Guidelines on the Primary Prevention of Cardiovascular Disease
ASCVD remains the leading cause of morbidity and mortality globally.
All individuals should be encouraged to follow a heart-healthy lifestyle, and estimating an individual’s 10-year absolute ASCVD risk enables matching the intensity of preventive interventions to the patient’s absolute risk to maximize anticipated benefit and minimize potential harm from over treatment. You may check your cardiovascular disease risk profile or you may make an appointment with a cardiology.
The 10-year ASCVD risk estimate is used to guide decision-making for many preventive interventions, including lipid management and blood pressure management; it should be the start of a conversation with the patient about risk-reducing strategies. After calculation of the risk score, it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions for borderline- or intermediate-risk adults. However, the value of preventive therapy may remain uncertain for many individuals with borderline or intermediate estimated 10-year risk, and some patients may be reluctant to take medical therapy without clearer evidence of increased ASCVD risk.
For these individuals, the assessment of CAC is a reasonable tool to reclassify risk either upward or downward as part of shared decision-making. For younger adults 20-59 years of age, estimation of lifetime risk may be considered.
After the age of 20, it is reasonable to measure traditional risk factors at least every 4-6 years. For adults 20-39 years of age, limited data exist on the performance and utility of 10- year risk estimation tools. It is therefore important to consider lifetime risk estimation in this population. Periodic assessment of risk factors (e.g., at least every 4-6 years in adults 20-39 years of age), discussions about intensity of lifestyle interventions, and treatment of nonlipid risk factors need to be performed.
| 10 Year Risk | Recommendations | ||
| 1 | Low Risk | <5% | Emphasize healthy life style changes. |
| 2 | Borderline Risk | 5% to <7.5% | Emphasize healthy life style changes. Evaluate for risk enhancing factors. Consider CAC to help reclassify risk for preventive interventions. |
| 3 | Intermediate Risk | ≥7.5% to <20% | Emphasize healthy life style changes. Evaluate for risk enhancing factors. Consider CAC to help reclassify risk for preventive interventions. |
| 4 | High Risk | ≥20% | Consider treatment with high-intensity statin. |
- 1. Adults should engage in at least 150 minutes of accumulated moderate-intensity physical activity per week or 75 minutes of vigorous-intensity physical activity per week.
- 2. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol (LDL-C) levels (≥190 mg/dL), those with diabetes mellitus who are 40-75 years of age, and those determined to be at sufficient ASCVD risk after a clinician-patient risk discussion.
- 3. 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 mmHg.
Risk-Enhancing Factors for Clinician-Patient Risk Discussion :
- Family history of premature ASCVD (males aged <55 years; females aged <65 years)
- Primary hypercholesterolemia (LDL-C = 160-189 mg/dL; non-high-density lipoprotein cholesterol [HDL-C] = 190-219 mg/dL
- Metabolic syndrome (increased waist circumference [by ethnically appropriate cutpoints], elevated triglycerides [>150 mg/dL, nonfasting], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 mg/dL in women] are factors; a tally of 3 makes the diagnosis)
- Chronic kidney disease
- Chronic inflammatory conditions, such as psoriasis, rheumatoid arthritis, lupus, or human immunodeficiency virus
- High-risk race / ethnicity, such as South Asian ancestry
- History of premature menopause (before age 40 years) and history of pregnancy-associated conditions that increase later ASCVD risk, such as preeclampsia
- Lipids/biomarkers associated with increased ASCVD risk:
- Persistently elevated primary hypertriglyceridemia (≥175 mg/dL, nonfasting)
- If measured :
- Elevated high-sensitivity C-reactive protein (≥2.0 mg/L)
- Elevated lipoprotein(a): A relative indication for its measurement is family history of premature ASCVD. A lipoprotein(a) ≥50 mg/dL or ≥125 nmol/L constitutes a risk-enhancing factor, especially at higher levels of lipoprotein(a).
- Elevated apolipoprotein B (≥130 mg/dL): A relative indication for its measurement would be triglyceride ≥200 mg/dL. A level ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor.
- Ankle-brachial index (<0.9)
- For individuals with intermediate predicted risk (≥7.5% to <20%) or for select adults with borderline (5% to <7.5%) predicted risk, CAC measurement can be a useful tool in refining risk assessment for preventive interventions (e.g., statin therapy). In these groups, CAC measurement can reclassify risk upward (particularly if CAC score is ≥100 Agatston units or ≥75th age/sex/race percentile) or downward (if CAC is zero) in a significant proportion of individuals.
- For patients with CAC scores of 1-99, it is reasonable to repeat the risk discussion. If these patients remain untreated, repeat CAC measurement in 5 years
- CAC might also be considered in refining risk for selected low-risk adults (<5%), such as those with a strong family history of premature coronary heart disease.
References: Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;Mar 17: