The choices we make every day can have a lasting effect on our heart and vascular health. Adopting a heart healthy eating plan, getting more exercise, avoiding tobacco and managing known risk factors are among the key recommendations in the 2019 Primary Prevention of Cardiovascular Disease guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA). Also, it is recommended that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease.
The guideline, presented at ACC’s 68th Annual Scientific Session, offers comprehensive but practical recommendations for preventing cardiovascular disease, which remains the leading cause of death for both men and women in the US. Nearly 1 out of 3 deaths in the US is due to cardiovascular disease.
“The most important way to prevent cardiovascular disease, whether it’s a build-up of plaque in the arteries, heart attack, stroke, heart failure or issues with how the heart contracts and pumps blood to the rest of the body, is by adopting heart healthy habits and to do so over one’s lifetime,” said Dr Roger S Blumenthal, co-chair of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease and the Kenneth Jay Pollin professor of cardiology at Johns Hopkins Medicine. “More than 80% of all cardiovascular events are preventable through lifestyle changes, yet we often fall short in terms of implementing these strategies and controlling other risk factors.”
The new prevention guideline, he said, is intended to provide a roadmap of strategies that can be used and tailored to help people without a history of heart disease stay heart healthy and, importantly, emphasise the need to identify and address personal or social barriers for doing so (income and education levels, cost concerns, lack of health insurance, access to healthy foods or safe places to exercise, life stressors).
According to the guideline, any effort to prevent a first instance of cardiovascular disease (called primary prevention) should ideally start with a thorough assessment of one’s risk – that is, estimating how likely someone is to develop blockages in their arteries and have a heart attack or stroke or die as a result. All patients should openly talk with their care team about their current health habits and personal risk for cardiovascular disease and, together, determine the best way to prevent it based on current evidence and personal preferences.
“We have good evidence now for how to identify these very high-risk individuals with a physical exam and a good history, and for those at borderline risk there are additional factors that can help us determine who is at greater risk and should, for example, be on a medication like a statin earlier to prevent a cardiovascular event,” Blumenthal said. “In the past, a lot of people may have had a fatalistic attitude that they were going to develop heart problems sooner or later but, in reality, most cardiovascular events can be prevented.”
The document synthesises the best data and proven interventions for improving diet and exercise, tobacco cessation and optimally controlling other factors that affect one’s likelihood of heart problems and stroke (obesity, diabetes, high cholesterol and high blood pressure). The document also discusses the challenges that may interfere with individuals being able to integrate better lifestyle habits.
The guideline underscores healthy lifestyle changes as the cornerstone of preventing heart disease and goes a step further by providing practical advice based on the latest research.
“We can all do better with our dietary and exercise habits, and that’s so important when we think about wanting to live longer and healthier lives, whether it’s to see our grandchildren grow up or to stay as active as possible in older age,” Blumenthal said.
Some of the key lifestyle recommendations include: eating heart healthier – choosing more vegetables, fruits, legumes, nuts, whole grains, and fish, and limiting salt, saturated fats, fried foods, processed meats, and sweetened beverages; specific eating plans like the Mediterranean, DASH and vegetarian diets are reviewed; engaging in regular exercise – experts advise aiming for at least 150 minutes of moderate-intensity exercises such as brisk walking, swimming, dancing or cycling each week. For people who are inactive, some activity is better than none and small 10-minute bursts of activity throughout the day can add up for those with hectic schedules. Currently, only half of American adults are getting enough exercise and prolonged periods of sitting can counteract the benefits of exercise; aiming for and keeping a healthy weight – for people who are overweight or obese, losing just 5% to 10% of their body weight (that would be 10-20 pounds for someone who weighs 200 pounds) can markedly cut their risk of heart disease, stroke and other health issues; and avoiding tobacco by not smoking, vaping or breathing in smoke – 1 in 3 deaths from heart disease is attributable to smoking or exposure to second-hand smoke, so every effort to try to quit through counselling and/or approved cessation medications should be supported and tailored to each individual.
For people who’ve had a heart attack, stroke, open heart surgery or stents placed to open clogged arteries, aspirin can be lifesaving. But regular use of aspirin to prevent heart attacks and stroke in healthy people isn’t as clear-cut.
In this guideline, ACC/ AHA experts offer science-based guidance that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. Recent research suggests that the chance of bleeding, given – the blood-thinning effect of aspirin, may be too high and the evidence of benefit – the number of heart attacks or strokes that are actually prevented – is not sufficient enough to make a daily aspirin worth taking for most adults in this setting.
“Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease,” Blumenthal said. “It’s much more important to optimise lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin. Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”
Based on a simplified synopsis of the latest ACC/AHA cholesterol guideline, for primary prevention, statins should be commonly recommended with lifestyle changes to prevent cardiovascular disease among people with elevated low-density lipoprotein (LDL) cholesterol levels (190 mg/dl), type 2 diabetes, and anyone who is deemed to have a high likelihood of having a stroke or heart attack upon reviewing their medical history and risk factors and having a detailed discussion with their clinician.
For people with type 2 diabetes, which is one of the strongest risk factors for cardiovascular disease, there are new data that two classes of diabetes medications, which work to lower blood sugar levels, can also cut the risk of heart attack, stroke and related deaths.
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association.
This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the American Heart Association Executive Committee in February 2019.
Donna K Arnett, Roger S Blumenthal, Michelle A Albert, Erin D Michos, Andrew B Buroker, Michael D Miedema, Zachary D Goldberger, Daniel Muñoz, Ellen J Hahn, Sidney C Smith, Cheryl D Himmelfarb, Salim S Virani, Amit Khera, Kim A Williams, Donald Lloyd-Jones, Joseph Yeboah, William McEvoy, Boback Ziaeian, Patrick T O’Gara, Joshua A Beckman, Glenn N Levine, Sana M Al-Khatib, Mark A Hlatky, Kim K Birtcher, John Ikonomidis, Joaquin E Cigarroa, José Joglar, Anita Deswal, Laura Mauri, Lee A Fleisher, Mariann R Piano, Federico Gentile, Barbara Riegel, Zachary Goldberger, Duminda N Wijeysundera