Cardiovascular Disease Prevention

Chart risk estimators that use population-based and clinical trial outcomes are used to match the need of preventive therapies to the absolute risk; usually 10 years for an atherosclerotic vascular disease event. ³ The atherosclerotic vascular disease Risk Estimator Plus guideline suggests the race and sex-specific Pooled Cohort Equation (PCE) to estimate the 10-year ASCVD risk for asymptomatic individuals between the ages of 40-79 years. Adults are categorized into low (<5%), borderline (5 to <7.5%), intermediate (≥7.5 to <20%), or high (≥20%) 10-year risk. The PCEs are best validated among non-Hispanic whites and non-Hispanic blacks within the United States. ⁵ The PCE may be overestimated or underestimated in other race groups and non-US populations. Among those who have borderline (5 to <7.5%) and intermediate cardiovascular risk (≥7.5 to <20%), The healthcare provider should consider additional individual “risk-enhancing” clinical factors that can be used to revise the 10-year ASCVD risk estimate. For example, initiating or intensifying statin therapy would include a borderline risk (5 to <7.5%), and family history of premature ASCVD, high cholesterol, chronic kidney disease, rheumatoid arthritis, lupus, HIV, metabolic syndrome, pre-eclampsia, or premature menopause. The American Heart Association and the American College of Cardiology identified the following behaviors that pose an increased risk for heart disease. ¹˒²˒³

Nutrition 

To reduce the risk, individuals should consume a healthy diet that is high in fruits, vegetables, whole grains, nuts, and lean animal protein which has been shown to lower the risk of cardiovascular disease related mortality.¹ Longstanding dietary patterns that focus on low intake of carbohydrates and a high intake of animal fat and protein as well as high carbohydrate diets are associated with increased cardiac and noncardiac mortality. The increased availability of affordable, palatable, and high-calorie foods along with decreased physical demands of many jobs have fueled the epidemic of obesity and the consequent increases in hypertension and type II diabetes mellitus. 

Obesity 

Adults who are diagnosed as overweight (BMI 25-29.9 kg/m²) or obese (body mass index [BMI ≥30 kg/m²) are at increased risk of developing atherosclerotic heart disease and heart failure compared with those of a normal weight.¹ Obese and overweight adults should be instructed to participate in comprehensive lifestyle changing programs for 6 months that will assist them in adhering to a low-calorie diet and high levels of physical activity.  Weight loss is associated with improved blood pressure, cholesterol levels, and glucose levels among overweight and obese individuals. Weight loss can also delay the development of type II diabetes mellitus. In addition to diet and exercise, FDA-approved pharmacologic therapies and bariatric surgery may have a role for weight loss in select individuals. 

Exercise 

Despite the public health emphasis for regular exercise based on extensive observational data that physical activity lowers atherosclerotic cardiovascular disease, approximately 50% of adults in the United States do not meet the minimum recommendations.³ There is a strong inverse relationship between the amount of moderate-to-vigorous physical activity and incident ASCVD events and mortality; meaning the less exercise an individual has, the more likely they are to experience a cardiovascular event. To reduce the risk, adults should engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week. 

Hypertension 

Hypertension accounts for more atherosclerotic cardiovascular disease deaths than any other modifiable risk factor. ²The prevalence of stage I hypertension is 46% higher in African Americans, Asian, and Hispanic Americans, and this number increases with age. Stage I hypertension is defined as having a systolic blood pressure ≥130 mmHg or a diastolic blood pressure ≥80 mmHg.  
In adults with prehypertension (121/80 mmHg) or stage I hypertension, the initial recommendations include exercise and weight loss, sodium restricted diet, and a heart healthy diet that is rich in potassium with supplements, as necessary. Non pharmacologic therapy to treat stage I hypertension in adults who have an estimated 10-year heart disease risk of less than 10%. Adults who have a 10% or higher 10-year heart disease risk should be recommended a blood pressure lowering medication with a blood pressure target of less than 130/80 mmHg. This goal includes adults with chronic kidney disease and diabetes. Adults with stage II hypertension ≥140/90 mm should also have a target goal of less than 130/80 mmHg.² This target goal is also recommended for adults with Stage II hypertension.  The following table lists ranges of hypertension and common drug classifications administered: 

Smoking 

Tobacco use is the leading preventable cause of death, disease, and disability. Inhaled and chewing tobacco increases the risk for atherosclerotic cardiovascular heart disease. Secondhand smoke can also cause of ASCVD and stroke. ² In fact, almost one third of heart disease deaths are attributed to smoking and exposure to secondhand smoke. Even infrequent smoking increases the risk of heart attack. Because even smoking infrequently increases this risk, reducing the number of cigarettes per day will not eliminate the risk of heart attack. Electronic Nicotine Delivery Systems (ENDS), also known as e-cigarettes and vaping, are a class of tobacco products that emit aerosol containing fine and ultrafine particulates, nicotine, and toxic gases that may increase risk for cardiovascular and pulmonary diseases. Arrhythmias, hypertension, and deaths related to e-cigarette use have been reported. Chronic e-cigarette use is associated with persistent increases in oxidative stress and sympathetic stimulation in young healthy adults. 
Adults should be assessed at every visit for tobacco use, and those who use tobacco should be strongly advised and provided resources to quit smoking on every visit. Adults should be referred to specialists for behavioral modification, nicotine replacement such as the nicotine receptor blockers varenicline and bupropion, antidepressants.  

