By Virginia Haiduc
The American College of Cardiology (ACC) and American Heart Association (AHC) released this March their latest Guideline on the Primary Prevention of Cardiovascular Disease. The main goal of primary prevention is to reduce the risks of developing heart disease or strokes in healthy individuals. Published in The Journal of the American College of Cardiology and Circulation, the 2019 report covers nine topics: diet, exercise, heart disease risk assessment, obesity and weight loss, diabetes, blood cholesterol, high blood pressure, smoking cessation, and aspirin use.
What is the emphasis of the guidelines this year?
The emphasis of the latest ACC/AHA guidelines is not on medication but on a healthy lifestyle with a focus on a heart-friendly diet, physical exercise, and no smoking.
If we care about our cardiovascular health but we are still eating fried foods, or drinking sugar-sweetened or artificially sweetened beverages on a daily basis, the experts are recommending a change in our eating habits. A heart-friendly diet is one that includes fruits and vegetables, nuts, whole grains, and fish, and is not based on refined carbohydrates, processed meats, trans fats or sugary drinks.
“Plant-based and Mediterranean diets, along with increased fruit, nut, vegetable, legume, and lean vegetable or animal protein (preferably fish) consumption, with the inherent soluble and insoluble vegetable fiber, have consistently been associated with lower risk of all-cause mortality than control or standard diets in observational studies” says the 2019 report. White bread, white pasta, and white rice are all considered refined carbohydrates. Processed meats include bacon, ham, salami, hot dogs, fast food chicken nuggets and hamburgers, beef jerky and pepperoni. Trans fats are considered the worst. In 2015, the U.S Food and Drug Administration or FDA decided to remove artificial trans fats from processed foods because they were no longer “Generally Recognized as Safe”. This is an ongoing process, and currently, the compliance date for the removal of these foods was extended to January 1, 2020.
The new report underlines that a good diet and physical activity are significant not only for healthy people, but also for those diagnosed with diabetes or high blood pressure.
When it comes to physical activity, the guidelines’ recommended goal is “at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity)”. If we are caught in a sedentary lifestyle, with no physical activity, we need to start slowly and increase the amount of physical exercise gradually. It is important to remember that any physical activity is better than no physical activity.
Adults who are overweight (Body Mass Index or BMI=25–29.9 kg/m2) or obese (BMI ≥30 kg/m2) have an increased risk of heart disease compared with those with a normal BMI, and they should follow specific lifestyle interventions in order to lose weight: increased physical activity, counseling, calorie restricted diet, regular BMI and waist circumference measurements and evaluations. “Existing clinical guidance strongly recommends face-to-face or telephone-delivered weight-loss maintenance programs that provide regular contact (at least monthly) with a trained interventionist to help participants engage in high levels of physical activity (200 to 300 minutes/week), monitor body weight regularly (at least weekly), and consume a reduced-calorie diet” specifies the report.
The 2019 guidelines strongly recommend that all adults should be assessed for tobacco use since “tobacco use is the leading preventable cause of disease, disability, and death in the United States.” Smoking, chewing tobacco, and exposure to secondhand smoke increase the risk of heart disease and stroke. Electronic Nicotine Delivery Systems (ENDS) or E-cigarettes are not considered safe either.
What is risk assessment or Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimation?
In order to prevent heart disease, doctors are periodically evaluating patients’ risk factors with the purpose of identifying those at risk for cardiovascular disease. A multidisciplinary team approach is considered a more efficient tool for primary prevention, compared with standard patient care, when one doctor guides the patient. A team might include not only physicians from different specialties but also nurses, nutritionists, pharmacists, and social workers. They all work together to guide the patients to better manage their risk factors.
Physicians can assess the ASCVD risk for each of the following age groups: 0–19 years, 20–39 years, 40–75 years and over 75 years. The 2013 ASCVD risk calculator endorsed by the American College of Cardiology and American Heart Association estimates the 10-year risk of ASCVD for age group 40 to 75 years old. The guidelines recommend that all patients should discuss their assessed risk with a physician for further evaluation, and tailored preventive interventions as coronary calcium scanning.
Recommendations for Cholesterol-Lowering Drugs Therapy
Cholesterol-lowering drugs or statins are recommended for adults 20 to 75 years of age with so-called “bad cholesterol” or low-density lipoprotein cholesterol (LDL) levels over 190 mg/dl , adults 40 to 75 years of age with diabetes, adults with diabetes and associated multiple risk factors, and adults at intermediate ASCVD risk (≥7.5%) as confirmed by a physician.
Does one Aspirin per day can still keep the doctor away?
One of the big shifts in the guidelines is the change in Aspirin use recommendations for primary prevention. In healthy people, studies showed that the risk of bleeding outweighs the potential benefits of Aspirin. Therefore, the new guidelines say: “Low-dose aspirin should NOT be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age, or among adults of any age who are at increased risk of bleeding. Low-dose aspirin (75–100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.’
In conclusion, one Aspirin per day can still keep the doctor away, but it is not indicated for everybody.
Virginia Haiduc has a Doctor of Medicine (M.D.) degree, and she is a member of American Medical Association.