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primary prevention of cardiovascular disease

Management: - counselling may be of some benefit to some patients (grade C recommendation) USPSTF [11,12] - minimize cardiac risk factors - control blood pressure, chronic hypertension - antihypertensive agents reduce myocardial infarction & stroke - role of statins & antiplatelet agents controversial - USPSTF recommended aspirin prophylaxis (primary prevention) for: [1,2,3,18] - prevention of both cardiovascular disease & colorectal cancer in adults 40-59 years of age with a 10-year cardiovascular risk of >= 10% - small net benefit at best, shared decision making indicated - adults >= 60 years no net benefit (see aspirin) - men age 45-79 years when the potential benefitb due to a reduction in myocardial infarctions outweighs the potential harm (GI bleed) - women age 55-79 years when the potential benefit due to a reduction in strokes outweighs the potential harm (GI bleed) - insufficient evidence to recommend aspirin for patients > 79 years of age or in men < 45 or women < 55 years of age [1,2] - reduces myocardial infarction & ischemic stroke [20] - risk for nontrivial bleeding roughly equals benefit in primary prevention of nonfatal myocardial infarction [4] - no benefit in primary prevention of fatal myocardial infarction [4] - FDA & AHA/ACC recommend against aspirin for primary prevention [5,14] - statins for primary prevention - statins are recommended with lifestyle changes for patients with elevated LDL cholesteroal (>= 190 mg/dL), type 2 diabetes, or other cardiovascular risk factors [14] - benefit of statins for primary prevention confirmed [6] - benefits in patients with low cardiovascular risk (5 year risk < 10%) similar to benefits in high-risk patients [6] - use cardiovascular risk calculator - suggestion is made that everyone over 50 years of age should take a statin: allegedly, benefits of statins outweigh risks, even in the healthiest patients [6] - reduction in myocardial infarction & ischemic stroke [20] - no reduction in mortality [6] - no mortality benefit for primary prevention [7] - benefit for primary prevention in the elderly (73 +/- 3 years) [8]; does not reduce all-cause mortality [8] - in older adults with at least one risk factor*, rosuvastatin 10 mg/day lowers mean LDL cholesterol level by 35 mg/dL, & reduces combined outcomes of CV-related death, nonfatal ischemic stroke, or nonfatal myocardial infarction vs placebo (3.7 vs 4.8%) [10] - rosuvastatin & other statins do not lower all-cause mortality [10,20] - financial incentives associated with statin recommendations for primary prevention rarely (if ever) discussed - statins never compared directly with Mediterranean diet - PCSK9 inhibitors reduce myocardial infarction & ischemic stroke [20] - ezetimibe reduces myocardial infarction & ischemic stroke [20] - candesartan/HCTZ (16/12.5 mg) reduced combined outcome vs placebo only in a subgroup with baseline systolic BP > 143 mm Hg (4.8 vs 6.5%) - soluble (viscous) fiber lowers LDL cholesterol & estimated 10-year cardiovascular risk [15,16,17] - meditation may reduce cardiovascular mortality [13] - no benefit for vitamins & antioxidants [9] * elevated waist-hip ratio, low HDL cholesterol, current smoking, or diet-controlled diabetes Notes: - see cardiovascular risk factor for AHA Predicting Risk of CVD EVENTs (PREVENT) equations [19]

Related

cardiovascular disease (CVD) cardiovascular risk calculator; cardiovascular risk score cardiovascular risk factor coronary artery disease; coronary atherosclerosis (CAD) ischemic stroke peripheral vascular disease (PVD) secondary prevention in patients with cardiovascular disease

