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Recommendations
Begin risk factor assessment in adults at age 20.
Update family history of coronary heart disease (CHD) regularly.
Assess smoking status, diet, alcohol intake and physical activity at every routine evaluation.
Record blood pressure (BP), body mass index (BMI), waist circumference and pulse (to screen for atrial fibrillation) at each visit (at least every two years).
Measure fasting serum lipoprotein profile (or total and HDL cholesterol if fasting is unavailable) and fasting blood glucose according to the person’s risk for hyperlipidemia and diabetes, respectively (at least every five years; if risk factors are present, every two years).
Global risk estimation
All adults over age 40 should know their absolute risk of developing CHD. Goal: As low risk as possible.
Recommendations
Adults, especially those over age 40 or with two or more risk factors, should have their 10-year risk of CHD assessed with a multiple risk factor score every five years (or more often if risk factors change).
Risk factors used in global risk assessment include age, sex, smoking status, systolic (and sometimes diastolic) blood pressure, total (and sometimes LDL or “bad”) cholesterol, HDL “good” cholesterol, and in some risk scores, diabetes.
People with diabetes or a 10-year risk over 20 percent can be considered “CHD risk equivalent.” That is, they’re at a level of risk similar to a patient with established CVD.
Equations for calculating a 10-year stroke risk are also available.
Guide to primary prevention of cardiovascular diseases: Risk intervention
Smoking
Goal: Complete cessation. No exposure to environmental tobacco smoke.
Recommendations
Ask about tobacco use status at every visit. Advise every tobacco user to quit in a clear, strong and personalized manner.
Assess the tobacco user’s willingness to quit. Assist by counseling and developing a plan for quitting. Arrange for follow-up, referral to special programs or prescription drug therapy.
Urge avoidance of exposure to secondhand smoke at work or home.
Blood pressure control
Goal: Less than 120/80 mm Hg; for people who have been diagnosed with high blood pressure, the goal is less than 140/90 mm Hg; less than 130/80 mm Hg in people with renal (kidney) disease or diabetes.
Recommendations
Promote healthy lifestyle modification. Advocate reducing weight; reducing sodium (salt) intake; eating fruits, vegetables and low-fat dairy products; moderating alcohol intake; and physical activity in people with BP of 120 mm Hg or greater systolic or 80 mm Hg or greater diastolic.
For people with renal (kidney) disease or diabetes, start drug therapy if BP is 130 mm Hg or greater systolic or 80 mm Hg or greater diastolic.
Start drug therapy for those with BP of 140/90 mm Hg or greater if BP goal is not achieved with lifestyle modifications. Add blood pressure medications, individualized to the patient’s other requirements and characteristics (such as age, race or need for drugs with specific benefits).
Dietary intake
Goal: An overall healthy eating pattern.
Recommendations
Advocate eating a variety of fruits, vegetables, grains, legumes, low-fat or nonfat dairy products, fish, poultry and lean meats.
Match energy (calorie) intake with energy needs and make appropriate changes to achieve weight loss when needed.
Modify food choices to reduce saturated fats to less than 10 percent of calories, cholesterol to less than 300 mg per day, and trans fats. (Trans fats result from adding hydrogen to vegetable oils.) Substitute grains and unsaturated fats from fish, vegetables, legumes and nuts.
Limit salt intake to less than 6 grams per day (2,300 mg of sodium).
Limit alcohol intake to no more than two drinks per day in men, one drink per day in women among those who drink alcohol.
Aspirin
Goal: Low-dose aspirin in people at higher risk of coronary heart disease (especially those with a 10-year CHD risk of 10 percent or greater).
Recommendations
Do not recommend for patients with aspirin intolerance (or allergy).
Low-dose aspirin increases risk for gastrointestinal bleeding and hemorrhagic stroke. Do not use in people at increased risk for these diseases.
Benefits of reducing cardiovascular risk outweigh these risks in most patients with higher coronary risk.
Doses of 75–160 mg per day are as effective as higher doses. Consider 75–160 mg aspirin per day for people at higher risk (especially those with a 10-year CHD risk of 10 percent or greater).
Blood lipid management
Primary goal
LDL cholesterol less than 160 mg/dL if no more than one risk factor is present.
LDL cholesterol less than 130 mg/dL if two or more risk factors are present and 10-year CHD risk is less than 20 percent.
LDL cholesterol less than 100 mg/dL if two or more risk factors are present and 10-year CHD risk is 20 percent or higher or if person has diabetes.
Secondary goals (if LDL cholesterol is at goal range): If triglycerides are greater than 200 mg/dL, then use non-HDL cholesterol as a secondary goal:
Non-HDL cholesterol less than 190 mg/dL for no more than one risk factor.
Non-HDL cholesterol less than 160 mg/dL for two or more risk factors and 10-year CHD risk of 20 percent or less.
