New prevention guideline: Collaboration encouraged, aspirin downplayed

Amit Khera NEW ORLEANS — The new prevention guideline from the American College of Cardiology and the American Heart Association emphasizes team-based care and shared decision-making and recommends against use of aspirin for primary prevention in most adults.

“For the clinician, this guideline is a one-stop shop,” writing committee member Amit Khera , MD, MSc , FACC, FAHA , professor of internal medicine and director of the UT Southwestern Preventive Cardiology Program, who holds the Dallas Heart Ball Chair in Hypertension and Heart Disease, told Cardiology Today . “This is very important because there are so many different guidances out there, and to have all of this in one place is great. It is also important to note that lifestyle is the foundation of this guideline. There are recommendations about exercise, nutrition, smoking cessation and other components that underpin risk factors.”

The guideline, unveiled at the ACC Scientific Session and simultaneously published in Circulation and the Journal of the American College of Cardiology , also encourages a focus on social determinants of health and endorses the use of SGLT2 inhibitors and GLP-1 receptor agonists for CVD prevention in certain patients with diabetes.

Collaboration emphasized

Cardiology Today Prevention Section Editor Roger S. Blumenthal, MD, director of the Ciccarone Center for the Prevention of Heart Disease and professor of medicine at Johns Hopkins Medicine and co-chair of the writing panel, told Cardiology Today “this is the first comprehensive prevention guideline that the ACC and AHA have ever put together. It is geared not only to clinicians in cardiology, but also in primary care, and we also believe it will be understood by the lay public.” The new prevention guideline from the American College of Cardiology and the American Heart Association emphasizes team-based care and shared decision-making and recommends against use of aspirin for primary prevention in most adults. Donna K. Arnett, PhD, MSPH, FAHA, dean of the College of Public Health and professor of epidemiology at the University of Kentucky and past president of the AHA, who co-chaired the writing committee, said during a press conference that “we decided there are three themes that have to underlie all prevention. The first is that we need a team-based approach to care for risk factors for ASCVD. The second is that all decisions should be shared between the clinician and the patient as they are discussing the best strategies to reduce risk. Finally, we adopted the recommendation that social determinants of health should inform optimal implementation of treatments for the prevention of ASCVD.”

Focus on aspirin

Notably, aspirin is not recommended for primary prevention in most adults, and the panel based that decision in part on the results of the recent ARRIVE, ASCEND and ASPREE trials.

The single top message from this guideline is that a healthy lifestyle is essential for the prevention of CVD and stroke. These factors are crucial regardless of one’s state of health. Also important is that in clinical settings, this notion of team-based care, shared decision-making and assessing social determinants of health can help deliver the clinical guidelines in a way that takes into account the context of the patient’s life and uses the team that already exists to optimally effect change in individuals.

The emphasis on tobacco may have been overlooked before. It is still the single leading preventable cause of death in the U.S. The recommendation to use aspirin very sparingly for primary prevention is also going to change practice. Eduardo J. Sanchez , MD, MPH

Chief Medical Officer for Prevention
Chief, Center for Health Metrics and Evaluation
American Heart Association

Disclosures: Sanchez reports no relevant financial disclosures.

There is not a lot in this guideline that is new. A certain amount regurgitates the prior prevention guidelines. Many of the messages are self-evident: People should eat a healthy diet, exercise regularly and not smoke. Much of what’s in there represents a safe route. Controversial issues such as the keto diet are not addressed. There is support for the Mediterranean diet, which is evidence-based. I have some issues with the sodium recommendations because there are mixed data on salt. In people without hypertension, it’s not entirely clear if salt is as bad as it’s portrayed to be. It’s also not clear if all saturated fats are the same; saturated fats that come from meat may promote different outcomes than those that are naturally occurring, but that is not really addressed.

The emphasis on healthy lifestyle is appropriate and appreciated, but, the reality is, most Americans don’t necessarily follow healthy lifestyles, so I would have hoped for a bit more acknowledgement that there are significant numbers of people who have never had a heart-related event that need to be treated with cholesterol-lowering drugs.

I do like the idea of shared decision-making. In all areas of medicine, it is advisable to sit down with a patient, tell them what we know and don’t know, and then together make a decision about whether they should be treated with a medication. That is reasonable advice.

For the last 15 years, I have been on the warpath that aspirin should not be used in primary prevention. Unless you are very high risk, you should not be taking aspirin, and most of the people taking it are the “worried well.” I am glad this has been acknowledged. More people are taking aspirin than should be.

There is one subtlety: the authors have acknowledged that the Pooled Cohort Equation can overestimate or underestimate risk. When it was introduced in 2013, many of us were critical because it had not been verified or published but was appearing for the first time in a guideline for more than 300 million Americans. It has taken 6 years to acknowledge that maybe there are some issues with it. I’m glad this happened, because I have always been worried that people could be undertreated or overtreated based on a risk calculator that had not been fully verified at the time it was published. Steven E. Nissen, MD, MACC

Cardiology Today Editorial Board Member
Cleveland Clinic

Disclosures: Nissen reports no relevant financial disclosures.

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