cardiovascular%20disease%20prevention
CARDIOVASCULAR DISEASE PREVENTION
Patients 18 years old and above should receive a risk factor assessment for cardiovascular disease (CVD) at every routine physician visit.
Cardiovascular disease development is closely related to lifestyle characteristics and associated risk factors.
There is an overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a cardiovascular event.
Very high-risk group refers to patients with documented CVD, by invasive or non-invasive testing, and with presence of risk factors.
High-risk patients are those who have already experienced a cardiovascular event or have very high levels of individual risk factors.
Moderate-risk patients require monitoring of risk profile every 6-12 months.
Low-risk patients may be given conservative management, focusing on lifestyle interventions.

Management of Other Risk Factors

Blood Pressure (BP) Control

  • Goal: BP <140/90 mmHg; <130/80 in patients with diabetes mellitus (DM) and chronic kidney disease
    • SBP may be reduced to between 150 and 140 mmHg in patients >60 years with SBP >160 mmHg or in patients >80 years in good physical and mental condition with SBP >160 mmHg
  • BP should be recorded at each visit
    • Start lifestyle modification in all patients: Weight reduction, eating fruits, vegetables and low-fat dairy products, reducing salt intake, drinking alcohol moderately, and increasing physical activity
    • If BP goals are not achieved with lifestyle modifications, start drug therapy individualized for each patient, considering age, race or need for drugs with specific benefits
    • Patients with grade 3 hypertension regardless of cardiovascular risk or grade 1 or 2 hypertension with very high cardiovascular risk are recommended to have drug therapy
  • See Hypertension Disease Management Chart for details

Lipid Management

  • Reduction of plasma TC by 10% decreased the incidence of coronary artery disease (CAD) by 25% after 5 years, and a reduction of LDL-C by 1 mmol/L (40 mg/dL) was accompanied by 20% reduction in coronary heart disease (CHD) events
  • Goal for LDL-C based on risk groups:
    • Low risk <130 mg/dL
    • Moderate-high risk <100 mg/dL
    • Very high risk <70 mg/dL
    • Extreme risk <55 mg/dL
  • General goal:
    • TC <200 mg/dL,
    • HDL-C as high as possible but at least >40 mg/dL in men and >45 mg/dL in women,
    • TG  <150 mg/dL
      • If TG is ≥200 mg/dL, non-HDL-C should be <130 mg/dL or <100 mg/dL for very high-risk individuals
    • Apolipoprotein B <90 mg/dL in high-risk patients, <80 mg/dL in very high-risk patients with established atherosclerotic cardiovascular disease (ASCVD) or DM with ≥1 additional risk factor, and <70 mg/dL in extreme risk patients
  • Therapeutic lifestyle changes should be advised to all patients above the goal range
  • Stress the importance of smoking cessation, weight reduction and physical activity
  • Lipid-lowering therapy may be initiated
    • Secondary causes of dyslipidemia (such as hypothyroidism, alcohol abuse, Cushing’s syndrome, diseases of liver and kidneys) should be ruled out before initiating therapy
    • Statins are usually used in both primary and secondary CVD events in high-risk patients
      • First-line therapy in patients ≥75 years old with clinical atherosclerotic CVD unless contraindicated
    • Fibrates have not been found to reduce cardiovascular (CV) events but may be used in the treatment of severe hypertriglyceridemia
    • Individuals with TG >500 mg/dL should be started with fibrate in addition to statin to prevent acute pancreatitis
    • Initiation of statin therapy is recommended for patients 40-75 years with LDL-C of 70-189 mg/dL without clinical atherosclerotic CVD or DM, and in patients ≥21 years of age with primary LDL-C ≥190 mg/dL, and in patients 40-75 years with DM
  • See Dyslipidemia Disease Management Chart for more details

Diabetes Management

  • Diabetic patients (type 1 or type 2) are at increased risk for CVD and have worse outcomes after surviving a cardiovascular disease event
  • Good glycemic control substantially reduces the risk of cardiovascular events
  • Treatment of DM is always recommended regardless of the overall risk of vascular disease
  • The goal, in general, is HbA1c <7% (<53 mmol/mol) for both type 1 and 2 DM, but since HbA1c may vary with patients’ ethnicity/race, values must be individualized
    • A HbA1c goal of ≤6.5% (≥48 mmol/mol) should be considered in type 2 DM patients with good health status and without CVD
  • Start appropriate therapy to achieve near-normal fasting plasma glucose (<7 mmol/L) or as indicated by near-normal HbA1c, starting with diet and exercise
  • Lipid-lowering drugs are recommended for all type 2 DM patients and for type 1 DM patients >40 years old
    • May be considered in patients <40 years at high risk, with multiple risk factors and microvascular complications
  • Lifestyle modification with blood pressure and lipid management are recommended in all diabetic patients
    • If lifestyle modification fails, oral antidiabetic medications, preferably Metformin, or insulin should be added to the treatment regimen
  • See Diabetes Mellitus Disease Management Chart for more details

Obesity/Overweight Management

  • Weight loss is indicated for patients with a BMI of >30 or 25-29.9 with risk factors (eg DM, prediabetes, hypertension, dyslipidemia, waistline >35 inches for women/>40 inches in men) or obesity-associated comorbidities
  • Lifestyle modifications (diet modification, increased physical activity, weight management) are recommended in all obese/overweight patients
  • Comprehensive lifestyle intervention is recommended if no weight loss is seen with lifestyle modifications
  • Addition of pharmacological therapy is recommended if patient continues to gain weight or is unable to lose weight even with comprehensive lifestyle interventions
  • May refer patients for bariatric surgery if all interventions fail and patient has a BMI ≥40 kg/m2 or BMI ≥35 kg/ mwith comorbidities
  • See Obesity Disease Management Chart for more details

Cardiac Rehabilitation

  • Comprehensive outpatient cardiovascular rehabilitation program is recommended in patients with acute coronary syndrome (ACS), chronic angina, post coronary artery bypass surgery (CABG) or post percutaneous coronary intervention

Depression Management

  • Screening for depression is advisable in patients with recent CABG or myocardial infarction (MI)
  • Management of depression has not been shown to improve cardiovascular disease prognosis but may be advisable for its other clinical effects

Prevention

Vaccination

  • Patients with CVD or other atherosclerotic vascular disease [such as peripheral artery disease (PAD), CAD] should have an annual influenza vaccination
  • Some studies support the association of pneumococcal pneumonia and the development of concurrent acute cardiac events [eg MI, arrhythmia, new or worsening of congestive heart failure (CHF)], hence they recommend pneumococcal vaccination in high-risk populations
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