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NEW ORLEANS – The American College of Cardiology (ACC) and the American Heart Association (AHA) have released new guidelines on the primary prevention of cardiovascular disease.
As expected, one of the key changes is a recommendation against the widespread use of aspirin in primary prevention, after the recently published results of the ARRIVE, ASCEND and ASPREE trials have challenged the balance between risk and risk. benefit of treatment in various populations. .
2019 ACC / AHA Guideline on Primary Prevention of Cardiovascular Disease is published online March 17 Journal of the American College of Cardiology and circulation and presented here at the 68th Annual Scientific Session 2019 of the American College of Cardiology (ACC.19).
The document is also endorsed by the American Association for Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology and the Preventive Association of Cardiovascular Nurses.
The co-chairs of the editorial board are Donna K. Arnett, PhD, Dean and Professor of Epidemiology at the Faculty of Public Health of the University of Kentucky, and former President of the American Heart Association, and Roger Blumenthal, MD, professor of medicine at the Johns Hopkins School of Medicine and director of the Johns Hopkins Ciccarone Center for Cardiovascular Disease Prevention, Baltimore, Maryland.
At a press conference, the Chairs of the CAC and AHA discussed the objectives of the new directive.
"What we are here to talk about today is that, thanks to lifestyle choices and modifications, almost 80% of all cardiovascular diseases can be prevented," said John J. Warner, MD, past president of the American Heart Association and leader. Vice President of Health System Affairs, UT Southwestern Medical Center, Dallas. "These 2019 prevention guidelines deal with the whole person and how individuals, working with their clinicians and physicians, can manage their vulnerabilities."
The paper points out that healthy living is "the most important part of lifelong prevention, but these guidelines also address prevention from the perspective of the social determinants of health," Warner said. "According to scientific evidence, we now know that only 10% to 20% of our health is actually determined by the health care we receive and that 70% to 80% of it is affected by determinants. health and under-served and low-income populations have a higher risk of heart disease and life expectancy may vary by more than 20 years for people living only 5 km away. "
Richard Kovacs, MD, Professor of Clinical Medicine and Clinical Director of the Krannert Institute of Cardiology at Indiana University's School of Medicine in Indianapolis, is Vice President of the American College of Cardiology and badumes the role of VAC President during this meeting. He congratulated the editorial board for completing this task in one year, through 33 peer reviews.
"It will be a comprehensive resource for public health and clinical practices in cardiovascular disease prevention, and it will fit perfectly with other guidelines," Kovacs said. , updating the 2013 guidelines on CV risks and lifestyle, as well as the 2013 guidelines on overweight and obesity, but also "includes and reproduces" parts of the 2017 guidelines on blood pressure and the 2018 guideline on cholesterol.
At the press conference, Arnett and Editorial Board member Amit Khera, MD, professor of medicine at the Southwestern Medical School of the University of Texas at Dallas and president of the American Society of Preventive Cardiology , presented some of the major changes to the new guidelines. .
"A different aspect of this directive is that we decided that there were three general themes that needed to emphasize any prevention," Arnett said. "The first is that we really need a team approach to treat ASVVD risk factors (atherosclerotic cardiovascular disease) .The second recommendation is that all decisions be shared between the clinician and the patient when they discuss the best strategies for reducing risks, and finally, we adopted the recommendation that the social determinants of health should guide the optimal implementation of treatment recommendations for the prevention of ASCVD. "
For busy clinicians, Khera said, "This is a one-stop shop, a central resource for clinicians, bringing together all the previous work, as well as the new and evolving components you'll be hearing about, and we hope that will contribute to the effectiveness of the implementation ".
The main recommendations include:
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Risk estimation: "You can not do prevention without understanding your risk factors," said Khera. The recommendation is therefore aimed at adults aged 40 to 75 years and whose prevention of cardiovascular disease is being evaluated should be the subject of a 10-year ASCVD risk estimate. For those aged 20 to 39, "every 4 to 6 years, it is reasonable to badess the risk factors, even if you can not formally calculate this risk over 10 years". Before initiating a pharmacological treatment, for example antihypertensive therapy, a statin or aspirin, you must have a discussion about the risk between the patient and your doctor. In addition, the badessment of other risk-increasing factors may help guide decisions regarding preventative interventions in selected individuals, as well as the scanning of calcium in the coronary arteries, says the summary. of the document.
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Diet: Adults should have a healthy diet, focused on eating vegetables, fruits, nuts, legumes, whole grains, lean vegetable or animal protein and fish, and minimize consumption of processed meats, refined carbohydrates, sodium and sugary drinks. The paper recommends replacing saturated fats with poly and monounsaturated fats and, for the first time, recommends not consuming trans fats, added Arnett.
Diet is one area, for example, where the social determinants of health come into play, said Arnett. "We must badess the barriers to adopting a heart-healthy diet," such as urban or rural environments where access to fresh fruits and vegetables is scarce, or those who suffer from a socio-economic disadvantage or from an advanced age.
