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).[37]
Smoking is a leading preventable cause of disease, disability, and death; even low levels of smoking increase risk of atherosclerotic cardiovascular disease (ASCVD).[37][38] Support programs, medications, and alternative therapies are available. In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended.[37] Secondhand smoke exposure should be avoided.[37]
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).[37][39] [ ASCVD Risk Estimator Plus Opens in new window ]
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.[40] 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.
Among adults at borderline (5.0% to <7.5%) and intermediate (≥7.5% to <20.0%) 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.[37]
Family history of premature ASCVD (men, age <55 years; women, age <65 years)
Primary hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C], 160-189 mg/dL [4.1 to 4.8 mmol/L]; non-high density lipoprotein cholesterol [non-HDL-C] 190-219 mg/dL [4.9 to 5.6 mmol/L])
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 preeclampsia
High-risk race/ethnicity (e.g., South Asian ancestry)
Lipids/biomarkers: associated with increased ASCVD risk
Persistently elevated (optimally, three determinations) primary hypertriglyceridemia (≥175 mg/dL, nonfasting)
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)
The US Preventive Services Task Force recommends that adults ages 40-75 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, should be started on a statin for primary prevention. Those with 10-year risk between 7.5% and 10.0% may selectively be offered a statin. For patients who are 76 years or older there is insufficient evidence to recommend for or against starting a statin for primary prevention.[41]
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.[42]
The table that follows summarizes recommendations for primary prevention of cardiovascular disease (CVD) from the ACC/AHA.[37] Estimate CVD risk using a 10-year risk calculator, such as the Pooled Cohort Equations (ASCVD Risk Estimator Plus). [ ASCVD Risk Estimator Plus Opens in new window ] Newer calculators such as PREVENT™ may yield fewer treatment recommendations if applied at thresholds as outlined in the table below; adjustments to risk thresholds may be required if using PREVENT™ in conjunction with the ACC/AHA primary prevention guidance, although evidence to support this approach is limited.
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adults at borderline risk for ASCVD; without type 2 diabetes
5.0% to <7.5% 10-year ASCVD risk
With tobacco use or exposure
Intervention
Smoking cessation counseling ± pharmacotherapy
Advise all adults who use tobacco to quit; a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.
Advise all patients to avoid secondhand smoke exposure to reduce ASCVD risk.
See Smoking cessation.
Goal
Tobacco abstinence and avoidance of second hand smoke exposure; reduced overall risk of ASCVD
With overweight (BMI=25.0 to 29.9 kg/m²) or obesity (BMI ≥30 kg/m²)
Intervention
Counseling and comprehensive lifestyle interventions
Where feasible, refer patients for comprehensive lifestyle interventions as part of a structured program incorporating regular self-monitoring of food intake, physical activity and weight.
The ACC/AHA state that high intensity (≥14 sessions in 6 months) comprehensive weight-loss interventions provided by a trained interventionist work best. However, it is noted that other modalities, such as electronically delivered weight-loss programs with personalized feedback and some commercial-based programs, have also shown moderate results.
Consider whether to offer select patients, or refer them for, Food and Drug Administration (FDA) approved pharmacologic therapies and bariatric surgery, adjunctive to complementary lifestyle interventions.
It is recommended that BMI is interpreted with caution in people of Asian ancestry, older adults, and muscular adults.
See Obesity in adults.
Goal
Weight loss; reduced waist circumference; increased physical activity; reduced caloric intake; reduced overall risk of ASCVD
Weight loss:
The ACC/AHA define clinically meaningful weight loss as ≥5% initial weight.
Waist circumference:
Definitions of elevated waist circumference are ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women.
Physical activity:
Increased physical activity, preferably aerobic physical activity (e.g., brisk walking) for ≥150 minutes/week (equal to ≥30 minutes/day on most days of the week), is recommended for initial weight loss
Higher levels of physical activity, approximately 200-300 minutes/week, are recommended to maintain weight loss or minimize weight regain after 1 year.
Reduced caloric intake:
Caloric intake reduced by ≥500 kcal/day from baseline, which often can be attained by limiting women to 1200 to 1500 kcal/day and men to 1500 to 1800 kcal/day
A very-low-calorie diet (defined as <800 kcal/day) is recommended only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision
With moderate or severe hypercholesterolemia
Intervention
Individualized management
A maximally- tolerated statin is recommended for all patients ages 20-75 years with severe primary hypercholesterolemia, regardless of estimated 10-year ASCVD risk.
For patients age >75 years, statins are not routinely recommended, but may be considered on a case-by-case basis depending on the individual risk status and potential for adverse effects.
