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New prevention guideline: Collaboration encouraged, aspirin downplayed
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NEW ORLEANS — The new prevention guideline from the American College of Cardiology and the American Heart Association emphasizes team-based care and shared decision-making and recommends against use of aspirin for primary prevention in most adults.
“For the clinician, this guideline is a one-stop shop,” writing committee member Amit Khera, MD, MSc, FACC, FAHA, professor of internal medicine and director of the UT Southwestern Preventive Cardiology Program, who holds the Dallas Heart Ball Chair in Hypertension and Heart Disease, told Cardiology Today. “This is very important because there are so many different guidances out there, and to have all of this in one place is great. It is also important to note that lifestyle is the foundation of this guideline. There are recommendations about exercise, nutrition, smoking cessation and other components that underpin risk factors.”
The guideline, unveiled at the ACC Scientific Session and simultaneously published in Circulation and the Journal of the American College of Cardiology, also encourages a focus on social determinants of health and endorses the use of SGLT2 inhibitors and GLP-1 receptor agonists for CVD prevention in certain patients with diabetes.
Collaboration emphasized
Cardiology Today Prevention Section Editor Roger S. Blumenthal, MD, director of the Ciccarone Center for the Prevention of Cardiovascular Disease and professor of medicine at Johns Hopkins Medicine and co-chair of the writing panel, told Cardiology Today “this is the first comprehensive prevention guideline that the ACC and AHA have ever put together. It is geared not only to clinicians in cardiology, but also in primary care, and we also believe it will be understood by the lay public.”
Donna K. Arnett, PhD, MSPH, FAHA, dean of the College of Public Health and professor of epidemiology at the University of Kentucky and past president of the AHA, who co-chaired the writing committee, said during a press conference that “we decided there are three themes that have to underlie all prevention. The first is that we need a team-based approach to care for risk factors for ASCVD. The second is that all decisions should be shared between the clinician and the patient as they are discussing the best strategies to reduce risk. Finally, we adopted the recommendation that social determinants of health should inform optimal implementation of treatments for the prevention of ASCVD.”
Focus on aspirin
Notably, aspirin is not recommended for primary prevention in most adults, and the panel based that decision in part on the results of the recent ARRIVE, ASCEND and ASPREE trials.
“It was felt that the balance favored taking aspirin in the past, but the new studies suggest that balance has tipped the other way,” Khera said at the press conference. “The risk for bleeding may be outweighing the benefit in the era of all of our modern preventive therapies.”
Because ASPREE, which was conducted mostly in adults aged 70 and older, was negative, the guideline recommends against aspirin for primary prevention in that age group, Khera said. He noted that there is also a contraindication in patients at high bleeding risk, but aspirin for primary prevention may be considered in in patients aged 40 to 70 years with high ASCVD risk and low bleeding risk.
Diabetes, smoking, diet
For patients with diabetes, Khera said, lifestyle interventions and metformin should be the first lines of therapy, but for those with elevated ASCVD risk who require further glucose-lowering therapies, it may be reasonable to prescribe an SGLT2 inhibitor or GLP-1 receptor antagonist, as both classes of drugs have shown CV benefits in outcome trials.
The guideline calls for clinicians to persistently monitor patient tobacco use in a manner that has not been outlined in previous recommendations, Arnett said. Clinicians are asked to assess every adult for tobacco use at every visit, firmly advise all tobacco users to quit, recommend behavioral interventions and pharmacotherapy to help with quitting and advise that smoking cessation reduces ASCVD risk.
In addition, she said, “it is reasonable to dedicate trained staff to tobacco treatment in every health care system.”
Dietary recommendations include emphasizing intake of vegetables, fruits, legumes, nuts, whole grains and fish to prevent ASCVD; replacing saturated fats with unsaturated fats; encouraging a diet with reduced sodium and cholesterol intake; and minimizing consumption of processed meats, refined carbohydrates and sweetened beverages.
Also, Arnett said, “for the first time, we have issued a recommendation of harm for the consumption of trans fats.”
