ACC-AHA 2019 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.7 | I | B-NR | Downloaded from http://ahajournals.org by on October 7, 2026 screening tool to assess 5 domains of non–healthrelated measures that affect health outcomes: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety.S2.1-29 ASCVD prevention could benefit from such screening. ASCVD risk begins early in life, with heightened susceptibility tied to low socioeconomic status.S2.1-25 Examples of upstream social determinants of health that affect treatment adherence and ASCVD health outcomes include comorbid mental illness, lack of health literacy, exposure to adversity (eg, home/community violence, trauma exposures, safety concerns), financial strain, inadequate housing conditions, lack of food security (ie, access to affordable and nutritious food), and inadequate social support.S2.1-30 Systems of care should evaluate social determinants of health that affect care delivery for the primary prevention of ASCVD (eg, transportation barriers, the availability of health services). | |
| p.7 | IIa | B-NR | Important considerations related to socioeconomic disadvantage are not captured by existing CVD risk equations.S2.1-31 Addressing unmet social needs improves management of BP and lipids,S2.1-32 which highlights the importance of dietary counseling and encouraging physical activity.S2.1-19 More time may be required to address ASCVD prevention with adults of low health literacy or disadvantaged educational backgrounds. | |
| p.7 | IIa | B-NR | Differential cardiovascular outcomes persist by important sociodemographic characteristics that | |
| p.10 | IIa | B-NR | been shown to be associated with the likelihood of benefit from statin therapy for ASCVD risk reduction.S2.2-71 Coronary artery calcium scoring has superior discrimination and risk reclassification as compared with other subclinical imaging markers or biomarkers.S2.2-22,S2.2-27 In the MESA (Multi- Ethnic Study of Atherosclerosis) trial, the coronary artery calcium score was strongly associated with 10-year ASCVD risk in a graded manner across age, sex, and racial/ethnic groups, independent of traditional risk factors.S2.2-17 Coronary artery calcium may even refine ASCVD risk estimates among lower-risk women (<7.5% 10-year risk),S2.2-7 younger adults (<45 years of age),S2.2-20 and older adults (≥75 years of age),S2.2-26 but more data are needed to support its use in these subgroups. A coronary artery calcium score of zero identifies individuals at lower risk of ASCVD events and death over a ≥10-year period,S2.2-15,S2.2-17,S2.2-25 who appear to derive little or no benefit from statins for ASCVD risk reduction.S2.2-71 Thus, the absence of coronary artery calcium could reclassify a patient downward into a lower risk group in which preventive interventions (eg, statins) could be postponed.S2.2-22 Note that the absence of coronary artery calcium does not rule out noncalcified plaque, and clinical judgment about risk should prevail. Coronary artery calcium might also be considered in refining risk for selected low-risk adults (<5% 10-year risk), such as those with a strong family history of premature coronary heart disease (CHD).S2.2-23 MESAS2.2-28 and Astro-CHARM (Astronaut Cardiovascular Health and Risk Modification)S2.2-29 are risk estimation tools that incorporate both risk factors and coronary artery calcium for estimating 10-year CHD and ASCVD risk, respectively. Coronary artery calcium measurement is not intended as a “screening” test for all but rather may be used as a decision aid in select adults to facilitate the clinician–patient risk discussion. 5. For adults 20 to 39 years of age (who are not included in the PCE) and those 40 to 59 years of age who are not already at elevated (≥7.5%) 10-year risk, estimating a lifetime or 30-year risk of ASCVD may be considered (ASCVD Risk Estimator).S2.2-2 Younger individuals often have low estimated 10-year risk, but the presence of at least 1 major risk factor by middle age is associated with increased lifetime ASCVD risk and reduced survival free of morbidity compared with those with optimal risk factors.S2.2-32–S2.2-34 Calculation of lifetime risk with the ACC/AHA 30-year/lifetime risk estimator for those 20 to 59 years of age (not at high short-term risk) may be reasonable to consider as a communication strategy for reinforcing adherence to lifestyle recommendations.S2.2-2 Downloaded from http://ahajournals.org by on October 7, 2026 | |
| p.12 | I | B-R | Downloaded from http://ahajournals.org by on October 7, 2026 | |
| p.14 | IIa | B-NR | Downloaded from http://ahajournals.org by on October 7, 2026 | |
| p.15 | I | A | circumference, waist–hip ratio, bioimpedance, and dual-energy X-ray absorptiometry (DXA).S4.1-18 BMI, waist circumference, and waist–hip ratio are easily measured and therefore are the most widely used in clinical practice. A USPSTF document found good evidence supporting the use of BMI to identify adults at increased risk of future morbidity and mortality.S4.1-18 Because obesity/overweight defined by BMI is the most studied and standardized approach, we recommend its measurement for primary screening of individuals needing weight loss. BMI should be interpreted with caution in persons of Asian ancestry, older adults, and muscular adults.S4.1-19,S4.1-20 CLINICAL STATEMENTS AND GUIDELINES | |
