Clinician Guide to the ABCs of Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease

Cardiovascular disease remains the leading cause of death in America, with well-established and identifiable risk factors. Modifiable risk factors are the primary driver for first cardiovascular event, and risk factor modification has been a significant driver for reduction of cardiovascular death in certain populations in recent decades.1,2 However, there remains significant opportunity to improve clinician and patient participation in evidence-based screening and preventative care. According to registry-based studies, 40-60% of patients with cardiovascular risk factors are non-adherent to at least one key component of primary prevention.3 Among those with established atherothrombotic disease, up to 90% are taking antiplatelet, lipid-lowering or anti-hypertensive therapy. However, fewer than 50% are fully adherent to all medications with a class 1 indication in secondary prevention, which is associated with marked increase in risk for recurrent events and death.4

The Million Hearts Initiative was launched by the Centers for Disease Control and Prevention in 2012 in an effort to save 1 million lives from cardiovascular death in 5 years. Preventative care is at the heart of this initiative. A simple structured approach will allow clinicians responsible for preventative care to identify patients at high cardiovascular risk and to provide appropriate lifestyle and pharmacologic interventions in the current time-limited care environment. The ABCDEs of cardiovascular disease prevention were first proposed in 2001 as a straightforward template for use by both clinicians and patients to address the key components of risk factor modification. This now includes Assessing risk, Antiplatelet therapy, Atrial fibrillation, Blood pressure, Cholesterol therapy, Diabetes, Diet, Exercise, and Heart Failure. We offer an updated and concise clinician's guide to the ABCDEs based on updated guidelines and recent evidence for practical use in a practice setting.

A: Assess Risk

  • PRIMARY PREVENTION
    • Assess for risk factors at least every 4-5 years starting at age 20.
    • Apply pooled cohort equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) risk or similar CVD risk estimator in asymptomatic adults aged 40-79 (if not already on a statin) to estimate 10-year risk of myocardial infarction (MI)/cerebrovascular accident (CVA).
    • Patients with HIV or chronic inflammatory disorders are often at higher risk than predicted by PCE.
    • Consider selective use of coronary artery calcium (CAC) when risk-based treatment decisions are uncertain (e.g., if in the 5-20% 10-year risk estimate range).
    • For adults aged 20-59, estimate the 30-year or lifetime risk for ASCVD.
    • Women with a history of preeclampsia, pregnancy-induced hypertension, polycystic ovarian syndrome and/or gestational diabetes are often at higher risk than predicted by PCE.
  • SECONDARY PREVENTION
    • Aggressive comprehensive risk modification if known ASCVD, cerebrovascular, peripheral arterial or subclinical atherosclerosis.

A: Antiplatelet Therapy

  • PRIMARY PREVENTION
    • Consider aspirin 81 mg/day if 10-year ASCVD risk estimate is ≥10% if potential benefit outweighs bleeding risk after clinician-patient risk discussion.
  • SECONDARY PREVENTION
    • Aspirin 81-162 mg/day indefinitely [Class I].
    • Clopidogrel, prasugrel, or ticagrelor (i.e., P2Y12 inhibitor) in addition to aspirin after PCI [Class I].
      • If bare-metal stent, P2Y12 inhibitors should be taken for ≥1 month [Class I].
      • If drug-eluting stent, P2Y12 inhibitors for ≥1 year [Class I].
      • If on dual antiplatelet therapy (DAPT), use aspirin 81 mg/day [Class I].
    • If no PCI was performed after an ACS event, either clopidogrel or ticagrelor should be used.
    • Do not use prasugrel if history of stroke or TIA [Class III]. Caution in those over 70 years of age.
    • Aspirin 81 to 325 mg/day or clopidogrel for all patients following a non-cardioembolic ischemic stroke [Class I].

A: Atrial Fibrillation

  • PRIMARY PREVENTION
    • Control/prevention of risk factors of hypertension, obesity, alcohol, sleep apnea and diabetes.
  • SECONDARY PREVENTION
    • Warfarin or direct oral anticoagulant for CHA2DS2-VASC ≥2.
    • Aspirin if CHA2DS2-VASC ≤1.
    • Consider rhythm control.