Other notable recommendations
The guideline also advises clinicians to routinely counsel adults about maintaining a physically active lifestyle and minimizing sedentary behavior. For patients with obesity, clinicians should advise weight loss, recommend appropriate dietary regimens, calculate BMI routinely and, when warranted, measure waist circumference to identify patients at elevated CVD risk, according to the guideline.
Many of the prevention and risk management principles from the recent hypertension and cholesterol guidelines are restated and consolidated in the new guideline. For example, clinicians should routinely assess CVD risk factors and calculate 10-year CVD risk using the Pooled Cohort Equation in patients aged 40 to 75 years, while assessing traditional risk factors periodically in patients aged 20 to 39 years, the authors wrote.
Genetic risk scores are not included in the guideline, however.
“We considered that, but we think that right now, the risk-enhancing factors from the cholesterol guideline can help you decide if you need statin therapy earlier, and if you are still uncertain, the data from a $75 to $100 coronary artery calcium scan in the committee’s mind is still far stronger than genetic risk scores,” Blumenthal said. “That’s not to say that a year or two from now, the data from genetic risk scores won’t be as good.”
– by Erik Swain
References:
Arnett DK, et al. All You Needed to Know About Cardiovascular Disease Prevention Guidelines; Well — Almost All. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Arnett DK, et al. Circulation. 2019;doi: 10.1161/CIR.0000000000000678.
Arnett DK, et al. J Am Coll Cardiol. 2019;doi:10.1016/j.jacc.2019.03.016.
Disclosures: Arnett, Blumenthal and Khera report no relevant financial disclosures.
Perspective
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Eduardo J. Sanchez , MD, MPH
The single top message from this guideline is that a healthy lifestyle is essential for the prevention of CVD and stroke. These factors are crucial regardless of one’s state of health. Also important is that in clinical settings, this notion of team-based care, shared decision-making and assessing social determinants of health can help deliver the clinical guidelines in a way that takes into account the context of the patient’s life and uses the team that already exists to optimally effect change in individuals.
The emphasis on tobacco is very important. It is still the single leading preventable cause of death in the U.S. The recommendation to use aspirin sparingly in 40-to-70-year-old adults based on higher ASCVD risk and low bleeding risk and to not use it in persons over 70 years for primary prevention is also going to change practice.
Perspective
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Steven E. Nissen, MD, MACC
There is not much new material in this guideline, which mostly reinforces the recent prevention guidelines. Many of the key messages are not controversial: People should eat a healthy diet, exercise regularly and not smoke. Controversial issues such as the keto diet are not directly addressed. There is appropriate support for the Mediterranean diet, which is evidence-based. I have some concerns with the sodium recommendations because there are mixed data on the risks of salt in people without hypertension. It’s also not clear if all saturated fats are the same. Saturated fats that come from meat sources may represent a different level of risk than those that are naturally occurring from vegetable sources, but that issue is not directly addressed in the guidelines.
The emphasis on healthy lifestyle is appropriate and appreciated, but, the reality is, most Americans don’t necessarily follow healthy lifestyles, so I would have hoped for a bit more acknowledgement that there are significant numbers of people who have never had a heart-related event that need to be treated with cholesterol-lowering drugs.
I strongly support the advocacy of shared decision-making. In all areas of medicine, it is usually advisable to sit down with a patient, tell them what we know and don’t know, and then together make a decision about whether they should be treated with a medication. That is very sound advice.
For the last 15 years, I have been convinced that aspirin should not be used in primary prevention unless the patient is very high risk. Unfortunately, most of the people taking it are the “worried well.” I am glad this problem has now been acknowledged by the guidelines. Many more people are taking aspirin than should be.
In the new guidelines, there is an interesting shift: the authors acknowledge that the Pooled Cohort Equation can overestimate or underestimate risk in some populations. When it was introduced in 2013, many of us were critical because the risk calculator had not been verified or published prior to appearing time in a guideline for more than 300 million Americans. It has taken 6 years to acknowledge that maybe there are some issues with the risk calculator. I’m glad this has been acknowledged, because I have worried that people could be undertreated or overtreated based on a risk calculator that had not been fully verified at the time it was released.
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