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Physical activity: When visiting health centers, adults should be systematically informed of the need to do at least 150 minutes of moderate intensity physical activity or 75 minutes of physical activity. vigorous intensity per week. "Note that we are not saying exercise, we are talking about physical activity," said Arnett. Recent research suggests that just advising physical activity to sedentary people can improve their effectiveness to become physically active, with a number of patients to treat about 12 to 1 person to improve their activity, has she noted. "So, it's a pretty powerful intervention, just counsel our patients." Engaging in moderate or vigorous activity, even if it does not meet the recommendation, is always beneficial, she added.
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Obesity: For overweight and obese adults, advice and caloric restriction are recommended for achieving and maintaining weight loss. The calculation of body mbad index is recommended annually or more frequently to identify obesity and overweight, and it is "reasonable" to measure waist circumference to identify people with high metabolic risk . Lifestyle counseling for weight loss should include an badessment of psychosocial stressors and sleep hygiene, as well as individualized barriers, said Arnett. "These can be particularly pronounced in vulnerable populations."
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Diabetes: To reduce the risk of cardiovascular disease in diabetic patients, it has become clear that "it is not only blood sugar, but also complete prevention of cardiovascular disease: nutrition, exercise, weight, blood pressure , cholesterol and, of course, drugs, "said Khera. . For adults with type 2 diabetes, lifestyle changes, including a personalized nutrition plan and the implementation of exercise recommendations, are crucial. If a drug is indicated, metformin is a first-line treatment, followed by a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. These latter agents, he said, "have really revolutionized diabetes-cardiology, if you will, in that they not only lower blood glucose levels," it has also been proven that # 39, they reduced the number of ASCVD events and deaths.
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The tobacco: All adults should be badessed for smoking at each health-care visit, and smoking cessation should be strongly supported by those who use it. In adult tobacco users, it is recommended to use a combination of behavioral pharmacological treatments and one of seven approved pharmacological treatments, Arnett said. "We learned from the evidence that the use of two different types of nicotine replacement therapy moderately improved smoking cessation compared to a single type," she added, and adding varenicline or bupropion confer an added advantage.
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Aspirin: The recommendation on aspirin is one of the key changes to the guidelines, said Khera. The results of the ARRIVE, ASCEND and ASPREE studies have altered the balance between the benefits of aspirin treatment and hemorrhagic risk, "which really showed us that the place of aspirin is reduced in terms of primary prevention and that bleeding outweighs the modern day benefits with all our preventative therapies ".
Low dose aspirin now has a recommendation IIb, he said, "meaning not general, occasionally yes". Aspirin could be considered for primary prevention in some adults aged 40 to 70 years, who have a higher risk of ASCVD but not an increased risk of bleeding. There is a "damaging" recommendation that low-dose aspirin should not be routinely used in people over 70 years of age or in people of any age at increased risk of bleeding. "We do not pay enough attention to this risk of hemorrhagic component, but it is a call to arms to make sure we do it," Khera noted.
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statins: The cholesterol recommendations in this document reflect those of primary prevention in the 2018 cholesterol guideline for primary prevention, noted Khera. The statin is a first-line treatment for primary prevention of ASCVD in patients with high levels of low-density lipoprotein cholesterol (≥ 190 mg / dL), in those with diabetes mellitus, in those with 40 to 75 years and in those deemed at risk ASCVD sufficient, after a clinician-patient risk discussion. The coronary calcium test may be helpful here to help patients make a decision as to whether to resort to treatment, Khera said.
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Blood pressure: The blood pressure recommendations are also consistent with the recommendations of the 2017 guideline, starting with the recommendation for non-pharmacological interventions in all adults with high blood pressure or hypertension. "The cornerstone of blood pressure management is the way of life," Khera said, including the DASH diet. For those requiring pharmacological treatment, the target blood pressure should generally be less than 130/80 mm Hg.
"For over 150 years, the American Heart Association and the American College of Cardiology have been fighting cardiovascular disease and trying to limit the impact of stroke and heart disease, not only on residents of the United States, but also in the world, "says Warner. The new directive "is a comprehensive document that we believe will radically change the trajectory of cardiovascular disease prevention not only in the United States, but around the world".
In an editorial accompanying the circulation Vera Bittner, MD, a professor of medicine at the University of Alabama in Birmingham, concludes that "the new primary prevention guideline concisely summarizes the recommendations for an overall change in risk factors in health care. It is the responsibility of models of care to implement these guidelines in our individual practices and to inspire our patients to become our partners in this lifelong process. "
J Am Coll Cardiol. Posted online 17 March 2019. Guideline, Summary
circulation. Posted online 17 March 2019. Guideline, Summary, Editorial
American College of Cardiology 68th Annual Scientific Session 2019 (ACC.19). Presented on March 17, 2019.
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