General

Prevention of Cardiovascular Disease

References

  1. U.S. Preventive Services Task Force Aspirin for the Prevention of Cardiovascular Disease: U.S. Preventive Services Task Force Recommendation Statement Ann Intern Med. 2009 Mar 17;150(6):396-404. PMID: 19293072 - Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009 Mar 17;150(6):405-10. Review. PMID: 19293073
  2. U.S. Preventive Services Task Force recommendation statement. Aspirin for the Prevention of Cardiovascular Disease http://www.ahrq.gov/clinic/USpstf/uspsasmi.htm
  3. Prescriber's Letter 17(2): 2010 Aspirin for Primary Prevention Detail-Document#: 260201 (subscription needed) http://www.prescribersletter.com
  4. Seshasai SRK et al. Effect of aspirin on vascular and nonvascular outcomes: Meta-analysis of randomized controlled trials. Arch Intern Med 2012 Feb 13; 172:209 PMID: 22231610 - Mora S. Aspirin therapy in primary prevention: To use or not to use? Arch Intern Med 2012 Feb 13; 172:217. PMID: 22231608
  5. Husten L FDA Comes Out Against Aspirin for Primary Prevention Physician's First Watch, May 6, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - FDA.Information for Consumers. May 2, 2014. Use of Aspirin for Primary Prevention of Heart Attack and Stroke. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm390574.htm
  6. Cholesterol Treatment Trialists' (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: Meta-analysis of individual data from 27 randomised trials. Lancet 2012 May 17 PMID: 22607822 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60367-5/fulltext - Ebrahim S and Casas JP. Statins for all by the age of 50 years? Lancet 2012 May 17 PMID: 22607823 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60694-1/fulltext
  7. Prescriber's Letter 17(8): 2010 Statins for Primary Prevention Detail-Document#: 260802 (subscription needed) http://www.prescribersletter.com
  8. Savarese G et al Benefits Of Statins In Elderly Subjects Without Established Cardiovascular Disease. A Meta-Analysis. J Am Coll Cardiol. 2013 Dec 3;62(22):2090-9. PMID: 23954343 http://content.onlinejacc.org/article.aspx?articleid=1732396 - Waters DD Meta-analyses of Statin Trials: Clear Benefit for Primary Prevention in the Elderly. J Am Coll Cardiol. 2013 Dec 3;62(22):2100-1 PMID: 23994398 http://content.onlinejacc.org/article.aspx?articleid=1732395
  9. The NNT: Vitamin and Antioxidant Supplements for Primary Prevention of Cardiovascular Disease. http://www.thennt.com/nnt/vitamins-and-antioxidants-for-primary-prevention-of-cardiovascular-disease/
  10. Lonn EM et al Blood-Pressure Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. April 2, 2016 PMID: 27041480 http://www.nejm.org/doi/full/10.1056/NEJMoa1600175 - Yusuf S et al Cholesterol Lowering in Intermediate-Risk Persons without Cardiovascular Disease. N Engl J Med. April 2, 2016 PMID: 27040132 http://www.nejm.org/doi/full/10.1056/NEJMoa1600176 - Yusuf S et al Blood-Pressure and Cholesterol Lowering in Persons without Cardiovascular Disease. N Engl J Med. April 2, 2016 PMID: 27039945 http://www.nejm.org/doi/full/10.1056/NEJMoa1600177 - Cushman WC, Goff DC, Jr. More HOPE for Prevention with Statins N Engl J Med. April 2, 2016 PMID: 27039666 http://www.nejm.org/doi/full/10.1056/NEJMe1603504
  11. Capewell S, Dowrick C. Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk Factors. Is Behavioral Counselling Necessary? JAMA Intern Med. Published online July 11, 2017. PMID: 28697229 http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2643083
  12. US Preventive Services Task Force Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Risk Factors. US Preventive Services Task Force Recommendation Statement. JAMA. 2017;318(2):167-174 PMID: 28697260 http://jamanetwork.com/journals/jama/fullarticle/2643315 - Patnode CD, Evans CV, Senger CA, Redmond N, Lin JS. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017;318(2):175-193 PMID: 28697259 http://jamanetwork.com/journals/jama/fullarticle/2643314 - Greenland P, Fuster V. Cardiovascular Risk Factor Control for All. JAMA. 2017 Jul 11;318(2):130-131. PMID: 28697239 http://jamanetwork.com/journals/jama/fullarticle/2643292
  13. Levine GN, Lange RA, Bairey-Merz CN et al Meditation and Cardiovascular Risk Reduction A Scientific Statement From the American Heart Association. J Am Heart Assoc. Sept 28, 2017 PMID: 28963100 Free full text http://jaha.ahajournals.org/content/6/10/e002218
  14. WRITING COMMITTEE MEMBERS, Arnett DK et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. J Am Coll Cardiol. March 2019 PMID: 30894319 http://www.onlinejacc.org/content/early/2019/03/07/j.jacc.2019.03.010 - Bittner VA The New 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. March 17, 2019 PMID: 30879338 https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.119.040625
  15. Salvado J, Jenkins DJA, Kendall CWC, Sievenpiper JL. Portfolio Dietary Pattern and Cardiovascular Disease: A Systematic Review and Meta-analysis of Controlled Trials. Prog Cardiovasc Dis. 2018 May-Jun;61(1):43-53 PMID: 29807048 Review
  16. Surampudi P, Enkhmaa B, Anuurad E, Berglund L. Lipid Lowering with Soluble Dietary Fiber. Curr Atheroscler Rep. 2016 Dec;18(12):75. PMID: 27807734 Review.
  17. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  18. US Preventive Services Task Force Aspirin Use to Prevent Cardiovascular Disease. US Preventive Services Task Force Recommendation Statement. JAMA. 2022;327(16):1577-1584. April 26. PMID: 35471505 https://jamanetwork.com/journals/jama/fullarticle/2791399 - Davidson KW et al. Aspirin use to prevent cardiovascular disease. JAMA 2022 Apr 26; 327:1577-1584 PMID: 35471505 https://jamanetwork.com/journals/jama/fullarticle/2791399 - Guirguis-Blake JM et al. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2022 Apr 26; 327:1585-1597 PMID: 35471507 https://jamanetwork.com/journals/jama/fullarticle/2791401 - Brett AS Should Patients Take Aspirin for Primary Cardiovascular Prevention? Updated Recommendations From the US Preventive Services Task Force. JAMA. 2022;327(16):1552-1554 PMID: 35471530 https://jamanetwork.com/journals/jama/fullarticle/2791432
  19. Khan SS, Matsushita K, Sang Y et al. Development and Validation of the American Heart Association's PREVENT Equations. Circulation. 2024 Feb 6;149(6):430-449. PMID: 37947085 PMCID: PMC10910659 (available on 2025-02-06)
  20. Di Palo, Feder S, Baggenstos YT et al Palliative Pharmacotherapy for Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes. 2024 Jul 1:e000131 PMID: 38946532 Free article. Review. https://www.ahajournals.org/doi/epdf/10.1161/HCQ.0000000000000131