New recommendations for primary prevention Aspirin axis, systematic enrollment surges, social indices

NEW ORLEANS, LA – In a city renowned for its nightlife, its rich Cajun cuisine and sweet cocktails Bourbon Street, the American College of Cardiology and the American Heart Association (ACC / AHA) remind individuals that a healthy lifestyle is paramount. to prevent the development of cardiovascular disease, heart failure and atherosclerotic atrial fibrillation throughout life.

This reminder is in the form of new primary prevention guidelines – a comprehensive 103-page resource on clinical and public health practices – released today at the 2019 CAC Scientific Session.

Richard Kovacs, MD (Vice President of ACC, Indiana University School of Medicine, Indianapolis), said the latest guidelines were of paramount importance because CVMs Atherosclerotics remain the leading cause of morbidity and mortality worldwide. The new document, which was published simultaneously in the Journal of the American College of Cardiology, closely matches other clinical guidelines, including the most recent guidelines on cholesterol and hypertension.

"I'm responsible for sports metaphors for the college, and since this is a spring training, it covers all the bases," Kovacs joked at a press conference highlighting the news. recommendations.

With aspirin, no free meal. He is still bleeding. Amit Khera

For John Warner, MD (UT Southwest Medical Center, Dallas, TX), AHA's outgoing president, the new guidelines are coming at a time that is a big concern for the cardiac community. Earlier this year, the AHA has released a statistical update showing that almost half of American adults have some form of cardiovascular disease. However, "with lifestyle choices and modifications, nearly 80% of all cardiovascular disease can be prevented," Warner said. "These 2019 prevention guidelines are about the whole person and how people working with their doctor can manage their vulnerabilities."

Steven Nissen, MD (Cleveland Clinic, OH), who was not involved in the new report, praised this focus on shared decision making. "That's what good doctors do," he told the TCTMD. "If you're my patient and I say you have high LDL cholesterol and here are your options, I recommend a statin. But let's talk about your opinion about it. You hear yourself. If you do it in a shared way, people are more compliant than if you just say, "Here, take that."

Social determinants of health

Donna Arnett, PhD (University of Kentucky, Lexington), co-chair of the editorial board, called the new primary prevention guidelines a "one-stop shop" for clinical care. The recommendations cover nine different areas, including risk assessment, diet, exercise / physical activity, obesity, type 2 diabetes, cholesterol, blood pressure, smoking cessation and the use of aspirin. They point out that a "team care approach" is the most effective strategy for controlling CVD risk factors.

Arnett added that they also recommend a discussion on the social determinants of health that affect an individual's ability to make treatment decisions. The neighborhood environment and access to exercise facilities play a role in the prevention of CVD, she said.

"The social determinants of health and how we focus on it are the most influential factors. [aspect of the new guidelines]Arnett said. "So many patients, we do not even ask them if they can go to the pharmacy to get their prescription. [or] have access to healthy foods To make aggressive recommendations in the absence of this knowledge, it is very difficult for our patients to adopt a healthy lifestyle, often because they are socially disadvantaged. "

Adults should also be systematically assessed for "psychosocial stressors" and given appropriate counseling, she said.

For the media, Warner has noted that only 10 to 20% of health is determined by health care and that about 70 to 80% is a result of these social determinants. "Underserved and low-income populations have a higher risk of developing heart disease and life expectancy may vary by more than 20 years among people living within 5 miles of distance," he said. declared.

Risk and risk enhancement factors

For adults aged 40 to 75, physicians are recommended to "systematically" evaluate traditional cardiovascular risk factors and to calculate the risk of atherosclerotic CVD over 10 years using the combined cohort equations (recommended class I). For people aged 20 to 39, it is reasonable to assess cardiovascular risk factors every 4 to 6 years (Class IIa recommendation).

