Guide to Primary Prevention of Cardiovascular Diseases

HomeCirculationVol. 95, No. 9Guide to Primary Prevention of Cardiovascular Diseases Free AccessResearch ArticleDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticleDownload EPUBGuide to Primary Prevention of Cardiovascular Diseases A Statement for Healthcare Professionals From the Task Force on Risk Reduction Scott M. Grundy, Gary J. Balady, Michael H. Criqui, Gerald Fletcher, Philip Greenland, Loren F. Hiratzka, Nancy Houston-Miller, Penny Kris-Etherton, Harlan M. Krumholz, John LaRosa, Ira S. Ockene, Thomas A. Pearson, James Reed, Reginald Washington and Sidney C. SmithJr Scott M. GrundyScott M. Grundy , Gary J. BaladyGary J. Balady , Michael H. CriquiMichael H. Criqui , Gerald FletcherGerald Fletcher , Philip GreenlandPhilip Greenland , Loren F. HiratzkaLoren F. Hiratzka , Nancy Houston-MillerNancy Houston-Miller , Penny Kris-EthertonPenny Kris-Etherton , Harlan M. KrumholzHarlan M. Krumholz , John LaRosaJohn LaRosa , Ira S. OckeneIra S. Ockene , Thomas A. PearsonThomas A. Pearson , James ReedJames Reed , Reginald WashingtonReginald Washington and Sidney C. SmithJrSidney C. SmithJr Originally published6 May 1997https://doi.org/10.1161/01.CIR.95.9.2329Circulation. 1997;95:2329–2331The clinical and public health approaches to primary prevention are complementary. Primary prevention refers to guidance given to persons with no known cardiovascular disease. Physicians can contribute to the public health approach through patient education. The first goal of prevention is to prevent the development of risk factors. Physicians should instruct all patients about adopting healthy life habits that will prevent intensification of risk factors. Patient education should be family oriented. Ideally, risk factor prevention begins in childhood. Preventing cigarette smoking by children and adolescents is a prime goal. Another major goal is prevention of overweight and obesity in children and weight gain in adults; overweight lies at the heart of several risk factors. Encouraging life habits that incorporate regular physical activity, especially walking, and active recreational sports likewise will decrease intensity of risk factors. Patients and their families should be encouraged to reduce their intake of cholesterol and saturated fats by using unsaturated vegetable oils instead of animal-based saturated fats and adopting the habit of eating smaller portions. Evaluation of the family history may reveal that other family members need intervention to avoid developing cardiovascular disease. Adoption of healthy life habits and early intervention will mitigate the severity of risk factors that are the result of aging and genetic factors.In addition to complementing public health efforts, a clinical approach is needed to detect the presence of established risk factors and to effectively modify them. The physician should regularly check for established risk factors: smoking, physical inactivity, elevated lipid levels, and high blood pressure. In the case of the latter two, the physician should seek the causes (ie, diet and lack of exercise). The recommendations presented in the chart are consistent with the American Heart Association position on risk factor control123 and the 27th Bethesda Conference, "Matching the Intensity of Risk Factor Management With the Hazard for Coronary Disease Events."4 These recommendations are also in accord with the recommendations of the Fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure5 and the National Cholesterol Education Program (NCEP).6 The AHA, the Joint National Committee, and the NCEP recommend testing for risk factors, beginning in early adulthood. The NCEP has identified low-density lipoprotein cholesterol as the primary target for cholesterol modification. The AHA Task Force on Risk Reduction further recognizes low levels of high-density lipoprotein cholesterol and high levels of triglycerides as secondary targets for lipid modification.Successful implementation of these recommendations entails a multistep process including assessment, intervention, planning for change, and long-term maintenance and follow-up. These steps can be carried out directly by primary care physicians or through referrals to consultants or specialized programs. Implementation usually requires a team approach involving physicians and other healthcare professionals, including registered dietitians. The physician must commit the time to make a proper assessment and initiate preventive efforts. Patients should be involved in developing an effective plan for change and strategies for altering behavior. A long-term physician-patient relationship is usually needed for successful prevention and modification of risk factors. Physicians must establish office practices consistent with sound prevention strategies.Introduction of healthy life habits should be universal. These habits include avoidance or cessation of smoking, healthy eating, weight control, and appropriate exercise. The decision to use drug therapy to control risk factors depends on a balanced assessment of absolute risk and the efficacy, safety, and cost-effectiveness of the intervention. Medication for control of blood pressure is used to prevent both stroke and coronary heart disease. Use of cholesterol-lowering drugs for prevention of coronary heart disease depends heavily on assessment of absolute risk; drug therapy should be used cautiously for primary prevention in young adults who are otherwise at low risk. Use of cholesterol-lowering drug therapy in special groups was reviewed in detail in the NCEP report.6"Guide to Primary Prevention of Cardiovascular