Cardiovascular Prevention Samia Mora, MD, MHS Associate Physician Director, Center for Lipid Metabolomics Divisions of Preventive and Cardiovascular Medicine Department of Medicine Brigham and Women’s Hospital Associate Professor, Harvard Medical School
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Cardiovascular Prevention
Samia Mora, MD, MHS
Associate PhysicianDirector, Center for Lipid Metabolomics
Divisions of Preventive and Cardiovascular MedicineDepartment of Medicine
Brigham and Women’s HospitalAssociate Professor, Harvard Medical School
Samia Mora, MD, MHS
• Harvard Medical School
• Internal Medicine Residency: Mass General Hospital
• Cardiovascular Medicine Fellowship: Johns Hopkins
• Associate Professor of Medicine: Harvard Medical School
• Clinical focus: General Cardiology, Echocardiography
• Research focus: Prevention
Disclosures
• Dr. Mora has served as a consultant for Pfizer and Quest Diagnostics
Objectives
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Sonia Y. Angell. Circulation. 2020 141:e120-e138,
DOI: (10.1161/CIR.0000000000000758)
Global Burden of Disease Collaborative Network.
http://ghdx.healthdata.org/record/ihme-data/gbd-
2017-dalys-and-hale-1990-2017.
Leading Causes of Death in the US 2007-2017, by causes and risk factors
2. Eat a healthy diet (4-5 components of healthy diet score*)
2. Have a normal body weight (BMI < 25) 3. Never smoked or quit >1 year ago4. Total cholesterol <200 mg/dL5. Blood pressure <120/80 mm Hg6. Fasting blood glucose <100 mg/dL
AHA Life’s Simple 7
Lloyd-Jones et al. Circulation 2010; 121:586-613
* 1) 4.5 cups or more of fruits and vegetables per day 2) two or more 3.5-oz servings of fish per week 3) three servings per day of whole grains 4) less than 1500 mg of sodium per day 5) 36 ounces or less of sugar-sweetened beverages per week
Shiffman et al. JAMA Network Open 2020; 3(10): e2022119
Couples share heart disease risk factors and health habits
Concordance of AHA Life’s Simple 7 in US couples (N=10,728 individuals)
• Risk estimation (eg SCORE) is recommended for asymptomatic adults aged >40 years without evidence of
CVD, DM, CKD, FH, or LDL> 4.9 mmol/L (>190 mg/dL). IC
• High- and very-high-risk individuals (CVD, DM, moderate-to-severe renal disease, very high risk factors, FH,
or a high SCORE risk) are a priority for advice and management of all risk factors. IC
Lipid analyses for CVD risk estimation
• Total cholesterol is to be used for the estimation of total CV risk. IC
• HDL-C for further refining risk estimation. IC
• LDL-C is the primary lipid analysis method for screening, diagnosis, and management. IC
• Triglycerides (TGs) are recommended in routine lipid analysis. IC
• Non-HDL-C is recommended for risk assessment, particularly if high TGs, DM, obesity, or very low LDL-C.IC
• Apolipoprotein B is recommended for risk assessment, particularly in people with high TGs, DM, obesity,
MetS, or very low LDL-C. Can be used as an alternative to LDL-C, if available, as the primary measurement
for screening, diagnosis, and management, and may be preferred over non-HDL-C in people with high TGs,
DM, obesity, or very low LDL-C. IC
Treatment goals for LDL-C in primary prevention
In individuals at very-high risk, LDL-C reduction ≥ 50% and an LDL-C goal of <1.4 mmol/L (<55 mg/dL). IC
In individuals at high risk, LDL-C reduction ≥ 50% and LDL-C goal of <1.8 mmol/L (<70 mg/dL). IA
Mach et al Eur Heart J 2020; 41:111
2019 European dyslipidemia guidelines
26 yo Hispanic M, smoker, multiple borderline risk factors, BMI 33, Lp(a) 70 (uln 30 mg/dL)
One day prior to his myocardial infarction:
• Does he have any of the other risk enhancing factors that the 2018/2019 ACC/AHA guidelines recommend can be considered if a risk decision is not certain?
