Perspective:

The following are points to remember about the clinician’s guide to cardiovascular disease (CVD) prevention:

1. To help simplify the approach to prevention, the authors developed an easy-to-remember “ABCDEF” format that integrates the most recent CV guideline recommendations. There are several useful Tables. Clinicians can organize their office notes in this ABCDEF manner and use this format for easy communication of recommendations to other health care providers and their patients.

2. (Assess) First, assess risk of an atherosclerotic CVD (ASCVD) event. The American College of Cardiology/American Heart Association risk assessment guideline’s primary goal is to help in deciding the cutoff for statin therapy, and was chosen as a ≥7.5% 10-year risk for a ASCVD event. In adults ages 40-79 years, 10-year risk estimation should be done using the pooled cohort risk assessment tool, whereas those ages 20-59 years at low 10-year risk can be considered for lifetime risk. Guidelines recommend additional factors when the risk is not clear. These include coronary artery calcium (CAC) scoring (≥300 Agatston units or >75th percentile for age, sex, and race), high-sensitivity C-reactive protein (hs-CRP) level ≥2.0 mg/L, and a family history of premature ASCVD. A CAC score >100 was predictive of subsequent CV events among participants in the MESA study, who met JUPITER trial criteria of relatively low risk (e.g., men ≥50 years, women ≥60 years, low-density lipoprotein <130 mg/dl and hs-CRP >2 mg/dl).

3. (ASA) ASA (aspirin) 81 mg should be considered in men and women with at least a >10% 10-year risk of ASCVD events and women >65 years for stroke and myocardial infarction prevention; 81-162 mg in diabetics with a >10% 10-year risk or those with a 5-10% 10-year risk with other risk factors; 81 mg in all patients following an acute coronary syndrome (ACS); 81-325 mg following an ischemic stroke; and all patients with symptomatic peripheral arterial disease and coronary revascularization. A P2Y₁₂ receptor antagonist should be used with 81 mg of aspirin following an ACS, but not with aspirin, following coronary artery bypass grafting (CABG) for stable coronary artery disease (CAD) without other indications. Clopidogrel should be used in combination with aspirin in patients receiving percutaneous coronary intervention (PCI) for stable CAD, for a time period specific to the type of stent placed, followed thereafter by lifelong aspirin. If a bare-metal stent was used, clopidogrel should be taken for at least 1 month and ideally for 1 year. If a drug-eluting stent was used, clopidogrel should be taken for at least 1 year.

4. (Atrial Fibrillation) Once atrial fibrillation (AF) has been diagnosed, thromboembolic risk should be assessed with the CHA₂DS₂-VASc score. Although aspirin and warfarin have been shown to reduce the risk of stroke in AF, most warrant warfarin. Novel oral anticoagulants do not require prothrombin time monitoring and are associated with superior efficacy and/or safety in nonvalvular AF.

5. (Blood Pressure) Minor changes were made in blood pressure treatment goals by a group independent of the Joint National Committee-8 and the National Heart, Lung, and Blood Institute. The systolic treatment goal was raised from <140 to <150 mm Hg for patients aged ≥60 years. There is considerable debate about the best target, but agreement that a target of <140 mm Hg is more appropriate than 130 mm Hg in diabetes and chronic kidney disease. The figure in the article provides treatment options and goals for each scenario.

6. (Cholesterol) Randomized controlled trial data support the use of statins to reduce CV risk in four groups: (1) those with known ASCVD, (2) those with an low-density lipoprotein cholesterol (LDL-C) level ≥190 mg/dl, (3) those ages 40-75 years with diabetes mellitus and LDL-C 70-189 mg/dl, and (4) those ages 40-75 years with LDL-C 70-189 mg/dl and an estimated ASCVD 10-year risk of ≥7.5%. Intensity of statin therapy is chosen to match the risk of those who are most likely to benefit. For the minority of patients that are statin intolerant, it is reasonable to use bile acid sequestrants, ezetimibe, fibrates, or niacin. The value of combination therapy for the mixed dyslipidemias is unresolved.

7. (Cigarettes) Active smoking and second-hand smoke are major risk factors for subclinical atherosclerosis. Because smoking cessation is associated with a 36% relative reduction in mortality for coronary heart disease patients, it is imperative that every attempt be made to help patients end tobacco use.

8. (Diet) The many heart healthy diets including the DASH diet, the US Department of Agriculture’s ‘Choose My Plate,’ the American Heart Association diet, and the Mediterranean Diet can each be adapted for appropriate calorie requirements, and nutritional treatment of other medical conditions and should be part of a comprehensive lifestyle program to assist overweight and obese patients in adhering to a lower calorie diet and increasing physical activity as part of attaining an energy deficit.

9. (Diabetes) For those with diabetes mellitus, the American Diabetes Association recommends treatment to achieve a target hemoglobin A1c level <7%. Therapies include oral hypoglycemic agents and insulin, but metformin is recommended as first-line treatment for most patients with type 2 diabetes mellitus. More intensive goals should be avoided because they have not been associated with improvement in CV outcomes and have been associated with increased mortality.

10. (Exercise) Primary and secondary prevention requires regular aerobic physical activity with a goal of 3-4 sessions per week, lasting an average of 40 minutes per session, involving moderate- to vigorous-intensity physical activity; and cardiac rehabilitation for patients who have had an ASCVD event.

11. (Heart Failure) Treatment of heart failure (HF) should be facilitated by lifestyle modification, and more widespread detection and treatment of hypertension, dyslipidemia, diabetes, obesity, and excess use of alcohol. All patients with HF with reduced ejection fraction (EF) should be treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, as well as a beta-blocker shown to provide benefit in HF. In those with a reduced left ventricular EF (LVEF) and New York (NYHA) class II or greater symptoms, an aldosterone antagonist should be used. Implantable cardioverter-defibrillator placement should be considered in patients with an LVEF ≤35% if they have been on optimal medical therapy for at least 3 months and have a life expectancy of >1 year.

12. Cardiac rehabilitation (both exercise training and secondary prevention programs) has been demonstrated to improve outcomes in coronary heart disease patients with or without a myocardial infarction, as well as in patients with HF with reduced EF. Chronic stable systolic HF with LVEF ≤35% and NYHA class II-IV symptoms despite optimal medical therapy are now a Medicare and Medicaid approved indication for referral to cardiac rehabilitation.