New Guidelines Rethink Cardiovascular Risks

Prevention guidelines focused on assessment of cardiovascular (CV) risk, lifestyle modifications to reduce CV risk, and management of elevated blood cholesterol and body weight in adults have been released by the American College of Cardiology and the American Heart Association. They worked in collaboration with the National Heart, Lung, and Blood Institute and other organizations.

Each of the 4 prevention guidelines provides updated guidance for primary care physicians and other health care professionals on how best to manage the care of patients who are at risk for CV-related diseases.

A fifth guideline that addresses hypertension will be initiated early next year.

The Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults focuses on the use of statins for primary and secondary prevention of atherosclerotic CV disease (ASCVD) in higher-risk patients. Statin therapy is recommended for patients at increased risk for ASCVD who are most likely to experience a net benefit in the potential to reduce these events versus the potential for adverse effects. The use of statins to prevent nonfatal and fatal ASCVD events also is suggested. There is no evidence to support continued use of specific LDL-C and non–high-density lipoprotein cholesterol treatment targets, according to the guideline.

The Guideline for the Management of Overweight and Obese Adults addresses the appropriateness of the body mass index and waist circumference cutpoints used to determine risk in overweight and obese adults across diverse populations. It also examines the impact of weight loss on risk factors for CV disease and type 2 diabetes mellitus, optimal behavioral and dietary intervention strategies, lifestyle treatment approaches for weight loss and weight loss maintenance, and the benefits and risks of various bariatric surgical procedures. The information is designed help physicians decide who should be recommended for weight loss and what improvements may be expected.

The Guideline for Lifestyle Management to Reduce Cardiovascular Risk provides updates to dietary and physical activity recommendations for adult patients who have high LDL-C levels or hypertension. In addition to a focus on aerobic exercise and a diet high in vegetables, fruits, and whole grains, the recommendations for lowering both LDL-C and blood pressure include an upper limit of 2400 mg/d of sodium for treating patients with hypertension.

The Guideline for the Assessment of Cardiovascular Risk is designed to offer a new approach with additional benefits, such as the ability to estimate risk for a more broadly based ASCVD outcome that is more relevant to contemporary populations, especially women and African Americans, and to provide risk estimates specific to African Americans.

The authors of a “Journal Scan Summary” presented the following as key features of the new guidelines:

• The guidelines endorsed the existing paradigm of matching the intensity of preventive efforts with the individual patient’s absolute risk and recognized that none of the risk assessment tools or novel risk markers examined or recommended has been evaluated formally in randomized controlled trials of screening strategies with clinical events as outcomes.

• New Pooled Cohort Equations were established for estimating the 10-year risk of ASCVD (the risk of a first ASCVD event, such as nonfatal myocardial infarction or coronary heart disease death).

• Risk estimation is based on group averages that are then applied to individual patients in practice to target treatment to those most likely to benefit without undue risk for harm, in the context of a “risk discussion” that might include assessment of the patient’s risk for ASCVD and potential benefits, negative aspects, risks, and patient preferences about initiation of relevant preventive therapies.

• If a risk-based treatment decision is uncertain, assessment of family history, high-sensitivity C-reactive protein level, coronary artery calcium score, and ankle-brachial index may be considered to inform treatment decision making.

• The contribution to risk assessment for a first ASCVD event using apolipoprotein B, chronic kidney disease, albuminuria, and cardiorespiratory fitness is uncertain. Carotid intima-media thickness is not recommended for routine measurement in clinical practice for such risk assessment.