A. SmokingB. Obesity (his BMI 33)C. High lifetime risk D. High Lp(a) (his Lp(a) 70 mg/dL)
Case 2
Case 2 Discussion
Discussion:
• High lifetime risk is a factor that the guidelines say can inform treatment decision regarding initiation or intensification of statin therapy
• High Lp(a) (≥ 50 mg/dL or ≥ 125 nmol/L) is a risk enhancing factor
• Obesity is not a risk enhancing factor (but metabolic syndrome is)
• Smoking is a major risk factor
26 yo Hispanic M, smoker, multiple borderline risk factors, BMI 33, Lp(a) 70 (uln 30 mg/dL) - one day prior to ACS:• Does he have any of the other risk enhancing factors that the 2018/2019 ACC/AHA
guidelines recommend can be considered if a risk decision is not certain? A. SmokingB. Obesity (his BMI 33)C. High lifetime risk D. High Lp(a)
1. To review current challenges for CVD prevention
2. To review recent evidence / guidelines on:
• Lifestyle
• CV risk assessment
• Cholesterol
• Aspirin
Zheng et al. JAMA 2019; 321:277
Low-dose aspirin in the primary prevention of ASCVD
2019 Meta-analysis
2019 ACC/AHA Prevention Guidelines
Recommendations for Aspirin Use
COR LOE Recommendations
IIb A
1. Low-dose aspirin (75-100 mg orally daily) might be considered for theprimary prevention of ASCVD among select adults 40 to 70 years of agewho are at higher ASCVD risk but not at increased bleeding risk.
III:
HarmB-R
2. Low-dose aspirin (75-100 mg orally daily) should not be administered ona routine basis for the primary prevention of ASCVD among adults >70years of age.
III:
HarmC-LD
3. Low-dose aspirin (75-100 mg orally daily) should not be administered forthe primary prevention of ASCVD among adults of any age who are atincreased risk of bleeding.
Arnett et al JACC 2019;74:e177
• Europe
• USPSTF
Bibbins-Domingo et al. Ann Intern Med 2016;164:836Piepoli et al. Eur Heart J 2016;37:2315
What do other guidelines recommend?
Other Guidelines
2020 ADA Recommendations for Patients with DM
• Aspirin 75 to 162 mg/day for secondary prevention (DM + ASCVD) • clopidogrel 75 mg/day if asa allergy
• ASA 75-162 mg/day may be considered for primary prevention in diabetic patients at increased ASCVD risk and not increased risk of bleeding– Those at risk for ASCVD (10-year risk >10%)— age >50 yrs, with >1
additional risk factor:– Family history of premature ASCVD– HTN– Smoking– Dyslipidemia– CKD/Albuminuria
• Generally not recommended to start in patients older than 70 years • Not recommended for primary prevention in low risk groups (<50 yrs, no other
risk factors)ADA Diabetes Care 2018;41:S86-S104
Diabetes Care 2020;43:S111-S134.
Yusuf et al, N Engl J Med. 2021; 384: 216-228
N=5,713Intermediate risk (>1%/yr)M≥50y, F ≥55y37% DMLDL-C 120
TIPS-3
Aspirin-Guide app
www.aspiringuide.com
Individualize the risk:benefit assessment for primary prevention for patients at increased ASCVD risk and who are not at increased risk of bleeding
Mora et al JAMA 2016;316:709
Mora et al JAMA Intern Med 2016;176:1195
1. Cardiovascular disease #1 cause of death
2. Assess cardiovascular risk
(risk factors, risk-enhancing factors, global risk score, CAC)
3. Lifestyle improvement is the most important component of prevention and risk
factor control (Life’s Simple 7)
4. Statins added to lifestyle to reduce risk in higher risk individuals (risk-enhancing
factors, CAC); PCSK9i in the very highest risk patients
5. Blood pressure control: Target BP for most patients <130/80 mmHg; risk-
based assessment
6. Aspirin (low-dose) in higher risk individuals if benefit outweighs risk of bleeding
(avoid in low risk individuals and elderly)
Take-home messages:
Summary
ACC Cholesterol Guideline Tools
Guidelines Made Simple - A selection of the most impactful tables and figures
from the 2018 Cholesterol Guideline.