For people at marginal or intermediate risk of CVD, physicians may use "risk-enhancing" factors to facilitate decision-making about preventative interventions. These risk factors include a family history of CVD, a metabolic syndrome, chronic kidney disease, and other lipids / biomarkers, such as C-reactive protein, lipoprotein (a), or apolipoprotein B, among others.

Prevention guidelines are also self-evident, experts recommending people to eat more vegetables, fruits, legumes, nuts, whole grains and fish, and advises against consuming too much salt, fried foods, processed meats and sweet drinks. Trans fats should be avoided. They recommend at least 150 minutes of moderate intensity physical activity (brisk walking, swimming, dancing or cycling) or 75 minutes of vigorous intensity physical activity, and that certain physical activities, even small bursts of 10 minutes can be useful. change. It is also suggested to aim for a healthy weight and lose weight in case of obesity or overweight just like avoiding smoking, including vaping.

I'm responsible for the college sports metaphors and, as it's spring training, it covers all the basics. Richard Kovacs

Speaking to the media, Arnett said that when they were discussing diet, doctors had to take into account the patient's perception of the size of his body because "it's not a good thing." cultural influence directly determines whether people consider themselves obese or thin. She also pointed out that less than half of Americans are currently meeting. recommendations for physical activity. "The consequences are pretty bad," she said. "About 9.6% of health spending, or $ 105 billion a year, is directly attributable to the US's lack of physical activity."

In positive terms, talking about physical activity to individuals is a powerful tool, Arnett said. Research has shown that to counsel 12 patients, a person would become physically active.

Aspirin is no longer recommended

With regard to aspirin, the recommendations have been significantly revised in light of recent clinical trials.

The use of aspirin in the elderly (> 70 years) and in those at increased risk of bleeding is not recommended (Class III recommendation). For middle-aged adults, aged 40 to 70 years, aspirin could be considered for primary prevention if their risk of acquiring cardiovascular disease is higher, but without undue risk of bleeding (class recommendation IIb). Overall, however, aspirin should be rarely used for primary prevention, experts say.

"So many people are currently taking aspirin and there are many misconceptions," said Amit Khera, MD (UT Southwestern Medical Center), who co-chaired the editorial board with Arnett. New clinical trials …Aspree, ARRIVAL, and ASCEND– showed that the benefit / risk ratio was shifted to risk and that the role of aspirin in primary prevention should decrease, he added. "With aspirin, there is no free meal," said Khera. "He's still bleeding."

Nissen approved the decision not to recommend aspirin in general for the prevention of cardiovascular disease, noting that as early as 2003, an advisory committee of the US Food and Drug Administration had rejected an expanded indication of aspirin. in the context of primary prevention. "In my opinion, if the risk of CVD over 10 years is greater than or equal to 20%, think of aspirin," Nissen said. "For the typical worried, it's not a good idea."

With regard to statin therapy and cholesterol treatment, the new recommendations for primary prevention fall within 2018 Cholesterol Guidelines, which have been reported by TCTMD. For adults with high blood pressure or high blood pressure, the latest guidelines for primary prevention also give the field to hypertension specialists and adhere to the following principles: 2017 Guidelines. For people with high blood pressure, they recommend starting with nonpharmacological interventions, but if medication is needed, a target <130/80 mmHg is recommended.

In diabetic patients, a change in diet, weight loss and an increase in physical activity, including aerobic exercises and resistance, are recommended. Metformin is a reasonable first-line treatment with lifestyle modifications to improve glycemic control and reduce the risk of CVD (Class IIa recommendation). If additional hypoglycaemic therapy is required, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor agonist (GLP-1) is reasonable (Class IIb recommendation).

Nissen said the new guidelines contained little evidence, pointing out that lifestyle and diet were the cornerstone of non-cardiovascular disease. Dietary advice is rightly cautious, experts recommend the Mediterranean diet or herbal diet. Nissen pointed out that primary prevention guidelines recognize that pooled cohort equations for cardiovascular risk assessment overestimate or underestimate risk in some patients, which he and others have already stated.