Science News from research organizations ACC/AHA guidance for preventing heart disease, stroke released Adopting heart healthy habits, understanding risk and rarely using aspirin to prevent a first heart attack or stroke among recommendations Date: March 18, 2019 Source: American College of Cardiology Summary: Adopting a heart healthy eating plan, getting more exercise, avoiding tobacco and managing known risk factors are among the key recommendations in the 2019 Primary Prevention of Cardiovascular Disease guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA). Also, it is recommended that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. Share: FULL STORY The choices we make every day can have a lasting effect on our heart and vascular health. Adopting a heart healthy eating plan, getting more exercise, avoiding tobacco and managing known risk factors are among the key recommendations in the 2019 Primary Prevention of Cardiovascular Disease guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA). Also, it is recommended that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. The guideline, presented today at ACC's 68th Annual Scientific Session, offers comprehensive but practical recommendations for preventing cardiovascular disease, which remains the leading cause of death for both men and women in the United States. Nearly 1 out of 3 deaths in the U.S. is due to cardiovascular disease. "The most important way to prevent cardiovascular disease, whether it's a build-up of plaque in the arteries, heart attack, stroke, heart failure or issues with how the heart contracts and pumps blood to the rest of the body, is by adopting heart healthy habits and to do so over one's lifetime," said Roger S. Blumenthal, MD, co-chair of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease and the Kenneth Jay Pollin Professor of Cardiology at Johns Hopkins Medicine. "More than 80 percent of all cardiovascular events are preventable through lifestyle changes, yet we often fall short in terms of implementing these strategies and controlling other risk factors." The new prevention guideline, he said, is intended to provide a roadmap of strategies that can be used and tailored to help people without a history of heart disease stay heart healthy and, importantly, emphasize the need to identify and address personal or social barriers for doing so (e.g., income and education levels, cost concerns, lack of health insurance, access to healthy foods or safe places to exercise, life stressors). Risk Assessment According to the guideline, any effort to prevent a first instance of cardiovascular disease (called primary prevention) should ideally start with a thorough assessment of one's risk -- that is, estimating how likely someone is to develop blockages in their arteries and have a heart attack or stroke or die as a result. All patients should openly talk with their care team about their current health habits and personal risk for cardiovascular disease and, together, determine the best way to prevent it based on current evidence and personal preferences. "We have good evidence now for how to identify these very high risk individuals with a physical exam and a good history, and for those at borderline risk there are additional factors that can help us determine who is at greater risk and should, for example, be on a medication like a statin earlier to prevent a cardiovascular event," Blumenthal said. "In the past, a lot of people may have had a fatalistic attitude that they were going to develop heart problems sooner or later but, in reality, most cardiovascular events can be prevented." The document synthesizes the best data and proven interventions for improving diet and exercise, tobacco cessation and optimally controlling other factors that affect one's likelihood of heart problems and stroke (e.g., obesity, diabetes, high cholesterol and high blood pressure). The document also discusses the challenges that may interfere with individuals being able to integrate better lifestyle habits. Lifestyle Change Recommendations The guideline underscores healthy lifestyle changes as the cornerstone of preventing heart disease and goes a step further by providing practical advice based on the latest research. "We can all do better with our dietary and exercise habits, and that's so important when we think about wanting to live longer and healthier lives, whether it's to see our grandchildren grow up or to stay as active as possible in older age," Blumenthal said. Some of the key lifestyle recommendations include: Eating heart healthier -- choosing more vegetables, fruits, legumes, nuts, whole grains, and fish, and limiting salt, saturated fats, fried foods, processed meats, and sweetened beverages; specific eating plans like the Mediterranean, DASH and vegetarian diets are reviewed. Engaging in regular exercise -- experts advise aiming for at least 150 minutes of moderate-intensity exercises such as brisk walking, swimming, dancing or cycling each week. For people who are inactive, some activity is better than none and small 10-minute bursts of activity throughout the day can add up for those with hectic schedules. Currently, only half of American adults are getting enough exercise and prolonged periods of sitting can counteract the benefits of exercise. Aiming for and keeping a healthy weight -- for people who are overweight or obese, losing just 5 to 10 percent of their body weight (that would be 10-20 pounds for someone who weighs 200 pounds) can markedly cut their risk of heart disease, stroke and other health issues. Avoiding tobacco by not smoking, vaping or breathing in smoke -- 1 in 3 deaths from heart disease is attributable to smoking or exposure to secondhand smoke, so every effort to try to quit through counseling and/or approved cessation medications should be supported and tailored to each individual.