• Available at: ACC.org/GMSCholesterol
Guideline Overview Tool – A broad overview of primary and secondary
prevention, including evaluation, therapy, and treatment expectations.
• Available at: ACC.org/CholTool
2013 – 2018 Guideline Comparison Tool – A summary of the
major new and updated recommendations between the 2013
ASCVD risk enhancers used in the 2018 and 2019 ACC/AHA guidelines
• Family history of premature ASCVD (men <55 y, women <65 y)• Primary hypercholesterolemia (LDL-C ≥160 mg/dL [4.1 mmol/L]; non-HDL-C ≥190 mg/dL [4.9 mmol/L])• Chronic kidney disease (eGFR 15-59 ml/min/1.73 m2, not on dialysis or kidney transplant)• Metabolic syndrome • Conditions specific to women (e.g. preeclampsia, premature menopause)
• Chronic inflammatory conditions (especially rheumatoid arthritis, lupus, psoriasis, HIV)• High risk race/ethnicity (e.g. south Asian ancestry)
In selected individuals if measured:• hsCRP ≥2 mg/L• Lp(a) levels ≥50 mg/dL or ≥125 nmol/L • ApoB levels ≥130 mg/dL• Ankle-brachial index <0.9
Grundy S et al JACC 2019 PMID: 30423393 Arnett et al JACC 2019 PMID:30894318
2019 ACC/AHA Primary Prevention GuidelineAssessment of ASCVD: Use of CAC
*Clinicians and patients may not wish to postpone therapy in patients with a CAC score of 0 and diabetes mellitus, heavy current cigarette smoking, or strong family history of premature ASCVD.
2017 ACC/AHA Blood Pressure Guidelines
BP Classification (JNC 7 and ACC/AHA Guidelines)
SBP DBP
<120 and <80
120–129 and <80
130–139 or 80–89
140–159 or 90-99
≥160 or ≥100
2003 JNC7
Normal BP
Prehypertension
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
2017 ACC/AHA
Normal BP
Elevated BP
Stage 1 hypertension
Stage 2 hypertension
Stage 2 hypertension
• Blood Pressure should be based on an average of ≥2 careful readings on ≥2 occasions• Adults with SBP or DBP in two categories should be designated to the higher BP category
Whelton et al. Hypertension. 2018; 71:e13–e115.
130/80 140/90
10-yr risk <10%
10-yr risk ≥10%
Diabetes
CKD
Heart Healthy lifestyle
Pharmacotherapy
Pharmacotherapy
Goal BP
Heart Healthy lifestyle
Intensive lifestyle modification
Intensive lifestyle modification
Whelton et al. Hypertension. 2018; 71:e13–e115.
2017 ACC/AHA Blood Pressure Guidelines
1. Self-monitor BP at home & measure every clinic visit2. 10-yr risk ≥15%, goal <130/ <80 if safely attained3. 10-yr risk <15%: goal <140/ <90
2020 ADA Recommendations for patients with diabetes & HTN
Diabetes Care 2020;43:S111-S134.
Other BP Guidelines
1. 130-139/80-89 Lifestyle (drugs only if v. high risk)2. 140-159/90-99 & high risk: Lifestyle + drugs
low risk: Lifestyle + drugs after 3-6 months2. ≥ 160 / ≥ 100: Lifestyle + drugs3. Different targets based on age, comorbidities,