ACC, AHA Present New Cardiovascular Prevention Guideline

Roger S. Blumenthal, MD

The American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA), has released new guidance on the preventive care of cardiovascular conditions including heart disease and stroke.

The 2019 Primary Prevention of Cardiovascular Disease guideline, presented at the ACC 2019 Annual Scientific Sessions in New Orleans, LA, on Sunday, provides new key points on patient diet, tobacco use, and risk factor management for physicians. It also makes a notable recommendation to limit aspirin use in the prevention of heart attacks and stroke in patients without known cardiovascular disease.

According to the ACC, about 1 of 3 deaths in the US are currently due to cardiovascular disease (CVD). Potentially fatal major adverse cardiovascular events (MACE) are driven by a culmination of various factors, including unhealthy lifestyle, infrequent exercise, obesity or overweight status, tobacco use, and comorbid conditions including type 2 diabetes (T2D).

As such, the guideline provides clinical standards for all these factors, as well as recommendations for evaluation, diagnostic testing, and both pharmacological and procedural care. That said, they require the embrace of both physicians and patients alike.

“Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities,” Patrick T. O’Gara, MD, MACC, FAHA, chair of the ACC/AHA Task Force on Clinical Practice Guidelines, wrote in the executive summary.

The new guideline comes just 2 days after the ACC—along with the AHA and Heart Rhythm Association—shared updates to its guideline for the treatment of patients with atrial fibrillation.

The ACC-AHA conglomerate committee tasked with drafting the guidelines were comprised of clinicians, cardiologists, researchers, epidemiologists, internists, nurses, and a lay representative. On separate five-point grading scales of class of recommendation (COR) strength—based on clinical benefits versus risks—as well as level of evidence (LOE), the committee made a series of recommendations that scored highest for both standards. Among those recommendations are:

• A teambased care approach is recommended for the control of risk factors associated with atherosclerotic cardiovascular disease (ASCVD).
• Adults with T2DM should perform at least 150 minutes per week of moderateintensity physical activity or 75 minutes of vigorous-intensity physical activity to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.
• In adults with intermediate risk (≥7.5% to <20% 10year ASCVD risk), statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended.
• In adults 40 to 75 years of age with diabetes, regardless of estimated 10year ASCVD risk, moderate-intensity statin therapy is indicated.
• In adults with elevated blood pressure (BP) or hypertension, including those requiring antihypertensive medications, nonpharmacological interventions are recommended to reduce BP. These include: weight loss, hearthealthy dietary pattern, sodium reduction, dietary potassium supplementation, increased physical activity with a structured exercise program, and limited alcohol.

Regarding their recommendation for limited aspirin use, the committee referenced recent research which has shown the chance of bleeding due to aspirin’s blood-thinning effects may be too high for its evidenced benefit to make daily aspirin a worthwhile stroke prevention plan for most adults.

“It’s much more important to optimize lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin,” Roger S. Blumenthal, MD, co-chair of the guideline and the Kenneth Jay Pollin Professor of Cardiology at Johns Hopkins Medicine, said in a statement. “Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”

In an interview with MD Magazine®, Paul Gurbel, MD, FACC, director of Interventional Cardiology and Cardiovascular Medicine Research and professor of Medicine at Johns Hopkins School of Medicine, maintained that aspirin is still a reliable therapy for the secondary prevention of CVD.

“Aspirin is still the cornerstone of therapy,” Gurbel explained. “It’s important the message gets out to patients that no one should change their aspirin therapy until they get in touch with their doctor, because it can have serious consequences—meaning a recurrent heart attack or stroke.”

With the new guidelines, Gurbel reiterated that nothing should change within regard to aspirin’s status as an agent for secondary prevention. Among the patients it could still be applicable for care are those who have suffered a prior stroke, acute myocardial infarction, angina, cardio revascularization, or carotid revascularization.

Regarding sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists, the committee recommended that it would be “reasonable” for physicians to prescribe either agent as a treatment to improve glycemic control and reduce CVD risk in adults with T2DM and additional ASCVD risk factors, who may require glucose-lowering treatment despite initial lifestyle modifications and metformin.

Speaking on the role of SGLT-2 inhibitors for CVD prevention, Stephen Wiviott, MD, an associate professor of Cardiovascular Medicine at Harvard Medical School and cardiovascular medicine specialist at Brigham and Women’s Hospital, told MD Mag the guideline’s recommended for the therapy runs parallel to new findings presented at ACC 2019 this weekend.

“But I think it’s also important for the general medical community to recognize that the benefits related to heart failure and to kidney function, in particular, are really quite far-reaching,” Wiviott said. “And even in primary prevention patients, low-risk patients, there tends to be these same sort of benefits.”

Wiviott concluded the drug class could be used in a “wide swath of patients,” but emphasis should be put on the patients recommended for its care in the guideline and relevant data.

Citing that more than 80% of all cardiovascular events are preventable through changes of lifestyle, Blumenthal advised physicians and patients stay the course in practicing proven strategies and controlling risk factors.

“The most important way to prevent cardiovascular disease, whether it’s a build-up of plaque in the arteries, heart attack, stroke, heart failure or issues with how the heart contracts and pumps blood to the rest of the body, is by adopting heart healthy habits and to do so over one’s lifetime,” he said.

The guideline is available on the Journal of the American College of Cardiology.