Non-HDL cholesterol less than 130 mg/dL for diabetes or for two or more risk factors and 10-year CHD risk greater than 20 percent.
Other targets for therapy:
Triglycerides greater than 150 mg/dL.
HDL cholesterol less than 40 mg/dL in men and less than 50 mg/dL in women.
Recommendations
If LDL cholesterol is above goal range,
Start therapeutic lifestyle changes (TLC) diet to lower it: less than 7 percent of calories from saturated fat and less than 200 mg per day of dietary cholesterol.
If more LDL cholesterol lowering is needed, add dietary options (plant stanols/sterols not to exceed 2 g per day and/or soluble fiber 10–25 g per day); emphasize weight reduction and physical activity.
Rule out secondary causes of high LDL cholesterol (liver function tests, thyroid function tests, urinalysis).
After 12 weeks of TLC, consider LDL-lowering drug therapy if:
Two or more risk factors are present, 10-year risk is greater than 10 percent, and LDL cholesterol is 130 mg/dL or greater.
Two or more risk factors are present, 10-year risk is less than 10 percent, and LDL cholesterol is 160 mg/dL or greater.
No more than one risk factor is present, and LDL cholesterol is 190 mg/dL or greater.
Start drugs and advance dose to bring LDL cholesterol into range, usually with a statin, but also consider bile-acid-binding resin or niacin.*
If the LDL cholesterol goal is not achieved, consider combination drug therapy (statin plus resin or statin plus niacin).*
After LDL cholesterol goal has been reached, consider triglyceride level:
If triglycerides are 150–199 mg/dL, treat with therapeutic lifestyle changes (TLC).
If triglycerides are 200–499 mg/dL, treat high non-HDL cholesterol with TLC and, if needed, consider higher doses of statin or adding niacin* or fibrate.
If triglycerides are 500 mg/dL or greater, treat with fibrate or niacin to reduce the risk of pancreatitis.
If HDL cholesterol is less than 40 mg/dL in men and less than 50 mg/dL in women, start or intensify TLC. For higher-risk patients, consider drugs that raise HDL cholesterol (niacin*, fibrates, statins).
* Niacin (nicotinic acid) comes in prescription form and as “dietary supplements.” Dietary supplement niacin is not regulated by the U.S. Food and Drug Administration (FDA) the same way that prescription niacin is. It may contain widely variable amounts of niacin — from none to much more than the label states. The amount of niacin may even vary from lot to lot of the same brand.
Dietary supplement niacin must not be used as a substitute for prescription niacin. It should not be used for cholesterol lowering because of potentially very serious side effects.
Physical activity
Goal: At least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week.
Recommendations
If a patient has suspected cardiovascular, respiratory, metabolic, orthopedic or neurological disorders, or is middle-aged or older and sedentary, he or she should consult a physician before starting a vigorous exercise program.
Moderate-intensity activities (40 to 60 percent of maximum capacity) are equivalent to a brisk walk (15–20 minutes per mile).
Vigorous-intensity activities (more than 60 percent of maximum capacity) offer added benefits.
Recommend resistance training with eight to 10 different exercises, 1–2 sets per exercise, and 10–15 repetitions at moderate intensity on two or more days per week.
Include flexibility training and an increase in daily lifestyle activities to round out the regimen.
Weight management
Goal: Achieve and maintain desirable weight (body mass index 18.5–24.9 kg/m2). When a person’s BMI is 25 kg/m2 or higher, the waist measurement goal is 40 inches or less for men, 35 inches or less for women.
Recommendations
Start a weight-management program through restricting calories in diet and increasing caloric expenditure (exercise) as appropriate.
For overweight or obese persons, reduce body weight by 10 percent in the first year of therapy.
Diabetes management
Goal: Normal fasting plasma glucose (blood sugar) of 90 - 130 mg/dL and Hb1Ac of less than 7 percent.
Recommendations
Start appropriate therapy to achieve near-normal fasting plasma glucose or as indicated by near-normal Hb1Ac. The first step is diet and exercise.
Second-step therapy is usually oral hypoglycemic drugs: sulfonylureas and/or metformin with ancillary acarbose and thiazolidinediones. Third-step therapy is insulin.
Treat other risk factors more aggressively. For example, change BP goal to less than 130/80 mm Hg and LDL cholesterol goal to less than 100 mg/dL.
Chronic atrial fibrillation
Goal: Normal sinus rhythm or, if chronic atrial fibrillation is present, anticoagulation with international normalized ratio (INR) of 2.0–3.0 (target 2.5).
Recommendations
Verify irregular pulse with an electrocardiogram (ECG or EKG). Convert appropriate persons to normal sinus rhythm.
For patients in chronic or intermittent atrial fibrillation, use warfarin anticoagulants to INR 2.0–3.0 (target 2.5).
Use aspirin as an alternative in those with certain contraindications to oral anticoagulation. Patients under age 65 without high risk may be treated with aspirin.
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