B: Blood Pressure

    • Confirm diagnosis of hypertension with multiple home BP recordings; evaluate secondary causes as appropriate.
    • Rest for at least 5 minutes, feet flat on floor, rest arm at heart level.
  • PRIMARY AND SECONDARY PREVENTION
    • Lifestyle interventions (weight management, exercise, sodium restriction) [Class I]; at least yearly BP checks.
    • BP goal is <130/80.
    • Pharmacotherapy may be started with lifestyle changes, depending on hypertension stage and ASCVD risk estimate.
      • Can focus longer on lifestyle changes alone if ASCVD risk estimate is <10%.
    • Choose fresh foods; if canned foods use those marked reduced, low or no sodium.
    • Use spices and herbs to add flavor to food which can reduce need for salt.
    • Reduce the “salty six:” breads/rolls, canned soups, cold cuts/cured meats, pizza, poultry with added sodium such as pre-seasoned fillets and chicken nuggets, and burgers from fast-food restaurants.
    • Increase fruits, vegetables, whole grains and nuts [Class I].
    • Limit alcohol; no more than two drinks per day for men and one for women.

C: Cholesterol

  • PRIMARY PREVENTION
    • Lifestyle interventions [Class I].
    • Moderate to high-intensity statin for one of the clear statin-benefit groups after clinician-patient risk discussion (e.g., diabetes, LDL-C ≥190) [Class I].
    • Moderate to high-intensity statin should be strongly considered if ASCVD risk estimate is ≥7.5% after risk discussion; if patient or clinician is uncertain, selective use of CAC scan is reasonable if risk estimate is 5%-20%.
    • Factors supporting statin use if risk decision is uncertain include LDL-C ≥160, family history of premature ASCVD, high lifetime ASCVD risk, presence of CAC (especially if > 75th percentile for age/gender or absolute score ≥100) [Class IIb].
    • If familial hypercholesterolemia and LDL-C ≥70, non-HDL-C ≥100 after trial of highest tolerated dose of high-intensity statin, consider ezetimibe [Class IIa] and/or PCSK9 inhibitors [Class IIb].
  • SECONDARY PREVENTION
    • Lifestyle interventions [Class I].
    • Moderate to high-intensity statin [Class I].
    • If LDL-C ≥70, non-HDL-C ≥100, and high risk for another ASCVD event (e.g., TIMI risk score for secondary prevention >3)5 after trial of highest tolerated dose of a high-intensity statin, consider ezetimibe [Class IIa] and/or PCSK9 inhibitors [Class IIb].
    • If triglycerides >500 mg/dL, then fibrates [Class I] and/or high-dose omega 3.

C: Cigarette/Tobacco Cessation

    • Education.
    • Assessment of triggers, counseling, pharmacotherapy (nicotine patches, gum, inhalers, varenicline, bupropion, etc.). 
    • 5As: Ask, Advise, Assess, Assist, Arrange (follow-up).
      • Ask about tobacco use at every visit.
      • Advise to quit at every visit.
      • Assess willingness to quit at every visit.
      • Assist in quitting through counseling/prescriptions.
      • Arrange follow-up first week after quit date.
    • Counsel to avoid exposure to environment to tobacco smoke (e.g., work environment, second-hand exposure) [Class I].

D: Diet/Weight Management

  • PRIMARY PREVENTION AND SECONDARY PREVENTION
    • If overweight, aim for loss of 3-10% of body weight by caloric restriction and increased physical activity as part of comprehensive lifestyle program with focus on weight loss [Class I].
    • Goal BMI is 18.5-24.9 kg/m2; measure at least annually [Class I].
    • Diet should eliminate trans fats and decrease saturated fats, sodium, sugar-sweetened beverages, sugary foods, bread products and red meat [Class I].
    • Increase fruits, vegetables, whole grains, nuts, poultry and fish as part of an overall low-calorie diet appropriate for height, weight, and comorbid medical conditions [Class I]. Goal of ~25 grams of fiber/day.
    • Goal waist circumference (measured at the level of the iliac crest) is <40“ (94 cm) for men and <35“ (80 cm) for women [Class I]; smaller waist circumference targets for South Asians, Chinese, Japanese would be appropriate.

D: Diabetes (Type 2) Prevention and Treatment

  • PRIMARY PREVENTION
    • Lifestyle interventions [Class I].
    • Goal is fasting glucose <100, HgbA1C <5.7%.
  • SECONDARY PREVENTION
    • Goal A1C <7% if this can be achieved safely [Class IIb].
      • Lifestyle interventions are the first-line followed by antihyperglycemics [Class I].
    • Refer to a nutritionist.
    • Metformin is a reasonable first-line agent [Class IIa].
    • Newer antihyperglycemic agents (e.g., liraglutide and empagliflozin) reduce cardiovascular events and mortality and are next line when appropriate.
    • Other oral hypoglycemics and insulin can be used as needed to achieve goal.
    • ACEI or ARB is a good first line agent to treat hypertension in this population, especially if urine microalbumin to creatinine ratio is >30.
    • Treat elevated cholesterol and address weight loss as outlined above.
    • Ensure appropriate follow-up is in place for other end-organ damage from diabetes.

