Cardiovascular Disease Prevention

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Contact Hours: 3

This online independent study activity is credited for 3 contact hours at completion.

Course Purpose

To provide healthcare professionals with knowledge on atherosclerotic cardiovascular disease, it is risks, and preventions.

Overview

Arteriosclerotic cardiovascular disease is one of the leading causes of illness related death in the United States. It can occur at any age, and is prevalent in those who are obese, have high cholesterol, hypertension, diabetes, use tobacco, and do not exercise. There are many ways of improving the condition, including reducing obesity, cholesterol, hypertension, and diabetes through exercise and various medication treatment regimens. A healthcare provider must be able to identify risk factors related to the diagnosis to reduce the risk of disease and its progression. This learning activity provides a brief overview of atherosclerotic heart disease, the risk factors, and common treatment regimens. 

Objectives

Upon completion of the reading content, the healthcare professional will be able to: 

  • Define atherosclerosis
  • Identify risk factors that contribute to atherosclerotic cardiovascular disease.
  • Describe implementations to reduce the risk of atherosclerotic cardiovascular disease.

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Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

Fast Facts: Cardiovascular Disease Prevention

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Cardiovascular Disease Prevention Pretest

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Introduction

Arthrosclerosis is the result of plaques (fatty deposits) that clog the arteries. The plaques are made up of cholesterol, fatty substances, cellular waste products, calcium and fibrin, a clotting material in the blood. ² The wall of the artery becomes thick as a result of plaque buildup. This causes a narrowing of the channel within the artery which will reduce blood flow, causing a decrease in the amount of oxygen and other nutrients reaching the body. Atherosclerosis is a slow, progressive disease that can start at any age. It can progress rapidly in individuals as young as 30, and in others, it will not become dangerous until the age of 50 or greater. ² 

Exactly how atherosclerosis starts or what causes it is not known, however research has identified those at increased risk, and healthy habits that can reduce the incidence of having atherosclerotic cardiovascular disease. ¹ 

The American Heart Association and the American College of Cardiology created a guideline for cardiovascular disease prevention. ¹ The guideline was created after reviewing the most relevant studies and guidelines for atherosclerotic cardiovascular disease (ASCVD). The goal of the guideline is to increase prevention of heart disease, such as acute coronary syndromes, angina, myocardial infarction, stroke, peripheral arterial disease, and heart failure.¹ The guideline also emphasizes the shared responsibility of the patient and healthcare provider when making decisions and implementations on preventive strategies to improve cardiovascular health. 

Assessment of Atherosclerotic Cardiovascular Risk

To prevent atherosclerotic cardiovascular disease, one must first identify a risk. Identifying risk factors is the foundation of prevention. Individuals between the ages of 20-39 years should be assessed for risk factors of cardiovascular disease every four to six years to identify major contributing factors such as tobacco use, high cholesterol, high blood pressure, type II diabetes, family history of heart disease, etc.⁵ If major risk factors are identified, the healthcare provider should provide rationales for adopting a healthy lifestyle and track risk factor progression for possible treatment.  The atherosclerotic cardiovascular disease (ASCVD) Risk Estimator Plus guideline may be used for individuals aged 20-59 years who do not have an elevated 10-year risk. ASCVD Risk Estimator Plus uses science and user feedback to help a healthcare provider and patient build a customized risk lowering plan by estimating and monitoring changes over a 10-year period. Individuals 20-59 years of age not at high short-term risk, the 30-year and lifetime risk would be reasons for a discussion reinforcing adherence to healthy lifestyle recommendations and for possible drug therapy. 

Estimating the Risk of Developing Atherosclerotic Heart Disease

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

Behavior Prevalence 
Obesity 58.1% 
Hypertension 45.6% 
Low-Density Lipoprotein cholesterol ≥130 mg/dl 28.5% 
Lack of exercise 22.5% 
Smoking 15.5% 
Chronic kidney disease 14.8% 
Diabetes mellitus 13.5% 

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: 

Blood Pressure Classification Systolic Blood Pressure mmHg Diastolic Blood Pressure mmHg Lifestyle Changes Initial Drug Therapy 
Normal <120 <80 Encourage None indicted 
Prehypertension 121-139 80-89 Yes Drugs for compelling conditions 
Stage I Hypertension 140-159 90-99 Yes Usually a Thiazide, but may consider angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), beta blocker (BB), or calcium channel blocker (CCB) 
Stage II Hypertension  ≥160 ≥100 Yes Two combination drug therapy, usually a thiazide and an ACEI, ARB, BB, or CCB. 

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.  

Statin Treatment Recommendations

The following are guideline recommendations for statin treatment⁵:  

  • Individuals age 20-75 years who have LDL-C ≥190 mg/dl should use a high-intensity statin such as atorvastatin or rosuvastatin without a risk assessment.  
  • Individuals age 40-75 years who have type II diabetes mellitus should use a moderate-intensity statin such as simvastatin or lovastatin and have a risk estimate to consider high-intensity statins. Risk-enhancers in diabetics include ≥10 years for type II diabetes mellitus and 20 years for type I diabetes mellitus, retinopathy, and neuropathy, among others. In those with multiple atherosclerotic vascular disease risk factors, the healthcare provider should consider prescribing a high-intensity statin with aim of lowering LDL-C by 50% or more. 
  • Individuals older than 75 years should have a clinical assessment and plan for risk discussion. 
  • Individuals between the ages of 40-75 years with low density lipoprotein cholesterol >70 mg/dl and <190 mg/dl without diabetes should use the risk estimator that best fits and have risk enhancing factors assessed to decide the intensity of statin to be prescribed.  
    • If borderline risk (5% to <7.5%) and risk-enhancing factors are present the healthcare provider should consider a moderate-intensity statin. 
    • If intermediate risk (≥7.5-20%) is present, the healthcare provider should use moderate- intensity statins and increase to high-intensity with risk enhancers.  
    • If high risk (≥20%) is present the healthcare provider should consider a high-intensity statin to reduce LDL-C by ≥50%. 