Although statins are not routinely recommended in young adults ages 20-39 years, they may be considered in those with moderate hypercholesterolemia (LDL-C ≥160 mg/dL [≥4.1 mmol/L]) where there is a positive family history of premature ASCVD.
See Hypercholesterolemia.
With risk-enhancing factors or high coronary artery calcium score, but no hypercholesterolemia; ages 40-75 years
Intervention
Consider a moderate-intensity statin
If risk-enhancing factors are present, have a risk discussion with the patient regarding initiation of a moderate-intensity statin.
Coronary artery calcium scoring is not routinely used to guide treatment decisions in the borderline risk group. However in select borderline risk adults it may be used to guide decision making regarding the need for a statin as follows.
Coronary artery calcium score 0 Agatston units (AU): reasonable to withhold a statin and reassess in 5-10 years, providing higher risk conditions (e.g., diabetes, family history of premature CHD, cigarette smoking) are absent
Coronary artery calcium score 1-99 AU: reasonable to initiate statin treatment for patients age ≥55 years
Coronary calcium score ≥100 AU or ≥75th age/sex/race percentile: reasonable to initiate a statin
For patients age >75 years, statins are not routinely recommended; assessment of risk status and a clinician-patient risk discussion is needed to decide whether to continue or initiate statin treatment, taking into account statin safety and the potential for statin-associated adverse effects.
Goal
Reduction in LDL-C by 30% to 49%; reduced overall risk of ASCVD
With elevated blood pressure (120-129/<80 mmHg)
Intervention
Nonpharmacologic treatment to lower blood pressure
Recommend the following to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Goal
Blood pressure reduction; improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
Follow recommendations on blood pressure targets in line with published clinical guidance on management of hypertension.
With stage 1 hypertension (blood pressure 130-139/80-89 mmHg)
Intervention
Nonpharmacologic treatment to lower blood pressure
Recommend the following to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Goal
Blood pressure reduction; improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
Follow recommendations on blood pressure targets in line with published clinical guidance on management of hypertension.
With stage 2 hypertension (blood pressure ≥140/90 mmHg)
Intervention
Nonpharmacologic treatment and medication to lower blood pressure
Recommend the following nonpharmacologic treatment to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Offer antihypertensive medication in line with published clinical guidance on management of hypertension.
Goal
Blood pressure reduction (goal typically <130/80 mmHg); improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
A target blood pressure of <130/80 mmHg may be reasonable.
Adults at intermediate risk for ASCVD; without type 2 diabetes
≥7.5% to <20.0% 10-year ASCVD risk
With tobacco use or exposure
Intervention
Smoking cessation counseling ± pharmacotherapy
Advise all adults who use tobacco to quit; a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.
Advise all patients to avoid secondhand smoke exposure to reduce ASCVD risk.
See Smoking cessation.
Goal
Tobacco abstinence and avoidance of second hand smoke exposure; reduced overall risk of ASCVD
With overweight (BMI=25.0-29.9 kg/m²) or obesity (BMI ≥30 kg/m²)
Intervention
Counseling and comprehensive lifestyle interventions
Where feasible, refer patients for comprehensive lifestyle interventions as part of a structured program incorporating regular self-monitoring of food intake, physical activity and weight.
The ACC/AHA state that high intensity (≥14 sessions in 6 months) comprehensive weight-loss interventions provided by a trained interventionist work best. However, it is noted that other modalities, such as electronically delivered weight-loss programs with personalized feedback and some commercial-based programs, have also shown moderate results.
Consider whether to offer select patients, or refer for pharmacologic therapies and bariatric surgery, adjunctive to complementary lifestyle interventions.
It is recommended that BMI is interpreted with caution in people of Asian ancestry, older adults, and muscular adults.
See Obesity in adults.
Goal
Weight loss; reduced waist circumference; increased physical activity; reduced caloric intake; reduced overall risk of ASCVD
Weight loss:
The ACC/AHA define clinically meaningful weight loss as ≥5% initial weight
Waist circumference:
Definitions of elevated waist circumference are ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women
Physical activity:
Increased physical activity, preferably aerobic physical activity (e.g., brisk walking) for ≥150 minutes/week (equal to ≥30 minutes/day on most days of the week), is recommended for initial weight loss
Higher levels of physical activity, approximately 200 to 300 minutes/week, are recommended to maintain weight loss or minimize weight regain after 1 year.
