Primary prevention
The most important preventive actions involve combined dietary and lifestyle modifications (stopping smoking; increasing physical activity; losing weight; increasing consumption of fish, fruits, vegetables, fiber, and nuts; reducing salt intake).[72] The American Heart Association (AHA) recommends using the "5A model" (assess, advise, agree, assist, arrange) as a framework for counseling patients in behavioral change to reduce CVD risk.[73]
Smoking is a leading preventable cause of disease, disability and death; even low levels of smoking increase risk of atherosclerotic cardiovascular disease (ASCVD).[20][72]
Support programs, medications, and alternative therapies are available. In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended.[72] Secondhand smoke exposure should be avoided.[72]
Routine and/or opportunistic assessment of cardiovascular risk factors with calculation of 10-year risk of ASCVD should be used to guide decisions on treatment with preventive therapies (e.g., statins).[72][74] ACC: ASCVD Risk Estimator Plus Opens in new window
The US Preventive Services Task Force recommends starting statin therapy for primary prevention in adults ages 40 to 75 years without ASCVD but who have one or more cardiovascular risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year cardiovascular disease risk of 10% or greater.[75] Those with 10-year risk of between 7.5% and 10.0% may selectively be offered a statin.[75] For patients 76 years or older there is insufficient evidence to recommend for or against starting a statin for primary prevention.[75]
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.[76]
Secondary prevention
Aggressive risk-factor intervention is recommended.[1]
Smoking cessation should be strongly advised, including use of resources and adjunctive agents.
For adults with confirmed hypertension and known cardiovascular disease or 10-year atherosclerotic cardiovascular disease event risk of 10% or higher, a BP target of less than 130/80 mmHg is recommended.[174]
LDL levels should be lowered to goals of <55 mg/dL.
HbA1C should be kept at <0.07 (<7% of total hemoglobin) in patients with diabetes.
In patients with ischemic heart disease, an automated implantable cardioverter defibrillator (ICD) is recommended for primary prevention in the following scenarios:[155]
In patients with left ventricular ejection fraction of 35% or less that is due to ischemic heart disease who are at least 40 days post-myocardial infarction (MI) and at least 90 days post revascularization, and with New York Heart Association (NYHA) class II or III heart failure despite appropriate management, an ICD is recommended if meaningful survival of greater than 1 year is expected
In patients with left ventricular ejection fraction of 30% or less that is due to ischemic heart disease who are at least 40 days post-MI and at least 90 days post revascularization, and with NYHA class I heart failure despite appropriate management, an ICD is recommended if meaningful survival of greater than 1 year is expected
In patients with nonsustained ventricular tachycardia due to prior MI, left ventricular ejection fraction of 40% or less, and inducible sustained ventricular tachycardia or ventricular fibrillation at electrophysiological study, an ICD is recommended if meaningful survival of greater than 1 year is expected
For secondary prevention in patients with ischemic heart disease, an automated ICD is recommended when the history is consistent with an arrhythmic etiology for syncope and ejection fraction <35%.[155]
Clinicians caring for cardiac patients need to be aware of the high incidence of major depressive disorder in this population, and its association with worsened cardiovascular outcomes.[175] Accordingly, screening for symptoms of depression should be performed and therapy, including pharmacologic, should be offered.[176]
Cardiac rehabilitation, a long-term multifaceted program including exercise, dietary and lifestyle interventions, patient education, and counseling, is recommended for appropriate non-ST-elevation acute coronary syndrome patients and may improve clinical outcomes.[136][177][178][179][180][181]
[ 
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[Evidence B]
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