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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 e613 CLINICAL STATEMENTS AND GUIDELINES

Synopsis

Primary ASCVD prevention requires attention to AS- CVD risk factors beginning early in life (Figure 3). This guideline addresses major issues related to cholesterol management and primary ASCVD prevention, which are also addressed in the recently published 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Therefore, the relevant subset of those recommendations is presented here, along with its accompanying supportive text. This writing committee agrees that for young adults (20 to 39 years of age), priority should be given to estimating lifetime risk and promoting a healthy lifestyle. Only in select patients with moderately high LDL-C (≥160 mg/dL) or those with very high LDL-C (≥190 mg/dL) is drug therapy indicated. In adults 40 to 75 years of age, 10-year ASCVD risk should guide therapeutic considerations. The higher the estimated risk, the more likely the patient is to benefit from statin treatment. For patients >75 years of age, assessment of risk status and a clinician pa- tient risk discussion are needed to decide whether to continue or initiate statin treatment. For a detailed discussion of statin safety and management of statinassociated side effects, please refer to Section 5 of the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1

Recommendation-Specific Supportive Text

1 Large-scale RCTs in primary prevention dem-

onstrated ASCVD risk reduction with moderate-intensityS4.3-6,S4.3-36 and high-intensity statin therapyS4.3-7 that outweighed the observable risks. Subsequently, a large-scale RCT in an ethnically and racially diverse population confirmed statin benefit from a moderate-intensity statin therapy, as compared with placebo, in intermediate-risk patients. That RCT enrolled men ≥55 years of age and women ≥65 years of age with at least 1 cardiovascular risk factor. In the placebo

Figure 3. Primary prevention. Colors correspond to Class of Recommendation in Table 1. ABI indicates ankle-brachial index; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CHD, coronary heart disease; HIV, human immunodeficiency virus; hs-CRP, high-sensitivity C-reactive protein; LDL-C, lowdensity lipoprotein cholesterol; and Lp(a), lipoprotein (a). Reproduced with permission from Grundy et al.S4.3-1 Copyright © 2018, American Heart Association, Inc., and American College of Cardiology Foundation.

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