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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 e623 CLINICAL STATEMENTS AND GUIDELINES

There are additional challenges specific to the prevention realm. As described in the 2011 AHA policy statement, “Value of Primordial and Primary Prevention in CVD”:S5-1 “Assessing the value of prevention in apparently healthy patients is generally more difficult than evaluating therapy for established disease because the time horizon to the clinical manifestation of disease is generally long—many decades in the young. Thus, it is difficult, perhaps impossible, to assess longterm effectiveness in terms of survival or quality-adjusted life-years (QALYs) or associated costs because of increasing uncertainty about outcome the further one tries to look into the future.” Furthermore, the principle of discounting, which places relative emphasis on current costs and benefits while deemphasizing downstream costs and benefits, creates disadvantages for prevention because costs often accrue in the present while the benefit may only be fully realized long into the future. These methodological challenges notwithstanding, prior AHA statements have highlighted the public policies, community efforts, and pharmacological interventions that are likely to be cost-effective and, at times, cost-saving prevention tactics compared with common benchmarks. For example, robust evidence suggests that both antihypertensive therapyS5-3–S5-6 and statin therapy,S5-7–S5-9 particularly with low-cost generic drug formulations, are high-value interventions across a wide spectrum of risk and age strata. The incorporation of the value category into clinical practice guidelines is one of several considerations in medical decision-making and resource allocation. Clinicians, researchers, and policymakers must continue to place cost-effective analyses in the proper context, extracting key value determinations while acknowledging the challenges in fully characterizing and incorporating the downstream benefits of a given therapeutic prevention tactic. Further research and methodological advances are needed to comprehensively characterize the full spectrum of benefits produced by the prevention approach, thereby rendering cost-effectiveness assessments more consequential to clinical practice.

6 CONCLUSION

Most ASCVD events are avoidable through primordial prevention (ie, the prevention of risk factor development) and control of traditional cardiovascular risk factors. Tobacco avoidance is critically important for AS- CVD prevention, and all adults should strive to engage in regular brisk physical activity most days of the week and adhere to a healthy dietary pattern to help lower future ASCVD risk. A diet high in fruits, vegetables, and whole grains is best. Fish, legumes, and poultry are the preferred sources of protein. Minimizing the consumption of trans fats, added sugars (including sugar-sweetened beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in partnership with patients to assess their readiness for sustained lifestyle improvements, identify potential barriers to change, and encourage them to try to achieve measurable goals and continue to monitor their progress.S6-1 Finally, social determinants of ASCVD risk—and their impact on the patient’s ability to prevent or treat risk factors—must be taken into account. Clinicians need to consider patients’ health literacy and education levels and assess patients’ motivation to improve their lifestyle habits.

The goal of the clinician is to match the intensity of preventive efforts with an individual’s absolute risk of a future ASCVD event and with the individual’s willingness and capacity to implement preventive strategies. Risk estimation is imperfect and based on group averages that are then applied to individual patients. The clinician must balance an understanding of a patient’s estimated ASCVD risk with potential benefits and adverse risk from pharmacological therapy in the context of a risk discussion. To determine the appropriateness of pharmacological therapy after quantitative risk estimation in cases that are unclear, risk-enhancing factors or selective use of a coronary artery calcium measurement can inform decision-making for cholesterol-lowering or antihypertensive medication use in intermediate-risk individuals. This primary-prevention guideline strives to provide clinicians with the information they need to help their patients reduce their risk of ASCVD and encourage them to make healthier lifestyle changes when needed.

ACC/AHA TASK FORCE MEMBERS

Patrick T. O’Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Joaquin E. Cigarroa, MD, FACC; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Mark A. Hlatky, MD, FACC, FAHA; John Ikonomidis, MD, PhD, FAHA*; José A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD

*Former Task Force member; current member during the writing effort.

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