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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 September 10, 2019 e605 CLINICAL STATEMENTS AND GUIDELINES

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 3 LIFESTYLE FACTORS AFFECTING

CARDIOVASCULAR RISK

3.1 Nutrition and Diet

Recommendations for Nutrition and Diet Referenced studies that support recommendations are summarized in Online Data Supplements 4 and 5.

COR LOE Recommendations

I B-R 1.  A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors.S3.1-1–S3.1-11

IIa B-NR 2.  Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD risk.S3.1-12,S3.1-13

IIa B-NR 3.  A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk.S3.1-9,S3.1-14–S3.1-16

IIa B-NR 4.  As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk.S3.1-17–S3.1-24

III: Harm B-NR 5.  As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk.S3.1-12,S3.1-17,S3.1-25–S3.1-27

Synopsis

Approximately 630 000 Americans died from heart disease in 2015, of whom 366 000 died from coronary artery disease. After 4 decades of decline, heart disease deaths rose in 2015 by 1%.S3.1-28 This trend has been attributed to the obesity epidemic. Healthy nutrition has an important impact on ASCVD and its risk factors (see recommendations in the individual sections), potentially reversing or reducing obesity, high cholesterol, diabetes, and hypertension. The cardiovascular nutrition literature is limited by the paucity of large-scale prospective randomized trials with ASCVD outcomes. Although RCTs focused on hard endpoints are limited, multiple observational studies have focused on the association of CVD mortality with dietary patterns— specifically, sugar, low-calorie sweeteners, high-carbohydrate diets, low-carbohydrate diets, refined grains, trans fat, saturated fat, sodium, red meat, and processed red meat (eg, bacon, salami, ham, hot dogs, sausage).S3.1-1–S3.1-24 Processed meats are any meat preserved by smoking, curing, or salting, or additional chemical preservatives.S3.1-28a

Recommendation-Specific Supportive Text

1 Plant-based and Mediterranean diets, along with

increased fruit, nut, vegetable, legume, and lean vegetable or animal protein (preferably fish) consumption, with the inherent soluble and insoluble

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