| p.15 | IIb | B-R | 4 Increased waist circumference has been associ- ated with increased cardiometabolic and ASCVD risk.S4.1-3–S4.1-6 Central adiposity, captured by using waist circumference, has been associated with ASCVD risk and may be missed when BMI is used as the only measure of obesity.S4.1-21,S4.1-22 Waist circumference measurement is recommended in all patients with BMI <35 kg/m2.S4.1-9,S4.1-19,S4.1-23 Ethnic differences in waist circumference thresholds associated with cardiometabolic risk have been reported. Waist circumference may be more useful than BMI in persons with abdominal obesity (central adiposity).S4.1-24 Definitions of elevated waist circumference as ≥40 inches (≥102 cm) in men and ≥35 inches (≥88 cm) in women were recommended by the 1998 National Heart, Lung, and Blood Institute Obesity Initiative Expert PanelS4.1-25 and were adopted by the 2013 AHA/ACC/TOS writing committee.S4.1-1 Furthermore, waist circumference assessment is needed for the diagnosis of metabolic syndrome. Thus, combining waist circumference and BMI may be the best approach for assessing obesity-related risk. Counseling and comprehensive lifestyle interventions, including calorie restriction and adjunctive therapies (eg, FDA–approved drugs, bariatric surgery), have all been associated with significant reductions in waist circumference and improvement in cardiometabolic risk profiles.S4.1-1 Downloaded from http://ahajournals.org by on October 7, 2026 | |
| p.17 | I | A | CLINICAL STATEMENTS AND GUIDELINES | |
| p.17 | I | A | leading to a reduction in hyperglycemia in adults with T2DM. In a substudy of the UKPDS (United Kingdom Prospective Diabetes Study), metformin, compared with conventional therapy (ie, lifestyle modifications alone), resulted in a 32% reduction in microvascular and macrovascular diabetesrelated outcomes, a 39% reduction in MI, and a 36% reduction in all-cause mortality rate.S4.2-5 A 2016 systematic review and meta-analysis of glucose-lowering therapies for T2DM supported the use of metformin as first-line therapy for T2DM because of its beneficial effects on HbA1c, weight, and improved ASCVD outcomes (compared with sulfonylureas), as well as its acceptable safety profile and low cost. However, a separate systematic review found no evidence of reduced CVD events or CVD deaths with metformin.S4.2-8 Metformin carries a small risk of lactic acidosis and must be used with caution in patients with CKD. For younger individuals or those with a mildly elevated HbA1c at the time of diagnosis of T2DM, clinicians can consider a trial of lifestyle therapies for 3 to 6 months before reconsideration of metformin. 4. Several classes of medications have been shown to effectively lower blood glucose but may or may not affect ASCVD risk.S4.2-23–S4.2-26 However, 2 classes of glucose-lowering medications have recently been demonstrated to reduce CVD events in adults with T2DM and high ASCVD risk. SGLT-2 inhibitors act in the proximal tubule to increase urinary excretion of glucose and sodium, leading to a reduction in HbA1c, body weight, and BP. Three RCTs have shown a significant reduction in ASCVD events and heart failure with use of an SGLT-2 inhibitor.S4.2-9,S4.2-10, | |
| p.17 | IIa | B-R | Downloaded from http://ahajournals.org by on October 7, 2026 | |
| p.17 | IIa | B-NR | S4.2-12 Although most patients studied had established CVD at baseline, the reduction in heart failure has been shown to extend to primary prevention populations.S4.2-12,S4.2-27 The GLP-1R agonists increase insulin and glucagon production in the liver, increase glucose uptake in muscle and adipose tissue, and decrease hepatic glucose production. Three GLP-1R agonists have been found to significantly reduce the risk of ASCVD in adults with T2DM who are at high ASCVD risk.S4.2-11,S4.2-13,S4.2-14 As opposed to a reduction in heart failure with SGLT-2 inhibitors, the benefit of the GLP-1R agonists has been a reduction in ASCVD events though the majority of patients studied had established CVD. | |
| p.17 | IIb | B-R | In patients with T2DM and additional risk factors for CVD, it may be reasonable to initiate these 2 classes of medications for primary prevention of CVD. 4.3 Adults With High Blood Cholesterol Recommendations from the 2018 Cholesterol Clinical Practice GuidelinesS4.3-1 are included and adapted below. | |
| p.21 | I | A | CLINICAL STATEMENTS AND GUIDELINES Downloaded from http://ahajournals.org by on October 7, 2026 I | |
| p.23 | I | A | In the ACCORD (Action to Control Cardio vascular Risk in Diabetes) trial,S4.4-51 lowering the | |
| p.26 | IIb | A | Downloaded from http://ahajournals.org by on October 7, 2026 |