Reduced caloric intake:
Caloric intake reduced by ≥500 kcal/day from baseline, which often can be attained by limiting women to 1200-1500 kcal/day and men to 1500-1800 kcal/day
A very-low-calorie diet (defined as <800 kcal/day) is recommended only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision
With moderate or severe hypercholesterolemia
Intervention
Individualized management
A maximally-tolerated statin is recommended for all patients ages 20-75 years with severe primary hypercholesterolemia, regardless of estimated 10-year ASCVD risk.
For patients age >75 years, statins are not routinely recommended, but may be considered on a case-by-case basis depending on the individual risk status and potential for adverse effects.
Although statins are not routinely recommended in young adults ages 20-39 years, they may be considered in those with moderate hypercholesterolemia (LDL-C ≥160 mg/dL [≥4.1 mmol/L]) where there is a positive family history of premature ASCVD.
See Hypercholesterolemia.
Without severe primary cholesterolemia (LDL-C<190 mg/dL [<4.9 mmol/L]); ages 40-75 years
Intervention
Consider a moderate-intensity statin, following risk discussion
Have a risk discussion with the patient to decide whether to initiate moderate-intensity statin therapy.
Knowledge of risk-enhancing factors is useful for all patients but particularly for those at intermediate risk (ASCVD risk of 7.5% to ≤20.0%). The presence of risk-enhancing factors may lower the threshold for statin initiation or intensification.
In adults at intermediate risk, coronary artery calcium scores may also be used to guide treatment decisions as follows:
Coronary artery calcium score 0 AU: reasonable to withhold a statin and reassess in 5-10 years, providing higher risk conditions (e.g., diabetes, family history of premature CHD, and cigarette smoking) are absent
Coronary artery calcium score 1-99 AU: reasonable to initiate statin treatment for patients age ≥55 years
Coronary calcium score ≥100 AU or ≥75th age/sex/race percentile:reasonable to initiate a statin
For patients age >75 years, statins are not routinely recommended; assessment of risk status and a clinician-patient risk discussion is needed to decide whether to continue or initiate statin treatment, taking into account statin safety and the potential for statin-associated adverse effects.
Goal
Reduction in LDL-C by 30% to 49%; reduced overall risk of ASCVD
With elevated blood pressure (120-129/<80 mmHg)
Intervention
Nonpharmacologic treatment to lower blood pressure
Recommend the following to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Goal
Blood pressure reduction; improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
Follow recommendations on blood pressure targets in line with published clinical guidance on management of hypertension.
With stage 1 hypertension (blood pressure 130-139/80-89 mmHg) and estimated 10-year ASCVD event risk <10%
Intervention
Nonpharmacologic treatment to lower blood pressure
The ACC/AHA notes that nonpharmacologic intervention is an appropriate first-line treatment for adults with stage 1 hypertension who have an estimated 10-year ASCVD risk <10%.
Recommend the following to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Goal
Blood pressure reduction; improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
Follow recommendations on blood pressure targets in line with published clinical guidance on management of hypertension.
With stage 1 hypertension (blood pressure 130-139/80-89 mmHg) and estimated 10-year ASCVD event risk of 10% or higher
Intervention
Nonpharmacologic treatment and medication to lower blood pressure
Recommend the following nonpharmacologic treatment to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Offer antihypertensive medication in line with published clinical guidance on management of hypertension.
Goal
Blood pressure reduction (goal typically <130/80 mmHg); improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
For those requiring pharmacologic treatment for hypertension, including those with chronic kidney disease, a target blood pressure <130/80 mmHg is usually recommended.
With stage 2 hypertension (blood pressure ≥140/90 mmHg)
Intervention
Nonpharmacologic treatment and medication to lower blood pressure
Recommend the following nonpharmacologic treatment to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Offer antihypertensive medication in line with published clinical guidance on management of hypertension.
Goal
Blood pressure reduction (goal typically <130/80 mmHg); improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium.
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
For those requiring pharmacologic treatment for hypertension, including those with chronic kidney disease, a target blood pressure <130/80 mmHg is usually recommended.
With comprehensive evaluation suggestive of a favorable risk:benefit ratio for prophylactic aspirin; ages 40-70 years
Intervention
Consider low-dose aspirin
To balance the benefits and risks, low-dose aspirin is recommended only for select adults ages 40-70 years who are at higher ASCVD risk but not at increased bleeding risk, following shared decision making.
The ACC/AHH notes that prophylactic aspirin generally becomes more favorable for patients with >10% estimated 10-year ASCVD risk. This is an individualized decision:
Contemporary data show that absolute risk for ASCVD events typically exceeds that of bleeding and, although the gap of relative benefit to relative harm for aspirin has narrowed, the number needed to treat to prevent an ASCVD event remains lower than the number needed to harm to cause bleeding.
