2019 ACC-AHA Guideline on the Primary Prevention of Cardiovascular Disease with Dr. Erin Michos
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2019 ACC-AHA Guideline on the Primary Prevention of Cardiovascular Disease with Dr. Erin Michos

October 10, 2019

>>Hi, I’m Erin Michos and I’m a co-author on the
guidelines that we just released that was put forward by the
American College of Cardiology and the American Heart Association on the primary prevention
of cardiovascular disease. So primary prevention means individuals who have not yet had clinical signs of heart disease or a stroke and we’re trying to
prevent that first event. So what’s new about these
guidelines is that it takes pieces from previous documents from
the American Heart Association about blood pressure treatment,
cholesterol treatment, diet, exercise, diabetes,
and really puts it forward into one document focused
on primary prevention that can be utilized for
clinicians and for their patients. So the current guidelines still emphasize that the most important way to prevent cardiovascular disease is to follow a healthy lifestyle
throughout one’s life. Additionally, when we’re
considering about drug therapy for individuals aged 40 to 75, the guidelines recommend
using this risk calculator put forward by the
American Heart Association to estimate one’s 10 year risk
for heart attacks or strokes. And so based on that, it
helps guide some decisions such that if individuals
are above 7.5% 10 year risk of a heart attack or stroke, generally statins are
recommended for prevention. However, what these new guidelines and update is they’re more personalized, in that they also list a
number of what they call risk enhancing factors to consider when making these statin decisions. So these are factors that
wouldn’t be in that calculator. They include things like
autoimmune disease, HIV disease, chronic kidney disease, having
some abnormal biomarkers such as a persistently
elevated triglycerides, elevated C-reactive protein,
lipoprotein little a, a number of things. So when these risk enhancing
factors are present, this may strengthen the
decision to initiate a statin or if somebody is on a statin, it may prompt you to consider intensifying the therapy a little further. But additionally, these
new guidelines recognize that in many cases the decision to treat with a statin is still uncertain and so when there is uncertainty, sort of for a tie breaker,
the guidelines recommend using a coronary artery calcium score. This is obtained by a cardiac CT. And so for individuals who
have a calcium score of zero, so no evidence of calcified
plaque in their heart arteries, generally they’re at low enough risk over the next five to 10 years that statin therapy can
be deferred or postponed if patients don’t want to take it. On the other hand, if there is a significant calcified plaque such as a coronary calcium
score greater than 100 or above the 75th
percentile for one’s age, that would further
strengthen the recommendation that statins would be recommended. So the guidelines
recommend estimating risk and then personalizing it
to make treatment decisions. Initially they also say that individuals that have diabetes
should recommend a statin sort of regardless of
what their 10 year risk is and also individuals who have
really high LDL cholesterol, above 190, would be
recommended for statin. So what else is new is sort of that aspirin actually got a
little bit of a de-emphasize in the current guidelines. So keep in mind that these
are for primary prevention so the guidelines don’t
change recommendation for people who have known heart disease so if you had a heart attack
or you had a coronary stent, aspirin is still recommended. But in the current
guidelines they indicate, based on some recent trials and the overall evidence
that most healthy people, aspirin therapy is not routinely
recommended for prevention. The risk of bleeding may
outweigh any benefits and so most individuals who are healthy don’t need to take an
aspirin for prevention but it still may be considered in select high risk individuals after discussion with one’s doctor. So in some, these
guidelines really synthesize previous documents that were put forward and tries to put it all
together to help clinicians and their patients prevent that very first heart
attack or stroke event. Thank you.

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