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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 e607 CLINICAL STATEMENTS AND GUIDELINES

low-carbohydrate diets using animal-derived protein and fat sources (eg, lamb, beef, pork, chicken),S3.1-22 but plant sources (eg, vegetables, nuts, peanut butter, whole-grain breads) were associated with lower mortality rate. In addition, the ARIC investigators noted a 23% increase in mortality rate associated with high-carbohydrate diets, with the optimal carbohydrate intake observed to be 50% to 55%. 5.	 Intake of trans fat has been shown to be harmful and increase risk of ASCVD. Trans fat was associated with higher all-cause mortality rate in the REGARDS US healthcare professionals cohort studies.S3.1-12,S3.1-17 Additionally, regulations to curb use of trans fat in the food industry have been associated with a decrease in stroke and MI.S3.1-25 Trans fats have adverse effects on lipid and lipoproteins and promote endothelial dysfunction, insulin resistance, inflammation, and arrhythmias.S3.1-26 Since partially hydrogenated oils are optional food additives, their elimination has been a public health priority.S3.1-27

3.2 Exercise and Physical Activity

Recommendations for Exercise and Physical Activity Referenced studies that support recommendations are summarized in Online Data Supplements 6 and 7.

COR LOE Recommendations

I B-R 1.  Adults should be routinely counseled in healthcare visits to optimize a physically active lifestyle.S3.2-1,S3.2-2

I B-NR 2.  Adults should engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) to reduce ASCVD risk.S3.2-3–S3.2-8

IIa B-NR 3.  For adults unable to meet the minimum physical activity recommendations (at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity), engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial to reduce ASCVD risk.S3.2-5,S3.2-6

IIb C-LD 4.  Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD risk.S3.2-3,S3.2-9–S3.2-11

Synopsis

The numerous health benefits of regular physical activity have been well established,S3.2-12–S3.2-15 and physical activity is a cornerstone of maintaining and improving cardiovascular health.S3.2-6 Nevertheless, approximately half of adults in the United States do not meet the minimum physical activity recommendations.S3.2-12 Strategies are needed to increase physical activity at both the individual and the population levels.S3.2-16,S3.2-17

Extensive observational data from meta-analyses and systematic reviews support recommendations for aerobic physical activity to lower ASCVD risk.S3.2-3–S3.2-8, S3.2-12,S3.2-18,S3.2-19 Resistance exercise should also be encouraged because of its several health benefits, including improving physical functioning,S3.2-20 improving glycemic control in individuals with diabetes,S3.2-21 and possibly BP lowering.S3.2-22 Whether resistance exercise lowers ASCVD risk is unclear.S3.2-12 Aerobic physical activity is generally very safe.S3.2-23 However, sedentary individuals starting an exercise program should initiate exercise at a lower intensity (eg, slow walking) and duration and progress gradually to recommended levels.S3.2-24 It is uncertain whether an upper limit of habitual exercise, either in amount or intensity, may have adverse cardiovascular consequences.S3.2-25 But, in discussions with patients, it should be mentioned that these very high levels of physical activity (ie, >10 times the minimum recommended amount) pertain to only a small fraction of the population.S3.2-12 Individuals with significant functional impairments may need modifications to and more specific guidance on the type, duration, and intensity of physical activity.

Recommendation-Specific Supportive Text

1 Physical activity assessment and counseling in

the healthcare setting have important complementary roles in promoting increased physical activity.S3.2-16 Ascertaining physical activity patterns during a standard clinical visit is the first step toward effective counseling and can be accomplished through several available simple assessment tools.S3.2-16 The results of these tools can be recorded in the electronic health record, along with parameters such as weight and BP.S3.2-16 Physical activity counseling by clinicians can result in modest improvements in physical activity levels, with a number needed to counsel as low as 12 for an individual to achieve recommended physical activity levels.S3.2-1,S3.2-2 This counseling might include an exercise prescription that consists of recommended frequency, intensity, time (duration), and type of exercise. 2.	There is a consistent, strong, inverse dose– response relationship between the amount of moderate to vigorous physical activity and incident ASCVD events and death.S3.2-3–S3.2-8,S3.2-12 The shape of the dose–response relationship is curvilinear, with significant benefit observed when comparing those engaging in little or no physical activity with those performing moderate

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