Within the field of Cardiology, primary prevention of heart disease is an area that is just MADE for primary care clinicians. What do the guidelines say, and how can PCPs best put them into action with our patients? Academic cardiologist Dr. Stan Liu is back for a helpful primer on the primary and secondary prevention of cardiovascular disease for the PCP.
Pearls:
- Assess women with obstetric history to better assess CV risk. For those with relevant obstetric history, counsel them on the increased risk and consider more closely monitoring preventable CV risk factors.
- Sleep is an important CV risk factor that is newly added to AHA guidelines
- Primary prevention aspirin should rarely be used.
- Use the ACC/AHA risk calculator along with risk enhancing factors for patients 40-75.
- For those patients with established disease, goal LDL < 70 or even 55.
- 1. Diet
- 2. Participation in physical activity
- 3. Not smoking
- 4. Healthy weight
- 5. Healthy blood lipids
- 6. Healthy glucose
- 7. Healthy blood pressure
- 8. Sleep (recent addition)
Sleep is an important CV risk factor:
- Question: “Do you have any problems falling asleep, staying asleep, or sleeping too much?”
- Sleep is a recognized risk factor for CV health particularly how it impacts hypertension
History of obstetric complications predicts future CV risk:
- Women who had preeclampsia, gestational hypertension or gestational diabetes have increased risk of essential hypertension, diabetes, MI and stroke
- History of preeclampsia confers 3x relative risk for developing CV issues compared to women with no pre-eclampsia
- Gestational diabetes predicts diabetes – up to 50% of patients will have diabetes in 5 years and they are 2x likely to develop CV complications later in life compared to women with no gestational diabetes
- Preterm delivery and stillbirth birth are also associated with cardiovascular risk
- Bottomline: Assess women with obstetric history to better assess CV risk. For those with relevant obstetric history, counsel them on the increased risk and consider more closely monitoring preventable CV risk factors
Male-specific CV risk:
- Erectile dysfunction is an independent CV risk factor that may be as high as 50-60%
- For men with ED, take an opportunity to provide lifestyle counseling
ASCVD risk calculator:
- ACC/AHA ASCVD risk calculator is still alive and well but they have added risk categories:
- High risk > 20% 10-year risk of ASCVD
- If in this category you want to get LDL down by 50%
- Intermediate risk 7.5-20% 10-year risk of ASCVD
- Borderline risk 5-7.5% 10-year risk of ASCVD
- Pearl: New risk enhancers that may not be reflected in the calculator:
- Inflammatory disease
- South Asian ancestry - not in the calculator but this group has overall higher prevalence of CV disease
- Abnormal ABIs
- Obstetric history
Aspirin:
- No longer recommended for primary prevention
- ASCEND trial in 2018 showed that aspirin use for those with diabetes reduced CV risk by 2% but increased risk of bleeding, especially after 60-70 years of age
Coronary artery calcium scoring:
- CT scan without contrast that calculates the total amount of calcium build up in the coronary arteries
- No calcification does no mean zero risk as some plaques aren’t calcified are you can have small vessel disease
- A high score is also not necessarily predictive either
- earl: Use as another data point if you’re on the fence about CV risk but it is not meant to be another risk stratified (like a stress test)
Secondary prevention:
- These patients have established disease so the risk factor no longer applies to them
- Goal LDL < 70 mg/dL (European guidelines say < 55), highest dose of tolerated statin
- If you can’t get LDL goal with statin alone, you can try ezetimibe because of a trial that showed small mortality benefit
- Another possibility is the injectable PCSK9 inhibitors every 2-4 weeks but it is very expensive
Want to hear more from our experts? Listen to the full podcast episode here.
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