The primary prevention of coronary artery disease (CAD) has the potential to avert the significant associated morbidity and mortality. Modifying three risk factors – diabetes, hyperlipidemia and hypertension – is key in this regard. But, two consistent questions are the threshold to start treatment and the target levels for this treatment.

A review published Oct. 16 in the Journal of the American College of Cardiology summarizes the current guidelines as well as the perspectives and controversies regarding these guidelines that stem from an evolving evidence base. Kimberly N. Hong, MD, MHSA, et al., also discuss pertinent clinical trial data from intervention trials that included a primary prevention cohort.

The authors note that primordial prevention of diabetes, hypercholesterolemia and hypertension has the greatest potential to decrease the morbidity and mortality associated with cardiovascular disease but that this is a resource intensive strategy.

In relation to primary prevention of cardiovascular disease, they write that for diabetes and hypertension, “there is no role for pharmacological interventions in individuals without overt disease, and rather, changes in lifestyle could be encouraged.” In patients with diabetes but without CAD, especially those without evidence of microvascular disease, they recommend aggressive glycemic control (HbA1c <6.5 percent). They add that importantly glycemic targets should be achieved slowly based on extrapolation of data from ACCORD.

In patients with hypertension but without diabetes or cardiovascular disease, they recommend that pharmacological treatment should be started as soon as the patient becomes hypertensive by current guidelines (systolic blood pressure [SBP] ≥140 mm Hg) and the target should be SBP <130 mm Hg. The authors note that new guidelines are forthcoming from the American Heart Association and ACC.

In contrast to diabetes and hypertension, the authors state that in the absence of overt hyperlipidemia there appears to be an opportunity to reduce cardiovascular disease events by starting statin therapy in individuals at intermediate risk. “Accurate identification of individuals with subclinical disease allows not only earlier lifestyle interventions or risk factor modifications but also the reclassification of patients and discontinuation of a therapy where the risk–benefit ratio may not have been favorable,” they write.

A priority should be identifying new methods and variables to improve risk estimation in order to develop a model that correctly discriminates between disease states that are and are not modifiable. The authors also review issues with current risk calculators and suggest that they may not completely identify all who would benefit from lipid-lowering therapy, because of the evidence that the atherosclerotic process begins early in infancy. They suggest that starting treatment earlier than indicated by conventional risk calculators must be considered.

In lower risk patients, the authors recommend lifestyle and behavioral interventions. “Appropriate selection of individuals who will benefit from more aggressive pharmacological therapies will hinge on the accuracy of cardiovascular risk calculators,” they write.

Keywords: Risk Factors, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Blood Pressure, Glycated Hemoglobin A, Coronary Artery Disease, Cardiovascular Diseases, Hypertension, Risk Assessment, Odds Ratio, Primary Prevention, Diabetes Mellitus, Life Style, Lipids

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