Both moderate and high-intensity statin therapy reduces the risk of atherosclerotic cardiovascular disease, but a greater reduction in LDL-C is associated with a greater reduction in atherosclerotic cardiovascular disease outcomes. After a six-week period, if the reduction of the LDL-C is adequate as evidenced by a ≥30% reduction with intermediate statins and a 50% reduction with high-intensity statins, regular monitoring of risk factors and compliance with statin therapy can occur on a yearly basis.  

Antiplatelet Therapy

Low-dose aspirin has been widely used for primary prevention of heart disease. Aspirin reduces the risk of blood clots by irreversibly blocking platelet function, but it also increases the risk of bleeding, particularly in the gastrointestinal tract. Aspirin is well known regarding its effects for prevention of atherosclerotic heart disease and is widely used for this indication, but recent studies have shown that aspirin should not be used in the routine primary prevention of heart disease due to lack of net benefit. Aspirin should be avoided in adults with increased risk of bleeding, including a history of gastrointestinal bleeding, peptic ulcer disease, bleeding from other sites, are older than 70 years old, have a history of thrombocytopenia, coagulopathy, chronic kidney disease, or are currently using nonsteroidal anti-inflammatory drugs, steroids, or anticoagulants. The following are recommendations based on meta-analysis and three recent trials⁵: 

  • Low-dose aspirin should not be given on a routine basis to prevent atherosclerotic cardiovascular disease in adults over age 70. 
  • Low-dose aspirin should not be given to anyone for atherosclerotic cardiovascular disease who is at increased risk of bleeding. 
  • Low-dose aspirin may be considered for prevention of arteriosclerotic heart disease in adults age 40-70 who do not have an increased risk for bleeding. 

The American College of Cardiology also recommends aspirin therapy in adults who have experienced a heart attack or acute coronary syndrome (an umbrella term that describes a blockage of blood supply to the heart) in conjunction with a P2Y12 inhibitor. ⁴ The P2Y12 receptor is involved in platelet aggregation and is the target for the treatment of blood clots. Clopidogrel, prasugrel, or ticagrelor are P2Y12 inhibitors that are used in addition to aspirin after percutaneous coronary intervention after a cardiac event. ⁴ The American College of Cardiology has also recommended a timeline for use of P2Y12 inhibitors⁴: 

  • If bare-metal stent is placed, P2Y12 inhibitors should be taken for ≥1 month. 
  • If drug-eluting stent is placed, P2Y12 inhibitors for ≥1 year. 
  • If on dual antiplatelet therapy, use aspirin 81 mg/day. 
  • If no percutaneous coronary intervention was performed after an acute coronary syndrome event, either clopidogrel or ticagrelor should be used. 
  • Prasugrel should not be used if an individual has a history of stroke or transient ischemic attack and should be used with caution in adults 70 years of age. 
Conclusion

Arteriosclerotic cardiovascular disease can occur at any age and it is one of the leading causes of illness related death in the United States. It is most prevalent in those who have high cholesterol, hypertension, diabetes, are obese, use tobacco, and do not exercise. Arthrosclerosis can be reduced through increased exercise, weight reduction, lifestyle changes, and medication regimens to reduce hypertension, diabetes, and high cholesterol. The American Heart Association and the American College of Cardiology created a guideline for cardiovascular disease prevention with the goal of preventing heart disease which includes acute coronary syndromes, angina, myocardial infarction, stroke, peripheral arterial disease, and heart failure. In conjunction with the guidelines created by the American Heart Association and the American College of Cardiology, the healthcare provider can be a vital ally in preventing or reducing the risks that are associated with cardiovascular disease.

References
  1. 2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease. (2019, March 7). Retrieved from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention 
  2. Acute coronary syndrome. (2016, July 13). Retrieved from https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/acute-coronary-syndrome 
  3. AHA 2019 heart disease and stroke statistics. (2019, February 15). Retrieved from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/02/15/14/39/aha-2019-heart-disease-and-stroke-statistics 
  4. Banerjee, S. (2016). P2Y12 Inhibitors: Which One to Choose? CSI: Cardiology update 2015 (2 Volumes), 422-422. doi:10.5005/jp/books/12785_66 
  5. Bohula, E. A., Morrow, D. A., Giugliano, R. P., Blazing, M. A., He, P., Park, J., … Braunwald, E. (2017). Atherothrombotic risk stratification and ezetimibe for secondary prevention. Journal of the American College of Cardiology69(8), 911-921. doi: 10.1016/j.jacc.2016.11.070 
  6. Nissenson, A. R., & Fine, R. E. (2016). Handbook of dialysis therapy. Amsterdam, Netherlands: Elsevier.  
  7. Rangaswami, J., Lerma, E. V., & Ronco, C. (2017). Cardio-Nephrology: confluence of the heart and kidney in clinical practice. Basingstoke, England: Springer.  
  8. Swanepoel, C. (2017). Chronic kidney disease is a risk factor for cardiovascular disease. SA Heart4(3). doi:10.24170/4-3-2087 
Cardiovascular Disease Prevention Evaluation

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