Diseases" was approved by the American Heart Association Science Advisory and Coordinating Committee in November 1996.A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Ask for reprint No. 71-0106. Table 1. Guide to Primary Prevention of Cardiovascular DiseasesRisk InterventionRecommendationsSmoking:Ask about smoking status as part of routine evaluation. Reinforce nonsmoking status.GoalStrongly encourage patient and family to stop smoking.complete cessationProvide counseling, nicotine replacement, and formal cessation programs as appropriate.Blood pressure control:Measure blood pressure in all adults at least every 21/2 years.GoalPromote lifestyle modification: weight control, physical activity, moderation in alcohol intake,≤140/90 mm Hgmoderate sodium restriction.If blood pressure ≥140/90 mm Hg after 3 months of life habit modification or if initial blood pressure>160/100 mm Hg: add blood pressure medication; individualize therapy to patient's other requirementsand characteristics.Cholesterol management:Ask about dietary habits as part of routine evaluation.Primary goalMeasure total and HDL cholesterol in all adults ≥20 y and assess positive and negative risk factors at leastLDL <160 mg/dL if 0-1every 5 years.risk factorsFor all persons: promote AHA Step I diet (≤30% fat, <10% saturated fat, <300 mg/d cholesterol),orweight control, and physical activity.LDL <130 mg/dL if ≥2Measure LDL if total cholesterol ≥240 mg/dL or ≥200 mg/dL with ≥2 risk factors or if HDL <35risk factorsmg/dLSecondary goalsHDL >35 mg/dLTG <200 mg/dLIf LDL: ≥160 mg/dL with 0-1 risk factors or ≥130 mg/dL on 2 occasions with ≥2 risk factors; then Start Step II diet (≤30% fat, <7% saturated fat, <200 mg/dL cholesterol) and weight control. Rule out secondary causes of high LDL (LFTs, TFTs, UA). If LDL: ≥160 mg/dL plus 2 risk factors; or ≥190 mg/dL; or ≥220 mg/dL in men <35 y; or in pre-menopausal women; thenRisk factors: age (men ≥45 y, women ≥55 y or post menopausal), hypertension, diabetes, smoking, HDL <35 mg/dL, family history of CHD in first-degree relatives (in male relatives <55 y, female relatives <65 y) HDL ≥60 mg/dL: Subtract 1 risk factor from the number of positive risk factors.Consider adding drug therapy to diet therapy for LDL levels > those listed above that persist despite Step II diet.Suggested drug therapy for high LDL levels (≥160 mg/dL)(drug selection priority modified according to TG level)TG <200 mg/dLTG 200-400 mg/dLTG >400 mg/dLHDL <35 mg/dL:StatinStatinConsider combinedEmphasize weight managementResinNiacindrug therapyand physical activity, avoidanceNiacin(niacin, fibrates, statin)of cigarette smoking. Niacin raises HDL. Consider niacin if patient has ≥2 risk factors and high LDL (except patients with diabetes).If LDL goal not achieved, consider combination drug therapy.Physical activity:Ask about physical activity status and exercise habits as part of routine evaluation.GoalEncourage 30 minutes of moderate-intensity dynamic exercise 3 to 4 times per week as well asIncrease amountincreased physical activity in daily life habits for persons who are inactive.Exercise regularlyEncourage regular exercise to improve conditioning and optimize fitness level.3-4 times perAdvise medically supervised programs for those with low functional capacity and/or comorbidities.week for 30 mintuesPromote environmental factors conducive to health (ie, golf courses that permit walking).Weight management:Measure patient's weight and height, BMI, and waist-to-hip ratio at each visit as part of routineGoalevaluation.Achieve and maintainStart weight management and physical activity as appropriate. Desirable BMI range: 21–25 kg/m2.desirable weightBMI of 25 kg/m2 corresponds to percentage desirable body weight of 110%;(BMI 21-25 kg/m2)desirable waist-to-hip ratio for men, <0.9; for middle-aged and elderly women, <0.8.Estrogens:Consider estrogen replacement therapy in postmenopausal women, especially those with multiple CHDrisk factors, such as elevated LDL.Individualize recommendation consistent with other health risks.TG indicates triglycerides; LFTs, liver function tests; TFTs, thyroid function tests; UA, uric acid; CHD, coronary heart disease; and BMI, body mass index. References 1 Krauss RM, Deckelbaum RJ, Ernst N, Fisher E, Howard BV, Knopp RH, Kotchen T, Lichtenstein AH, McGill HC, Pearson TA, Prewitt TE, Stone NJ, Horn LV, Weinberg R. Dietary guidelines for healthy American adults: a statement for physicians and health professionals by the Nutrition Committee, American Heart Association. Circulation..1996; 94:1795-1800.CrossrefMedlineGoogle Scholar2 Holbrook JH, Grundy SM, Hennekens CH, Kannel WB, Strong JP. Cigarette smoking and cardiovascular diseases: a statement for health professionals by a task force appointed by the steering committee of the American Heart Association. Circulation..1984; 70:1114A-1117A.MedlineGoogle Scholar3 Fletcher GF, Balady G, Blair SN, Blumenthal J, Caspersen C, Chaitman B, Epstein S, Sivarajan Froelicher ES, Froelicher VF, Pina IL, Pollock ML. Statement on exercise: benefits and recommendations for physical activity programs for all Americans: a statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation..1996; 94:857-862.CrossrefMedlineGoogle Scholar4 27th Bethesda Conference: Matching the Intensity of Risk Factor Management With the Hazard for Coronary Disease Events; September 14-15, 1995. J Am Coll Cardiol.1996; 27:957-1047.MedlineGoogle Scholar5 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med..1993; 153:154-183.CrossrefMedlineGoogle Scholar6 National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). 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