Some patients, in discussion with their clinician, may feel that the benefit of prophylactic aspirin is comparable to the risk and may instead choose to focus on optimal control of other modifiable ASCVD risk factors.
Consider risk enhancing factors ± coronary artery score, where available, as part of the risk:benefit analysis.
Prophylactic aspirin is not typically recommended for:
Adults age >70 years due to a potential risk of harm, including increased risk of bleeding.
Those age <40 years; there is insufficient evidence to judge the risk:benefit ratio of routine aspirin for the primary prevention of ASCVD in this age group
Goal
Reduction of CVD risk
Reassess the appropriateness of treatment at regular intervals, in case known risk factors for increased bleeding develop which may alter the risk:benefit assessment.
Consider treatment discontinuation at age 70 years; prophylactic aspirin in primary-prevention adults age >70 years is potentially harmful, and is not recommended on a routine basis.
Adults at high risk for ASCVD; without type 2 diabetes
≥20% 10-year ASCVD risk
With tobacco use or exposure
Intervention
Smoking cessation counseling ± pharmacotherapy
Advise all adults who use tobacco to quit; a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.
Advise all patients to avoid secondhand smoke exposure to reduce ASCVD risk.
See Smoking cessation.
Goal
Tobacco abstinence and avoidance of second hand smoke exposure; reduced overall risk of ASCVD
With overweight (BMI=25.0-29.9 kg/m²) or obesity (BMI ≥30 kg/m²)
Intervention
Counseling and comprehensive lifestyle interventions
Where feasible, refer patients for comprehensive lifestyle interventions as part of a structured program incorporating regular self-monitoring of food intake, physical activity and weight.
The ACC/AHA state that high intensity (≥14 sessions in 6 months) comprehensive weight-loss interventions provided by a trained interventionist work best. However, it is noted that other modalities, such as electronically delivered weight-loss programs with personalized feedback and some commercial-based programs, have also shown moderate results.
Consider whether to offer select patients, or refer for pharmacologic therapies and bariatric surgery, adjunctive to complementary lifestyle interventions.
It is recommended that BMI is interpreted with caution in people of Asian ancestry, older adults, and muscular adults.
See Obesity in adults.
Goal
Weight loss; reduced waist circumference; increased physical activity; reduced caloric intake; reduced overall risk of ASCVD
Weight loss:
The ACC/AHA define clinically meaningful weight loss as ≥5% initial weight
Waist circumference:
Definitions of elevated waist circumference are ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women
Physical activity:
Increased physical activity, preferably aerobic physical activity (eg, brisk walking) for ≥150 minutes/week (equal to ≥30 minutes/day on most days of the week), is recommended for initial weight loss
Higher levels of physical activity, approximately 200-300 minutes/week, are recommended to maintain weight loss or minimize weight regain after 1 year
Reduced caloric intake:
Caloric intake reduced by ≥500 kcal/day from baseline, which often can be attained by limiting women to 1200-1500 kcal/day and men to 1500-1800 kcal/day
A very-low-calorie diet (defined as <800 kcal/day) is recommended only in limited circumstances and only by trained clinicians in a medical care setting with the patient under medical supervision
With moderate or severe hypercholesterolemia
Intervention
Individualized management
A maximally- tolerated statin is recommended for all patients ages 20-75 years with severe primary hypercholesterolemia, regardless of estimated 10-year ASCVD risk.
For patients age >75 years, statins are not routinely recommended, but may be considered on a case-by-case basis depending on the individual risk status and potential for adverse effects.
Although statins are not routinely recommended in young adults ages 20-39 years, they may be considered in those with moderate hypercholesterolemia (LDL-C ≥160 mg/dL [≥4.1 mmol/L]) where there is a positive family history of premature ASCVD.
See Hypercholesterolemia.
Without severe primary hypercholesterolemia (LDL-C <190 mg/dL [<4.9 mmol/L]); ages 40-75 years
Intervention
High-intensity statin
For these patients, it is reasonable to use a high-intensity statin, following a risk discussion.
For patients age >75 years, statins are not routinely recommended; assessment of risk status and a clinician-patient risk discussion is needed to decide whether to continue or initiate statin treatment, taking into account statin safety and the potential for statin-associated adverse effects.
Goal
Reduction in LDL-C of 50% or more; reduced overall risk of ASCVD
With elevated blood pressure (120-129/<80 mmHg)
Intervention
Nonpharmacologic treatment to lower blood pressure
Recommend the following to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Goal
Blood pressure reduction; improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
Follow recommendations on blood pressure targets in line with published clinical guidance on management of hypertension.
