermediate risk (>1%/yr)M≥50y, F ≥55y37% DMLDL-C 120
TIPS-3
Aspirin-Guide app
www.aspiringuide.com
Individualize the risk:benefit assessment for primary prevention for patients at increased ASCVD risk and who are not at increased risk of bleeding
Mora et al JAMA 2016;316:709
Mora et al JAMA Intern Med 2016;176:1195
1. Cardiovascular disease #1 cause of death
2. Assess cardiovascular risk
(risk factors, risk-enhancing factors, global risk score, CAC)
3. Lifestyle improvement is the most important component of prevention and risk
factor control (Life’s Simple 7)
4. Statins added to lifestyle to reduce risk in higher risk individuals (risk-enhancing
factors, CAC); PCSK9i in the very highest risk patients
5. Blood pressure control: Target BP for most patients <130/80 mmHg; risk-
based assessment
6. Aspirin (low-dose) in higher risk individuals if benefit outweighs risk of bleeding
(avoid in low risk individuals and elderly)
Take-home messages:
Summary
ACC Cholesterol Guideline Tools
Guidelines Made Simple - A selection of the most impactful tables and figures
from the 2018 Cholesterol Guideline.
• Available at: ACC.org/GMSCholesterol
Guideline Overview Tool – A broad overview of primary and secondary
prevention, including evaluation, therapy, and treatment expectations.
• Available at: ACC.org/CholTool
2013 – 2018 Guideline Comparison Tool – A summary of the
major new and updated recommendations between the 2013
and 2018 Cholesterol Guidelines.
• Available at: ACC.org/CholesterolCompare
Supplemental References
1. 2018 Cholesterol guidelines. Gundy SM, Stone NJ, Bailey AL, et al. J Am Coll Cardiol. 2019
doi: 10.1016/j.jacc.2018.11.003.
2. 2018 EAS/EFLM Consensus Statement on Atherogenic Lipoproteins. Clin Chem 2018;64:1006-
1033.
3. 2017 ACC/AHA BP guidelines. Whelton PK et al. Hypertension 2018; 71:e13–e115. DOI: 10.1161/
HYP.0000000000000065.
4. 2018 ESC/ESH Hypertension guidelines. Eur Heart J. 2018;39:3021–104.
5. US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed.
Washington, DC; 2018.
6. 2019 ACC/AHA CVD Prevention Guidelines. Arnett D, Blumenthal R, et al JACC 2019; doi:
10.1016/j.jacc.2019.03.010
7. 2019 ESC/EAS Dyslipidemia Guidelines. Mach F et al Eur Heart J. 2020 Jan 1;41(1):111-188. doi:
10.1093/eurheartj/ehz455
8. 2020 US Surgeon General’s Report on Smoking Cessation.
9. 2020 ADA Standards of Medical Care. Diabetes Care 2020;43:S111-S134. doi.org/10.2337/dc20-s010
10. 2020 US Dietary Guidelines. https://www.dietaryguidelines.gov/2020-advisory-committee-report
Additional Slides
Gupta R and Wood DA, Lancet
2019; 394:685
Primordial, Primary, Secondary Prevention
Pri
mo
rdia
l
Pri
mar
y
Seco
nd
ary
Piepoli et al 2016 European Guidelines on cardiovascular disease
prevention in clinical practice. Eur Heart J 2016; 37: 2315
Psychosocial Risk Factors
How to assess in clinic?
Mediterranean diet + Extra-Virgin Olive Oil
Advice on MeDiet + EVOO ≥ 50 ml/day (~4 Tbsp/d)
(1 gallon/m)
Mediterranean diet + Nuts
Advice on MeDiet +
3 whole walnuts (15 g)
+
8 hazelnuts (7.5 g)
+
6 almonds (7.5 g)
Control group: Advice on a low-fat diet (Reduce fat, discourage use of nuts and olive oil; Non-food items)
30 g of raw nutsper day
PREDIMED: 3 Randomized Groups
Estruch et al NEJM 2013;368:1279
Sacks et al Circulation 2017;136:e1-23.