FEATURED Published in J William McEvoy MB BCh BAO, MEHP, MHS, FRCPI Interview by Aman Shah MD Get Topic Alerts 2019 ASCVD Guidelines Aspirin Utilization This multimedia content was independently funded and produced by PracticeUpdate. Publication does not constitute representation by PracticeUpdate that the data presented are correct or sufficient to support the conclusions reached. Dr. Shah: So earlier in this conversation, we talked about the overall ASCVD guidelines for primary prevention, and you had mentioned that aspirin is a particular area of focus and change. So, could you give us an overview of how physicians should be using aspirin for primary prevention? Dr. McEvoy: Yes. Thank you. I think this is the most important, well, in my view, the most important part of the new 2019 primary prevention guideline. It’s also very newsworthy and timely in the context of recent studies. I think some of the history around this is important to note in the context of where the guidelines stand right now. Historical trials, which were all done before the year 2000, did demonstrate in primary prevention populations who were given aspirin in a randomized trial setting a really significant reduction in the MI. That was offset by some excess bleeding, of course, which aspirin is prone to as an antiplatelet therapy, but based on that really robust reduction in the MI, prior guidelines did recommend aspirin in primary prevention for patients who had elevated CVD risk. Typically, the cut point there was 10%, similar to what the blood pressure guidelines still recommend today, but only in the context of having a low bleeding risk. If patients had bleeding risk and a prior history of ulcers, GI bleeding, other major bleeding, risk factors for bleeding, including additional medications like warfarin, for example, the guidelines weren’t recommending aspirin in that setting. But in the patient or the adult who had low bleeding risk and a high enough CVD risk estimate, aspirin was recommended, and based on the trials it actually had a very strong level of recommendation. It had a class of recommendation of I, which is the highest-class level of evidence, a. So, a Ia recommendation for aspirin in primary prevention with elevated risk, and those were from 2002. That was the last time that the ACC/AHA formally weighed in on primary prevention aspirin in the whole spectrum of adult patients who are at risk for CVD. Since then, there have been more recent trials, and really since 2000, four trials that were done in the early 2000s had null effect with aspirin, so no significant reductions in primary endpoints of those trials. And these were in patients who had elevated risk. And so on that basis, European guidelines, which were last updated in 2016, do not recommend aspirin for the primary prevention of CVD. And that’s in contrast, of course, with the American guidelines that recommended it as recently as 2002, and so that distinction has been a source of some controversy and confusion. The US Preventive Services Task Force also had a guideline in 2016. And to add to the confusion, they did recommend aspirin around the same time as the European guidelines said no, and only in patients who were age 50 to 59 who had an elevated risk. So all that led to some controversy and then along comes three major trials last year in aspirin and primary prevention, ASCEND, ARRIVE, AND ASPREE. Big studies, over 10,000 patients in each study. All primary prevention. Some differences in the studies. ARRIVE was a high-risk or a moderate-risk group, ASCEND was diabetics, and ASPREE was older participants, but all given aspirin or placebo, low-dose 100 mg aspirin allocation. Only one of those three trials met the primary endpoint or had a reduction in the primary endpoint and that was ASCEND, reduction in time to first vascular event. ARRIVE and ASPREE had no reduction in the primary endpoints and all three had increased bleeding. And the meta-analysis data that’s been done since has suggested that the benefit, if any, for aspirin, mostly relates to reduction in MI, and it’s offset to a large extent somewhat balanced by excess bleeding. And so it was really timely for the ACC/AHA to come in, in 2019, and give some guidance to physicians around how aspirin should be allocated for the primary prevention of CVD. Dr. Shah: And what are the guidelines as of today, don’t use it? Dr. McEvoy: The feeling was that it would be important to leave that option open to providers, to clinicians, having a discussion with their patient and discussing the risks and benefits of aspirin and finding the patient's preferences around aspirin to give them some leeway to continue to use aspirin in select circumstances. I will say that the recommendation, the IIb was only for those aged 40 to 70. Over 70, there was a recommendation not to provide aspirin for primary prevention because the bleeding risk is higher in those over 70 and because ASPREE, which was a trial in elderly patients, was very null. So, it’s really just in the kind of middle-aged group who have excess risk that aspirin might be considered. Again, a weak recommendation overall, but not a recommendation to say no in all cases. Dr. Shah: Very interesting. And to switch gears a little bit, for secondary prevention what is the state of the data and how would you approach it? Dr. McEvoy: So, secondary prevention—and I’m glad you asked that because it could be a source of confusion and I think it’s important to be very clear about this. Aspirin is still recommended for secondary prevention, class I, and so a strong recommendation in secondary prevention. The reason being is that those who’ve had an event in the past are much higher to have a recurrent event in the future than people who’ve never had an event ever. And so in that context, even though there’s a risk of bleeding, the benefit compared to the risk is more substantial for those who have a prior history, and so they stand more to benefit from aspirin than they do to lose in terms of bleeding. However in primary prevention, it’s a little bit more complicated, and again, that IIb recommendation is a fairly weak recommendation.
