Prevention of cardiovascular disease: highlights for the clinician of the 2013 American College of Cardiology/American Heart Association guidelines

Abstract

Prevention of cardiovascular disease, undoubtedly an emphasis of clinical care in 2014, will provide both opportunities and challenges to patients and their healthcare providers. The recently-released ACC/AHA guidelines on assessment of cardiovascular risk, lifestyle management to reduce cardiovascular risk, management of overweight and obesity, and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk, have introduced new concepts and revised prior conventional strategies. New to risk assessment are the Pooled Cohort Equations, targeting the expanded concept of atherosclerotic cardiovascular disease (ASCVD) and focusing not solely on mortality but as well on major nonfatal events. The lifestyle management focuses on diet and physical activity for lipid and blood pressure control. The cholesterol guideline identifies four high-risk groups with the greatest benefits from statin therapy: preexisting ASCVD, primary LDL-C elevations ≥ 190 mm/dl, those 45-75 years with diabetes and LDL-C 70-189 mm/dl without clinical ASCVD, and those 40-75 years without clinical ASCVD with an LDL-C 70-189 mg/dl with a 7.5% or greater 10-year ASCVD risk. Eliminated are arbitrary LDL-C treatment targets, with individual patient risk status guiding who should take statins and the appropriate intensity of statin drugs. Patient-physician discussions of individual benefits and risks are paramount. Management of high blood pressure remains controversial, with two different expert panels offering varying treatment targets; there is general agreement on a <140/90 mmHg goal, but substantial disagreement on blood pressure targets for older adults. Clinicians and their patients deserve a well-researched concensus document.

Figure 1

Applying classification of recommendation and level of evidence. *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with level of evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. †For comparative effectiveness recommendations (class I and IIa, level of evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. Reproduced with permission from Goff et al.2

Figure 2

Eighth Joint National Committee (JNC8) grading system for quality of evidence and strength of recommendations. Reproduced with permission from James et al.7

Figure 3

Evidence for major recommendations for statin therapy for atherosclerotic cardiovascular disease (ASCVD) prevention. Reproduced with permission from Stone et al.5

Figure 4

Initiating statin therapy in individuals without clinical ASCVD. Reproduced with permission from Stone et al.5

Figure 5

Lifestyle modifications. Reproduced with permission from Go et al.6

Figure 6

Hypertension treatment algorithm. Abbreviations: ACEI, angiotensin‐converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker; CKD, chronic kidney disease; DBP, diastolic blood pressure; SDP, systolic blood pressure. Reproduced with permission from James et al.7