New guidelines on the prevention of cardiovascular conditions

A collaboration between the American College of Cardiology (ACC) and the American Heart Association (AHA) released the 2019 Primary Prevention of Cardiovascular Disease guideline [1].

Co-chair of the guideline committee Prof. Roger S. Blumenthal (Johns Hopkins University, USA) provided a summarised update including new key points on patient diet, tobacco use, and risk factor management for physicians [2]. One notable change in the recommendations is to limit aspirin use in the primary prevention of cardiovascular disease and stroke (see Table).

The ACC-AHA committee made a series of recommendations which they systematically scored using a 5-point grading scale based on clinical benefits versus risks; coupled with the highest for level of evidence available. Some of the key recommendations are:

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   1. Employ a team-based care approach for the control of risk factors associated with atherosclerotic cardiovascular disease (ASCVD) utilising shared decision-making with the patient.
   2. Improve glycaemic control in adults with type 2 diabetes (T2DM), achieve weight loss if needed, and improve other ASCVD risk factors. T2DM patients should get at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity.
   3. T2DM patients 40-75 years old should receive moderate-intensity statin therapy, regardless of estimated 10-year ASCVD risk.
   4. It is “reasonable” to prescribe either sodium-glucose cotransporter 2 (SGLT-2) inhibitors or glucagon-like peptide-1 receptor agonist to reduce CVD risk in adults with T2DM and additional ASCVD risk factors, who may require glucose-lowering treatment despite initial lifestyle modifications and metformin.
   5. In adults with intermediate (≥7.5% to <20%) 10-year ASCVD risk, a moderate-intensity statin is recommended.
   6. In adults with hypertension, including those requiring antihypertensive medications, nonpharmacological interventions should include weight loss, a heart-healthy diet (focused on fruits, vegetables, legumes, nuts, whole grains, and fish), sodium reduction, dietary potassium supplementation, increased physical activity with a structured exercise programme, and limited alcohol.
   7. Recent evidence has shown that daily aspirin confers a bleeding risk that outweighs its benefit in primary stroke and CV risk prevention for most adults. For secondary prevention, the new guidelines still recommend aspirin for who have experienced a prior stroke, acute myocardial infarction, angina, coronary revascularisation, or carotid revascularisation.
      However, low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among those adults 40-70 years old at higher risk of ASCVD risk but not at increased bleeding risk (see Table).

Table: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease – Recommendations for aspirin use. Modified from [1]

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   1. Arnett DK, et al. 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 2019;140(11).
   2. Blumenthal RS, et al. 2019 AHA/ACC Prevention Guidelines. QU.SMP.505, AHA Scientific Sessions 2019, 14-18 November, Philadelphia, USA.

Posted on 26 February 202017 May 2024