cardiovascular prevention

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

http://ghdx.healthdata.org/record/ihme-data/gbd-2017-dalys-and-hale-1990-2017

http://ghdx.healthdata.org/record/ihme-data/gbd-2017-dalys-and-hale-1990-2017

• 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



• Lifestyle


• 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

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

https://doi.org/10.1161/cir.0000000000000510

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.


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



• Lifestyle


• 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

Lipid Tests

Fasting vs. Nonfasting Lipid Profiles


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


2019 ACC/AHA Primary Prevention GuidelineRefining Risk Estimates for Individual Patients


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


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


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?

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


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


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


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%



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?


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

http://tools.acc.org/ASCVD-Risk-Estimator/

Objectives



• Lifestyle


• 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


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.


• 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

[email protected]

@SamiaMoraMD

mailto:[email protected]

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

https://doi.org/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


2017 ACC/AHA

Normal BP

Elevated BP




• 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

cardiovascular prevention

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