Chronic Kidney Disease 

Chronic kidney disease is a major risk factor for atherosclerotic cardiovascular disease and is often associated with other risks such diabetes and hypertension. ⁶ When an individual has heart disease, the heart may not pump blood correctly.  The heart may become too full of blood which will cause pressure to build in the main vein connected to the kidneys, resulting in a blockage and reduced supply of oxygen rich blood to the kidneys. The cascade can potentially lead to kidney disease. Also, When the kidneys are not working well the hormone system that regulates blood pressure must work harder to increase blood flow and supply to the kidneys. When this occurs, the heart must pump harder, which in turn can lead to heart disease. 

Most individuals with chronic kidney disease have hypertension, but it is not clear if this is a universal finding when the glomerular filtration rate is reduced. Pulse wave velocity is the gold standard non-invasive measure of aortic stiffness. ⁷˒⁸ It is elevated chronic kidney disease and a strong predictor of atherosclerotic cardiovascular disease risk in individuals with chronic kidney disease. Individuals with Chronic kidney disease are also prone to anemia which results from the lack of red blood cells and oxygen being circulated to the organs and tissues. This results in an increased risk for heart attack. The risk for heart attack is also increased with blood pressure, which results from the release of too much renin; an enzyme that helps control blood pressure.  

Diabetes 

Type II diabetes mellitus (T2DM) is defined as having a hemoglobin A1c (HbA1c) >6.5%. ¹˒² It is a metabolic disorder that is characterized by insulin resistance that leads to hyperglycemia. The development and progression of T2DM is heavily influenced by diet, physical activity, and body weight. Individuals with T2DM should have dietary counseling for a heart-healthy diet. An individual should also have at least 150 minutes per week of moderate to vigorous physical activity to lower the HbA1c level. Other risk factors for T2DM should also be identified and treated aggressively. For younger individuals, or those with a mildly elevated HbA1c at the time of diagnosis of T2DM, healthcare providers can consider a trial of lifestyle therapies for 3-6 months before drug therapy. 
Metformin is the first-line therapy that is used to improve glycemic control and reduce ASCVD.¹˒²  Compared to lifestyle changes, metformin resulted in a 32% reduction in diabetes related outcomes, a 39% reduction in myocardial infarction rates, and a 36% reduction in all-cause mortality. Several classes of medications have been shown to effectively lower the blood glucose level, but they may not affect ASCVD risk, including sulfonylureas such as glipizide and glyburide. Two classes of glucose lowering medications have recently demonstrated a reduction in ASCVD events in adults with T2DM and ASCVD. Canagliflozin, dapagliflozin, and empagliflozin; Sodium-glucose cotransporter 2 (SGLT-2) inhibitors act in the proximal tubule of the kidney to increase urinary excretion of glucose and sodium, which causes a reduction in HbA1c, weight, and blood pressure.  In randomized clinical trials, significant reduction in atherosclerotic vascular disease events and heart failure also occurred. Exenatide, liraglutide, and dulaglutide; glucagon-like peptide-1 receptor (GLP-1R) agonists work by increasing insulin and glucagon production in the liver, increasing glucose uptake in muscle and adipose tissue, and decreasing hepatic glucose production. Glucagon-like peptide-1 receptor agonist has also been found to significantly reduce the risk of ASCVD events in adults with type II diabetes mellitus who are at increased risk for developing atherosclerotic disease. In patients with type II diabetes mellitus and additional risk factors for cardiovascular disease, it may be reasonable to initiate both classes of medication to prevent cardiovascular disease.  

Cholesterol 

Atherosclerotic vascular disease prevention requires assessing risk factors that begin in childhood. A statin is indicated for those less than 19 years old and have familial history of hypercholesterolemia. Young adults between the ages of 20-39 years should have their lifetime risk estimated and be given priority in promoting a healthy lifestyle. Statin should be considered in individuals with a family history of premature ASCVD and low-density lipoprotein cholesterol (LDL-C) of ≥160 mg/dl. Atherosclerotic cardiovascular disease risk-enhancing factors should be considered in all persons.