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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 e597 CLINICAL STATEMENTS AND GUIDELINES

TABLE OF CONTENTS

Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease . . . . . . . . . . . . . . e597 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e597 1.	Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e598 1.1.	 Methodology and Evidence Review . . . . . . . . . . e599 1.2.	 Organization of the Writing Committee . . . . . . e599 1.3.	 Document Review and Approval . . . . . . . . . . . . e599 1.4.	 Scope of the Guideline . . . . . . . . . . . . . . . . . . . e599 1.5.	 Class of Recommendation and Level of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . e600 1.6.	 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . e601 2.	Overarching Recommendations for ASCVD Prevention Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . e601 2.1.	 Patient-Centered Approaches to Comprehensive ASCVD Prevention . . . . . . . . . . e601 2.2.	 Assessment of Cardiovascular Risk . . . . . . . . . . e602 3.	Lifestyle Factors Affecting Cardiovascular Risk . . . . . . e605 3.1.	 Nutrition and Diet . . . . . . . . . . . . . . . . . . . . . . . e605 3.2.	 Exercise and Physical Activity . . . . . . . . . . . . . . e607 4.	Other Factors Affecting Cardiovascular Risk . . . . . . . e609 4.1.	 Adults With Overweight and Obesity . . . . . . . . e609 4.2.	 Adults With Type 2 Diabetes Mellitus . . . . . . . . e610 4.3.	 Adults With High Blood Cholesterol . . . . . . . . . e612 4.4.	 Adults With High Blood Pressure or Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . e616 4.5.	 Treatment of Tobacco Use . . . . . . . . . . . . . . . . . e618 4.6.	 Aspirin Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . e621 5.	Cost and Value Considerations . . . . . . . . . . . . . . . . . e622 6.	Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e623 Appendix 1: Search Criteria . . . . . . . . . . . . . . . . . . . . . . e636 Appendix 2: Author Relationships With Industry

and Other Entities (Relevant)���������������������e641 Appendix 3: Reviewer Relationships With Industry

and Other Entities (Comprehensive)�����������e642 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e624

TOP 10 TAKE-HOME MESSAGES FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

1 The most important way to prevent atherosclerotic

vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2.	A team-based care approach is an effective strategy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treatment decisions. 3.	Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning. 4.	All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5.	Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity. 6.	For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations, are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodiumglucose cotransporter 2 inhibitor or a glucagonlike peptide-1 receptor agonist. 7.	All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8.	Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9.	Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion. 10.	Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be <130/80 mm Hg.

PREAMBLE

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts.

Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing

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