Primary prevention
The American Heart Association defines eight key measures for improving and maintaining cardiovascular health, ‘Life’s Essential 8’, these are: healthy diet, participation in physical activity, avoidance of nicotine, healthy sleep, healthy weight, and healthy levels of blood lipids, blood glucose, and blood pressure.[58] Prevention of coronary disease includes community- and patient-level interventions to encourage exercise, healthy diet, and ideal body weight while discouraging smoking. The US Preventive Services Task Force (USPSTF) recommends that adults at increased risk of cardiovascular disease are offered behavioural counselling interventions to promote a healthy diet and physical activity; those not at high risk may also be selectively considered for behavioural counselling interventions, while recognising that the net benefit is smaller.[59][60]
Exercise: guidelines recommend that all adults should undertake 150 to 300 minutes of moderate-intensity aerobic physical activity, or at least 75 to 150 minutes of vigorous-intensity aerobic physical activity throughout the week.[18][33][61]
Diet: a Mediterranean-type diet, with a higher intake of vegetables, fruits, legumes, nuts, whole grains, lean protein (e.g., fish), and fibre is recommended to lower the risk of cardiovascular disease.[18][33] Intake of trans fats, red meat, processed meat, refined carbohydrates, and sweetened drinks should be minimised or avoided. Salt intake should be reduced.
Weight: individuals with overweight and obesity should be counselled on physical activity and diet to promote weight loss, reduce blood pressure and dyslipidaemia, and improve atherosclerotic cardiovascular disease (ASCVD) risk profile.[18][33] Although weight loss interventions improve cardiovascular risk factors (including weight, blood pressure, lipids, insulin resistance), there is limited evidence of improved cardiovascular outcomes in weight loss trials.[48] Given the imperfections of BMI as a risk marker, the limited efficacy of even multicomponent lifestyle interventions in promoting sustained weight loss, and concern for weight stigma as a barrier to care, providers might also focus on physical activity and cardiorespiratory fitness rather than weight per se as a treatment goal.
Smoking cessation: all adults who smoke/use tobacco are strongly advised to quit. Smoking cessation benefits all people who smoke regardless of age, comorbidities, or current health problems. See Smoking cessation.
Treatment targets for antihypertensive therapy and use of statin medications are typically guided by individual risk for cardiovascular disease, usually estimated with a 10-year risk calculator, such as the Pooled Cohort Equations or newer PREVENT™ calculator (US), QRISK or SCORE (Europe). SCORE2 and SCORE2-OP risk assessment models Opens in new window
Among adults at borderline (5% to <7.5%) and intermediate (≥7.5% to <20%) risk, the American College of Cardiology/American Heart Association (ACC/AHA) states that it is reasonable to use the following additional individual risk-enhancing clinical factors to guide decisions about preventive therapy:[62]
Family history of premature ASCVD (men aged <55 years; women aged <65 years)
Primary hypercholesterolaemia (low-density lipoprotein cholesterol [LDL-C], 4.1–4.8 mmol/L [160–189 mg/dL]; non-high density lipoprotein cholesterol [non-HDL-C], 4.9–5.6 mmol/L [190–219 mg/dL])
Optimally, three determinations
Metabolic syndrome (increased waist circumference [by ethnically appropriate cutpoints], elevated triglycerides [>150 mg/dL, nonfasting], elevated blood pressure, elevated glucose and low HDL-C [<40 mg/dL in men; <50 mg/dL in women] are factors; a tally of three makes the diagnosis)
Chronic kidney disease (estimated glomerular filtration rate [eGFR] 15–59 mL/min/1.73 m² with or without albuminuria; not treated with dialysis or kidney transplantation)
Chronic inflammatory conditions, such as psoriasis, rheumatoid arthritis, lupus or HIV/AIDS
History of premature menopause (before age 40 years) and history of pregnancy-associated conditions that increase later ASCVD risk, such as pre-eclampsia
High-risk race/ethnicity (e.g., South Asian ancestry)
Lipids/biomarkers: associated with increased ASCVD risk
Persistently elevated (optimally, three determinations) primary hypertriglyceridaemia (≥175 mg/dL, non-fasting)
If measured: elevated high-sensitivity C-reactive protein (≥2.0 mg/L)
If measured: elevated lipoprotein (a) (Lp(a)). A relative indication for its measurement is family history of premature ASCVD. An Lp(a) ≥50 mg/dL or ≥125 nmol/L constitutes a risk-enhancing factor, especially at higher levels of Lp(a)
If measured: elevated apolipoprotein B (apoB) (≥130 mg/dL). A relative indication for its measurement is triglyceride ≥200 mg/dL. A level ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor
If measured: ankle-brachial index (ABI) (<0.9)
[ PREVENT™ online calculator Opens in new window ] [ ASCVD Risk Estimator Plus Opens in new window ] [ QRISK Opens in new window ] The USPSTF recommends that adults aged 40 to 75 years who have one or more cardiovascular risk factors (i.e., dyslipidaemia, diabetes, hypertension, or smoking) and an estimated 10-year cardiovascular disease risk of 10% or greater should be started on a statin. Those with 10-year risk of 7.5% to less than 10% may selectively be offered a statin.[63]
Aspirin is no longer routinely recommended for primary prevention but may be considered in selected patients for whom the absolute cardiovascular benefit outweighs the absolute risk of increased bleeding.[18][33][64][65]
Secondary prevention
All patients with known chronic coronary disease should be provided with individualised education, risk factor modification, and guideline-directed medical therapy with the main goals of reducing the risk of future cardiovascular events and death.
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