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

September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e618

CLINICAL STATEMENTS AND GUIDELINES treatment outweighs the potential harm at threshold BP ≥130/80 mm Hg. 3.	Meta-analyses and systematic reviews of trials that compare more intensive BP reduction to standard BP reduction report that more intense BP lowering significantly reduces the risk of stroke, coronary events, major cardiovascular events, and cardiovascular mortality.S4.4-33,S4.4-39,S4.4-47,S4.4-71 Achieving an additional 10–mm Hg reduction in SBP reduced CVD risk when compared with an average BP of 158/82 to 143/76 mm Hg, 144/85 to 137/81 mm Hg, and 134/79 to 125/76 mm Hg. Patients with diabetes mellitus and CKD were included in the analyses.S4.4-39

4 Most patients with CKD have a 10-year ASCVD

risk ≥10%, requiring initiation of antihypertensive drug therapy at BP ≥130/80 mm Hg. In SPRINT, the participants with CKD who were randomized to intensive therapy (SBP target <120 mm Hg) derived the same beneficial reduction in CVD events and all-cause mortality that was seen among in their counterparts without CKD, with no difference seen in the principal renal outcome.S4.4-34 Other RCTsS4.4-43,S4.4-44 that evaluated the effect of differing BP goals on CKD progression in patients with CKD demonstrated no benefit for more intensive BP reduction, although post hoc follow-up analyses favored lower targets in patients with more severe proteinuria.S4.4-72 These trials were underpowered to detect differences in CVD event rates. Several meta-analyses and systematic reviews support more intensive BP treatment to reduce cardiovascular events but do not demonstrate a reduction in the rate of progression of kidney disease.S4.4-31,S4.4-33,S4.4-39 More intensive BP treatment may result in a modest reduction in glomerular filtration rate, which is thought to be primarily attributable to a hemodynamic effect and may be reversible. Electrolyte abnormalities are also more likely during intensive BP treatment. 5.	Most adults with diabetes mellitus a 10-year ASCVD risk ≥10%, requiring initiation of antihypertensive drug therapy at BP ≥130/80 mm Hg and a treatment goal of <130/80 mm Hg.S4.4-73 Several meta-analyses of RCTs included all trials with a difference in BP levelsS4.4-31,S4.4-71 and supported lowering BP to <130/80 mm Hg among those with diabetes mellitus. Two meta-analyses addressing target BP in adults with diabetes mellitus restricted the analysis to RCTs that randomized patients to different BP levels.S4.4-33,S4.4-47 Target BP of 133/76 mm Hg provided significant benefit compared with that of 140/81 mm Hg for major cardiovascular events, MI, stroke, albuminuria, and retinopathy progression.S4.4-33

In the ACCORD (Action to Control Cardio­ vascular Risk in Diabetes) trial,S4.4-51 lowering the BP target (SBP <120 mm Hg) did not reduce the rate of the composite outcome of fatal and nonfatal major cardiovascular events and was associated with greater risk of adverse events, such as self-reported hypotension and a reduction in estimated glomerular filtration rate. Secondary analyses of the ACCORD trial demonstrated a significant outcome benefit of stroke risk reduction in the intensive BP/standard glycemic group.S4.4-74

6 The relationship of SBP with CVD risk is continuous

across levels of SBP and similar across groups that differ in level of absolute risk.S4.4-55 The relative risk reduction attributable to BP-lowering medication therapy is consistent across the range of absolute risk observed in trials,S4.4-36 suggesting that relative risk reduction may be similar at lower levels of absolute risk. Indirect support is also provided by evidence from trials using BP-lowering medications to reduce the risk of developing higher levels of BP.S4.4-75,S4.4-76 In the HOPE-3 (Heart Outcomes Prevention Evaluation-3) BP Trial, there was no evidence of short-term benefit during treatment of adults (average age 66 years) with a relatively low risk of CVD (3.8% CVD event rate during 5.6 years of follow-up). However, subgroup analysis suggested benefit in those with an average SBP >140 mm Hg (and a CVD risk of 6.5% during the 5.6 years of follow-up).S4.4-59

7 The treatment of patients with hypertension with-

out elevated risk has been systematically understudied because lower-risk groups would require prolonged follow-up to have a sufficient number of clinical events to provide useful outcomes data. Although there is clinical trial evidence that both drug and nondrug therapy will interrupt the progressive course of hypertension, there is no trial evidence that this treatment decreases CVD morbidity and mortality. The clinical trial evidence is strongest for a target BP of 140/90 mm Hg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from BP control earlier in life.S4.4-77

4.5 Treatment of Tobacco Use

Recommendations for Treatment of Tobacco Use Referenced studies that support recommendations are summarized in Online Data Supplements 15 and 16.

COR LOE Recommendations

I A 1.  All adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.S4.5-1

I A 2.  To achieve tobacco abstinence, all adults who use tobacco should be firmly advised to quit.S4.5-2

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