E: Exercise

  • PRIMARY AND SECONDARY PREVENTION
    • Moderate-vigorous aerobic exercise for a total of at least 150 minutes/week (e.g., 30 minutes, 5 sessions a week) [Class I].
    • Recommend addition of two days of resistance training [Class IIa].
    • Aim for >10,000 steps a day or other reasonable target based on baseline activity.
    • Reduce sitting/sedentary time.
    • Cardiac rehabilitation for patients who have had an ASCVD event or heart failure with reduced ejection fraction (LVEF ≤35%) [Class I].

F: Heart Failure

  • PRIMARY PREVENTION
    • Treat heart failure risk factors.
  • SECONDARY PREVENTION
    • Lifestyle interventions [Class I].
    • Adherence to medications that reduce morbidity and/or mortality in patients with HFrEF: ACEI or ARB, ARNI, beta blocker, aldosterone antagonist, ISDN/hydralazine (if African American and on optimal ACEI and beta blocker) [Class I].
    • Consideration of ICD/CRT-D (following ≥3 months of optimal medical therapy or at least 40 days following myocardial infarction) in appropriate patient [Class I].
    • Cardiac rehabilitation [Class I].
    • Diuretics for overall maintenance of fluid balance and symptom relief [Class I].
    • Blood pressure goal in HFrEF and HFpEF is a SBP <130 mmHg [Class I].
    • Cigarette cessation/cholesterol management/blood sugar control [Class I].

This guide is an update of prior papers: 1) Kohli P, Whelton SP, Hsu S, et al. Clinician's guide to the updated ABCs of cardiovascular disease prevention. J Am Heart Assoc 2014;3:e0001098 and 2) Hsu S, Ton VK, Dominique Ashen M, et al. A clinician's guide to the ABCs of cardiovascular disease prevention: the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and American College of Cardiology Cardiosource Approach to the Million Hearts Initiative. Clin Cardiol 2013;36:383-93.

References

  1. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med 2007;356:2388-98.
  2. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937-52.
  3. Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med 2012;125:882-7.
  4. Kumbhani DJ, Steg PG, Cannon CP, et al. Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis. Am J Med 2013;126:693-700.
  5. Bohula EA, Morrow DA, Giugliano RP, et al. Atherothrombotic risk stratification and ezetimibe for secondary prevention. J Am Coll Cardiol 2017;69:911-21.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Sports and Exercise Cardiology, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Homozygous Familial Hypercholesterolemia, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Primary Hyperlipidemia, Statins, Acute Heart Failure, Interventions and Vascular Medicine, Diet, Exercise, Hypertension, Sleep Apnea

Keywords: Dyslipidemias, Adenosine, Anticoagulants, Antihypertensive Agents, Aspirin, Atherosclerosis, Atrial Fibrillation, Benzhydryl Compounds, Blood Glucose, Blood Pressure, Body Mass Index, Brain Ischemia, Bupropion, Caloric Restriction, Cardiac Rehabilitation, Cardiovascular Diseases, Cause of Death, Centers for Disease Control and Prevention (U.S.), Cholesterol, Cohort Studies, Coronary Vessels, Creatinine, Diabetes Mellitus, Type 2, Diabetes, Gestational, Diet, Diuretics, Drug-Eluting Stents, Factor V, Fasting, Fibric Acids, Follow-Up Studies, Gingiva, Glucose, Glucosides, Hemoglobin A, Glycosylated, Goals, Heart Diseases, Heart Failure, HIV Infections, Hydralazine, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypercholesterolemia, Hyperlipoproteinemia Type II, Hypertension, Hypertension, Pregnancy-Induced, Hypoglycemic Agents, Insulin, Life Style, Lipids, Medication Adherence, Metformin, Mineralocorticoid Receptor Antagonists, Myocardial Infarction, Nebulizers and Vaporizers, Nicotine, Nutritionists, Obesity, Overweight, Patient Participation, Polycystic Ovary Syndrome, Percutaneous Coronary Intervention, Pre-Eclampsia, Primary Prevention, Registries, Resistance Training, Risk Factors, Secondary Prevention, Sleep Apnea Syndromes, Smoke, Stroke, Stroke Volume, Ticlopidine, Tobacco, Tobacco Use, Tobacco Use Cessation, Triglycerides, Waist Circumference, Warfarin, Water-Electrolyte Balance, Weight Loss


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