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September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e602

CLINICAL STATEMENTS AND GUIDELINES Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

screening tool to assess 5 domains of non–healthrelated measures that affect health outcomes: housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety.S2.1-29 ASCVD prevention could benefit from such screening. ASCVD risk begins early in life, with heightened susceptibility tied to low socioeconomic status.S2.1-25 Examples of upstream social determinants of health that affect treatment adherence and ASCVD health outcomes include comorbid mental illness, lack of health literacy, exposure to adversity (eg, home/community violence, trauma exposures, safety concerns), financial strain, inadequate housing conditions, lack of food security (ie, access to affordable and nutritious food), and inadequate social support.S2.1-30 Systems of care should evaluate social determinants of health that affect care delivery for the primary prevention of ASCVD (eg, transportation barriers, the availability of health services). Important considerations related to socioeconomic disadvantage are not captured by existing CVD risk equations.S2.1-31 Addressing unmet social needs improves management of BP and lipids,S2.1-32 which highlights the importance of dietary counseling and encouraging physical activity.S2.1-19 More time may be required to address ASCVD prevention with adults of low health literacy or disadvantaged educational backgrounds.

Differential cardiovascular outcomes persist by important sociodemographic characteristics that include but are not limited to age, sex, and race/ ethnicity.S2.1-22,S2.1-33–S2.1-35 Failure to address the impact of social determinants of health impedes efficacy of proven prevention recommendations. Table 2 outlines key considerations related to social determinants of health and ASCVD prevention.

2.2 Assessment of Cardiovascular Risk

Recommendations for Assessment of Cardiovascular Risk Referenced studies that support recommendations are summarized in Online Data Supplement 3.

COR LOE Recommendations

I B-NR 1.  For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the pooled cohort equations (PCE).S2.2-1,S2.2-2

IIa B-NR 2.  For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years.S2.2-1–S2.2-3

IIa B-NR 3.  In adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk (≥7.5% to <20% 10-year ASCVD risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions (eg, statin therapy).S2.2-4–S2.2-14

IIa B-NR 4.  In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk) or selected adults at borderline risk (5% to <7.5% 10year ASCVD risk), if risk-based decisions for preventive interventions (eg, statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician–patient risk discussion.S2.2-15–S2.2-31

Table 2.  Example Considerations for Addressing Social Determinants of Health to Help Prevent ASCVD Events

Topic/Domain Example Considerations Cardiovascular risk Adults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.S2.1-31

Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.S2.1-36

Diet In addition to the prescription of diet modifications, body size perception, as well as social and cultural influences, should be assessed.S2.1-37,S2.1-38

Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age*.S2.1-39

Exercise and physical activity In addition to the prescription of exercise, neighborhood environment and access to facilities for physical activity should be assessed.S2.1- 30,S2.1-40,S2.1-41 Obesity and weight loss Lifestyle counseling for weight loss should include assessment of and interventional recommendations for psychosocial stressors, sleep hygiene, and other individualized barriers.S2.1-42–S2.1-44

Weight maintenance should be promoted in patients with overweight/obesity who are unable to achieve recommended weight loss.

Diabetes mellitus In addition to the prescription of type 2 diabetes mellitus interventions, environmental and psychosocial factors, including depression, stress, self-efficacy, and social support, should be assessed to improve achievement of glycemic control and adherence to treatment.S2.1-45–S2.1-48 High blood pressure Short sleep duration (<6 h) and poor-quality sleep are associated with high blood pressure and should be considered.S2.1-49 Because other lifestyle habits can impact blood pressure, access to a healthy, low-sodium diet and viable exercise options should also be considered. Tobacco treatment Social support is another potential determinant of tobacco use. Therefore, in adults who use tobacco, assistance and arrangement for individualized and group social support counseling are recommended.S2.1-50,S2.1-51 *Advanced age generally refers to age ≥75 years. ASCVD indicates atherosclerotic cardiovascular disease.

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