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.
Primary CVD prevention is aimed at the healthy population, individuals who have several CV risk factors or 1 CV risk factor at a very high level, and individuals whose risk for a CV event is high. Secondary CVD prevention is aimed at individuals with confirmed CVD.

Management of Other Risk Factors

Blood Pressure (BP) Control

  • Goal1: BP <130/80 mmHg including patients with DM and chronic kidney disease
    • BP may be reduced to <130/80 mmHg in individuals ≥65 years old (ambulatory, noninstitutionalized and community-dwelling) who have an average BP of ≥ 130/80 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, supplementing with dietary potassium (3.5-5 g/day), limiting alcohol intake, 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
    • Initiation of drug therapy is recommended for patients with a BP of ≥130/80 mmHg and ≥10% estimated 10-year ASCVD risk, and those with a BP of ≥140/90 mmHg and <10% estimated 10-year ASCVD risk
  • See Hypertension Disease Management Chart for details

1Recommendations for BP treatment goals may vary between countries. Please refer to available guidelines from local health authorities. 

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 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 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 ASCVD unless contraindicated
      • Initiation of statin therapy is recommended for patients 40-75 years with LDL-C of 70-189 mg/dL without clinical ASCVD or DM, and in patients ≥21 years of age with primary LDL-C ≥190 mg/dL, and in patients 40-75 years with DM
    • Fibrates have not been found to reduce 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
  • 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 and microvascular diseases
  • Treatment of DM is always recommended regardless of the overall risk of vascular disease
  • Start appropriate therapy to achieve near-normal fasting plasma glucose (<7 mmol/L) or as indicated by near-normal HbA1c, starting with a healthy diet and exercise
  • 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
    • To reduce the risk of hypoglycemia, individualize glycemic goals based on patient’s profile
  • Lifestyle modification with blood pressure and lipid management are recommended in all diabetic patients
    • If lifestyle modification fails, oral antidiabetic medications, preferably Metformin followed by consideration of a sodium-glucose co-transporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist, or Insulin should be added to the treatment regimen
  • 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
  • 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
  • Goal is 5-10% weight loss in 6 months and weight maintained within 2 years  
  • 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 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 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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