DOI: 10.1161/CIR.0000000000000510
ASCVD risk enhancers used in the 2018 and 2019 ACC/AHA guidelines
• Family history of premature ASCVD (men <55 y, women <65 y)• Primary hypercholesterolemia (LDL-C ≥160 mg/dL [4.1 mmol/L]; non-HDL-C ≥190 mg/dL [4.9 mmol/L])• Chronic kidney disease (eGFR 15-59 ml/min/1.73 m2, not on dialysis or kidney transplant)• Metabolic syndrome • Conditions specific to women (e.g. preeclampsia, premature menopause)
• Chronic inflammatory conditions (especially rheumatoid arthritis, lupus, psoriasis, HIV)• High risk race/ethnicity (e.g. south Asian ancestry)
Lipids/Biomarkers:• Persistently elevated triglycerides (≥175 mg/dL [2 mmol/L], fasting or nonfasting)
In selected individuals if measured:• hsCRP ≥2 mg/L• Lp(a) levels ≥50 mg/dL or ≥125 nmol/L • ApoB levels ≥130 mg/dL• Ankle-brachial index <0.9
Grundy S et al JACC 2019 PMID: 30423393 Arnett et al JACC 2019 PMID:30894318
2019 ACC/AHA Primary Prevention GuidelineAssessment of ASCVD: Use of CAC
*Clinicians and patients may not wish to postpone therapy in patients with a CAC score of 0 and diabetes mellitus, heavy current cigarette smoking, or strong family history of premature ASCVD.
2017 ACC/AHA Blood Pressure Guidelines
BP Classification (JNC 7 and ACC/AHA Guidelines)
SBP DBP
<120 and <80
120–129 and <80
130–139 or 80–89
140–159 or 90-99
≥160 or ≥100
2003 JNC7
Normal BP
Prehypertension
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
2017 ACC/AHA
Normal BP
Elevated BP
Stage 1 hypertension
Stage 2 hypertension
Stage 2 hypertension
• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions• Adults with SBP or DBP in two categories should be designated to the higher BP category
Whelton et al. Hypertension. 2018; 71:e13–e115.
130/80 140/90
10-yr risk <10%
10-yr risk ≥10%
Diabetes
CKD
Heart Healthy lifestyle
Pharmacotherapy
Pharmacotherapy
Goal BP
Heart Healthy lifestyle
Intensive lifestyle modification
Intensive lifestyle modification
Whelton et al. Hypertension. 2018; 71:e13–e115.
2017 ACC/AHA Blood Pressure Guidelines
1. Self-monitor BP at home & measure every clinic visit2. 10-yr risk ≥15%, goal <130/ <80 if safely attained3. 10-yr risk <15%: goal <140/ <90
2020 ADA Recommendations for patients with diabetes & HTN
Diabetes Care 2020;43:S111-S134.
Other BP Guidelines
1. 130-139/80-89 Lifestyle (drugs only if v. high risk)2. 140-159/90-99 & high risk: Lifestyle + drugs
low risk: Lifestyle + drugs after 3-6 months2. ≥ 160 / ≥ 100: Lifestyle + drugs3. Different targets based on age, comorbidities,
generally aim for 130-140, avoid <120
2018 ESC/ESH Guidelines
Eur Heart J. 2018;39:3021–104.
2018 ESC/ESH
Optimal BP <120/<80
Normal BP 120-129 / 80-84
High-normal 130-139 / 85-89
Grade 1 HTN 140-159 / 90-99
Grade 2 HTN 160-179 / 100-109
Grade 3 HTN ≥ 180 / ≥ 110
Modification Recommendation Approximate SBP Reduction
Range
Weight reduction Maintain normal body weight
(BMI=18.5-25)
5-20 mmHg/10 kg weight lost
DASH eating plan Diet rich in fruits, vegetables, low fat dairy
and reduced in fat
8-14 mmHg
Restrict sodium
intake
<2.4 grams of sodium per day
(further benefit <1.5 g/d)
2-8 mmHg
Physical activity Regular aerobic exercise
>30 minutes at least 5 days of the week
4-10 mmHg
Moderate alcohol <2 drinks/day for men
<1 drink/day for women
2-4 mmHg
Lifestyle Modifications for BP Control
Chobanian AV et al. JAMA 2003;289:2560-2572
Gentzke et al MMWR Morb Mortal Wkly Rep. 2019;68:157.
2020 Surgeon General’s Report on Smoking Cessation
Smoking remains one of the leading causes of death
in the US and globally
The 5 A’s
Ask about smokingAdvise to quitAssess willingness to make attemptAssist if readyArrange follow-up