Cardiovascular%20disease%20prevention Management

Blood Pressure (BP) Control

• Goal¹: BP <140/90 mmHg in all patients, though BP targets should be individualized
  • Target SBP range to <130-139 mmHg in individuals ≥65 years old 
  • DBP <80 mmHg is recommended in all treated patients
• 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, CVD risk, or presence of hypertension-mediated organ damage
• ACE inhibitors and ARBs as well as calcium channel blockers, thiazide or thiazide-like diuretics and, for certain indications, beta-blockers are commonly used in the treatment of CV disorders, eg hypertension, coronary artery disease (CAD) and congestive heart failure 
  • Risk of COVID-19 infection or risk of developing severe COVID-19 complications is not increased with prior or current treatment with ACE inhibitors or ARBs thus treatment should be continued as prescribed
• Please see Hypertension disease management chart for further information

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 CAD by 25% after 5 years, and a reduction of LDL-C by 40 mg/dL (1 mmol/L) was accompanied by 20% reduction in CHD events
• Goal for LDL-C based on risk groups:
  • Low risk <116 mg/dL (<3 mmol/L)
  • Moderate risk <100 mg/dL (<2.6 mmol/L) 
  • High risk <70 mg/dL (<1.8 mmol/L)
  • Very high risk <55 mg/dL (<1.4 mmol/L)
  • If LDL-C goals based on risk groups cannot be achieved, aim to decrease LDL-C by ≥50% from baseline and reduce other risk factors
• General goal:
  • TC <200 mg/dL (<5.18 mmol/L)
  • HDL-C as high as possible but at least >40 mg/dL in men (>1.0 mmol/L) and >45 mg/dL (>1.2 mmol/L) in women
  • TG <150 mg/dL (<1.69 mmol/L)
    • If TG is ≥200 mg/dL (≥2.26 mmol/L), non-HDL-C should be <130 mg/dL (<3.37 mmol/L) or <100 mg/dL (<2.59 mmol/L) 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 drugs of choice in high-risk patients with hypertriglyceridemia for decreasing CVD risk  
    • Initiation of statin therapy is recommended for patients 40-75 years with LDL-C of 70-189 mg/dL without clinical ASCVD or DM, patients ≥21 years of age with primary LDL-C ≥190 mg/dL, and patients 40-75 years with DM
    • May be considered for primary prevention in patients ≥70 years old if at high risk or above
    • First-line therapy in patients ≥75 years old with clinical ASCVD unless contraindicated
  • 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
• Current evidence shows that lipid-lowering therapy is safe in patients with COVID-19 infection 
  • Lipid-lowering therapy should be continued in patients with confirmed COVID-19 diagnosis and abnormal liver function tests (LFTs) unless alanine transaminase (ALT) or aspartate transaminase (AST) progressively increases, a significant drug-drug interaction between the lipid-lowering agents and COVID-19 drugs has been identified, or patient is critically ill and/or cannot take oral medications   
  • Bile acid sequestrants and Niacin may be temporarily discontinued in patients with COVID-19 infection due to the lack of evidence of CV outcome data 
• Please see Dyslipidemia disease management chart for further information

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 ASCVD
  • To reduce the risk of hypoglycemia, individualize glycemic goals based on patient’s profile
• Lifestyle modification with BP 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 linked transporter/co-transporter 2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-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
• Patients with diabetes require strict blood glucose monitoring and prevention of diabetes complications during the COVID-19 pandemic in order to keep their susceptibility low and to prevent severe COVID-19 disease courses 
  • According to the 2023 American Diabetes Association guidelines, there is no clear indication to modify prescribing of antidiabetic medications in patients with diabetes and COVID-19 disease   
• Please see Diabetes Mellitus disease management chart for further information

Obesity/Overweight Management

• Weight loss is indicated for patients with WHO BMI of >30 kg/m² or 25-29.9 kg/m² with risk factors (eg DM, prediabetes, hypertension, dyslipidemia, waistline >88 cm for women/>102 cm 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
• Preventive measures including lifestyle modifications decrease the risk of cardiometabolic diseases which in turn reduce the risk of severe COVID-19 infection 
• 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/m² with comorbidities
• Please see Obesity disease management chart for further information

Cardiac Rehabilitation

• Comprehensive outpatient CV rehabilitation program is recommended in patients with acute coronary syndrome, chronic angina, post coronary artery bypass surgery (CABG) or post percutaneous coronary intervention
  • It is recommended for patients after ASCVD events and/or revascularization and those with heart failure (particularly heart failure with reduced ejection fraction) to have an exercise-based cardiac rehabilitation and prevention program to improve patient outcomes 

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

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
• Influenza and pneumococcal vaccinations are important in decreasing the risk of respiratory infection and subsequent complications in patients with CVD during the COVID-19 pandemic
• All CVD patients are encouraged to receive COVID-19 vaccination as the risk of severe COVID-19 infection is high