New ACC/AHA primary prevention guideline takes a patient-centered approach

ACC 2019 The new guideline promotes a healthy lifestyle throughout life, and encourages physicians to assess social determinants of health to optimally implement the recommendations.

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Presented at ACC.19 by Donna K. Arnett and Amit Khera

The 2019 Primary Prevention of Cardiovascular Disease guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA) were presented at ACC’s 68th Annual Scientific Session. More than 80% of CV disease in the USA are preventable through lifestyle changes. The guideline committee therefore aimed to compose a comprehensive document, which serves as a central resource for doctors with strategies that can be used and tailored to help people without a history of heart disease stay healthy.

Dr. Donna Arnett (Lexington, KY, VS) discussed the main topics relevant to prevention:

• Patient-centered approaches: a team-based care approach is recommended and shared decision-making should guide discussions about the best strategies to reduce ASCVD risk. Social determinants of health should inform optimal implementation of treatment recommendations for prevention of ASCVD. For instance, often fundamental questions about access to healthy food or to a pharmacy are not asked, but their answers are crucial to whether advise can be followed.
• Dietary intervention: dietary modification is the cornerstone of prevention, but implementation in clinical practice is limited. Recommendations about the components of a healthy diet are given, along with a harm notice that intake of trans fats should be avoided. With regard to addressing social determinants of health, it could be considered to assess body size perception, and social and cultural influences affecting this. Moreover, a physician could assess and ask about potential barriers to adhering to a heart-healthy diet in vulnerable populations.
• Physical Activity: barely 50% of Americans meets the current recommendations on physical activity. Therefore, adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle (note that the recommendation is not focused on ‘exercise’). Effectiveness of counselling on physical activity has been demonstrated in (meta-analyses of) RCT’s, and the NNT is 12 for sedentary individuals to meet recommendations on physical activity. Specific recommendations are given on the duration and intensity of physical activity. To address social determinants, it is good to assess the neighborhood environment and access to facilities for physical activities.
• Overweight and obesity: Since less than a third of Americans are lean or of good body weight, overweight and obesity deserve more attention. Weight loss is recommended in those with overweight or obesity, and counselling and comprehensive lifestyle interventions are recommended. Calculating BMI is recommended annually and waist circumference may also be measured to identify those at higher cardiometabolic risk. In light of social determinants, psychosocial stressors, sleep hygiene and other individualized barriers should be assessed. And if weight loss cannot be achieved, weight maintenance should be promoted.
• Tobacco use: both tobacco use and secondhand smoke are a cause of CV disease. Use of electronic nicotine delivery systems also increase the risk for CV and pulmonary disease. Adults should therefore be assessed for tobacco use at every visit, and users should be firmly advised to quit. A combination of behavioral intervention plus pharmacotherapy (7 FDA-approved medications available) is recommended to maximize quit rates. It is reasonable to dedicate trained staff to tobacco treatment in every healthcare system. With regard to smoking, social support is important, thus assistance and arrangement for individualized and group social support counseling are recommended.

Dr. Amit Khera (Dallas, TX, USA) next discussed several risk factors that need to be addressed for primary prevention. Specific guidelines also exist for these risk factors, and the recommendations were kept as close as possible to the ones in those dedicated guidelines.

He briefly touched on the sections that dealt with assessment of CV risk, management of high blood pressure or hypertension with nonpharmacological interventions and/or antihypertensive medications, cholesterol, and management of diabetes and the associated increased CV risk with lifestyle interventions and/or medication, which in some patients may include members of the new classes of SGLT2 inhibitors or GLP-1 receptor agonists. Recommendations on aspirin use are now clarified based on recent data: aspirin should only rarely be used for primary prevention of myocardial infarction and stroke. This requires extra attention in clinical practice, since many people take aspirin although the evidence does not support a preventive role in their situation.

- Our coverage of ACC.19 is based on the information provided during the congress -

The guidelines are published simultaneously in JACC