With stage 1 (blood pressure130-139/80-89 mmHg) or stage 2 (blood pressure ≥140/90 mmHg) hypertension
Intervention
Nonpharmacologic treatment and medication to lower blood pressure
Recommend the following nonpharmacologic treatment to patients:
Weight loss
A heart-healthy dietary pattern
Sodium restriction
Dietary potassium supplementation
Increased physical activity with a structured exercise program
Limited alcohol intake
Offer antihypertensive medication in line with published clinical guidance on management of hypertension.
Goal
Blood pressure reduction (goal typically <130/80 mmHg); improved dietary habits; increased physical activity; reduced alcohol intake; reduced overall risk of ASCVD
Assess adherence to, and the impact of, nonpharmacologic treatment within 3-6 months.
Weight loss:
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Heart-healthy dietary pattern:
Aim for consumption of a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat.
Sodium restriction:
Optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults
Dietary potassium supplementation:
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium
Increased physical activity:
Aerobic exercise: aim for 90-150 minutes/week, 65% to 75% heart rate reserve
Dynamic resistance: aim for 90-150 minutes/week
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minute rest between exercises, 30% to 40% maximum voluntary contraction, three sessions/week for 8-10 weeks
Limited alcohol intake:
For people who consume alcohol, reduce consumption to ≤2 drinks daily (men) or ≤1 drink daily (women).
Blood pressure reduction:
For those requiring pharmacologic treatment for hypertension, including those with chronic kidney disease, a target blood pressure <130/80 mmHg is usually recommended.
With comprehensive evaluation suggestive of a favorable risk:benefit ratio for prophylactic aspirin; ages 40-70 years
Intervention
Consider low-dose aspirin
To balance the benefits and risks, low-dose aspirin is recommended only for select adults ages 40-70 years who are at higher ASCVD risk but not at increased bleeding risk, following shared decision making.
The ACC/AHH notes that prophylactic aspirin generally becomes more favorable for patients with >10% estimated 10-year ASCVD risk. This is an individualized decision:
Contemporary data show that absolute risk for ASCVD events typically exceeds that of bleeding and, although the gap of relative benefit to relative harm for aspirin has narrowed, the number needed to treat to prevent an ASCVD event remains lower than the number needed to cause harm (bleeding).
Some patients, in discussion with their clinician, may feel that the benefit of prophylactic aspirin is comparable to the risk and may instead choose to focus on optimal control of other modifiable ASCVD risk factors.
Consider risk enhancing factors ± coronary artery score, where available, as part of the risk:benefit analysis.
Prophylactic aspirin is not typically recommended for:
Adults age >70 years due to a potential risk of harm, including increased risk of bleeding
Those age <40 years; there is insufficient evidence to judge the risk:benefit ratio of routine aspirin for the primary prevention of ASCVD in this age group
Goal
Reduction of CVD risk
Reassess the appropriateness of treatment at regular intervals, in case known risk factors for increased bleeding develop which may alter the risk:benefit assessment.
Consider treatment discontinuation at age 70 years; prophylactic aspirin in primary-prevention adults age >70 years is potentially harmful, and is not recommended on a routine basis.
Secondary prevention
Patients with peripheral arterial disease (PAD) have significantly increased risk of cardiovascular mortality and morbidity, and it is crucial to modify their cardiovascular risk factors. All patients should have aggressive risk factor modification, regardless of their symptoms.[2] This should include: control of blood pressure; guideline-directed management for patients with diabetes; lipid-lowering therapy; cessation of smoking; dietary advice to reduce cardiovascular disease risk and control weight; and increased exercise.[1][2] Additionally, the presence of specific comorbidities and risk factors increases the risk for major adverse cardiovascular events and major adverse limb events in those with PAD. Multisociety US guidelines recommend that patients with PAD should be assessed for these risk amplifiers when developing patient-focused treatment recommendations.[2] These risk amplifiers include (in addition to hypertension, dyslipidemia, and diabetes) chronic kidney disease, depression, atherosclerotic disease in more than one vascular bed, microvascular disease (retinopathy, neuropathy, nephropathy), and older age and geriatric syndromes (frailty, mobility impairment, sarcopenia, malnutrition). Coordination of care across multispeciality teams is important for management of these patients.
Most patients with established peripheral arterial disease will benefit from preventive antiplatelet therapy. Although studies have investigated multiple agents (e.g., aspirin, clopidogrel, other antiplatelet agents, and low-dose anticoagulants [rivaroxaban]) alone and in combination, optimal therapy across the spectrum of disease (symptomatic or asymptomatic, pre- or post-intervention) remains uncertain.[108][110]
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