Case Study: Primary Prevention of Cardiovascular Disease

Let’s take what we learned in overview 2019 ACC/AHA Guidelines for Primary Prevention of Cardiovascular Disease and apply the chance assessment tool to a real-life scenario. Remember that variables to contemplate include age, gender, race, blood pressure, cholesterol profile, history of diabetes, smoking, and whether the patient is currently taking medications for blood pressure, cholesterol, or coronary artery disease.

A 53-year-old Caucasian man returns to your office after having blood work done to debate treatment options. His past medical history includes prediabetes (HgA1C 6.4); class I obesity (BMI 31), family history of premature CAD, each day smoking (1/2 PPD for 35 years), blood pressure 145/60 at today’s visit in addition to the last visit, and a cholesterol panel as follows: total cholesterol 189; HDL 31; LDL 141; triglycerides 87.

Your doctor wants your expert opinion on whether he should take statins or other medications.

What are its risks?

• The ASCVD Plus Risk Estimator estimates his 10-year ASCVD risk at 16.3% (intermediate level).
• His lifetime risk of ASCVD is 50%
• His optimal ASCVD risk is 2.9%

Should he start taking a statin?

• Moderate statin intensity is really helpful for patients with LDL-C 70-189 mg/dl. The presence of risk aspects (on this case metabolic syndrome and family history of premature ASCVD) favors the initiation of statin therapy. LDL-C must be reduced by no less than 30%.

If refractory to statin initiation, it is affordable to make use of the coronary artery calcium (CAC) result to make a decision whether to withhold, defer, or initiate statin therapy. In this case, the next rules apply:

• If the coronary artery calcium measurement is zero, it is affordable to discontinue statin therapy and reassess in 5 to 10 years, provided there aren’t any risk aspects (diabetes, family history of premature coronary heart disease, cigarette smoking).
• If the CAC rating is between 1 and 99, it is affordable to initiate statin treatment in patients ≥ 55 years of age.
• If the CAC rating is 100 or greater or within the seventy fifth percentile or above, it is affordable to initiate statin therapy.

Should he be treated for hypertension during this visit?

• For adults with confirmed hypertension and a known risk of heart problems or a 10-year risk of ASCVD of 10% or more, a goal blood pressure of lower than 130/80 mm Hg is really helpful.
• Adults with stage 2 hypertension must be evaluated or referred to a primary care physician inside 1 month of diagnosis, treated with combination non-pharmacological and antihypertensive drug therapy (using 2 agents from different classes), and blood pressure must be reassessed in 1 month.
• When initiating antihypertensive treatment, the first-line drugs are thiazide diuretics, calcium channel blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).

What other consultations must be conducted during this visit?

• Abstinence from tobacco is really helpful and the patient must be strongly advised to quit the habit.
• Offer a mix of behavioral interventions and pharmacotherapy.
• Avoid exposure to secondhand smoke.
• Assess tobacco use at every visit.
• Create a follow-up plan.

What other behavior changes should he make?

• Advice must be given on the advantages of weight reduction and a healthy food plan wealthy in vegetables, fruit, legumes, nuts, whole grains and fish.
• He also needs to be repeatedly advised on the right way to optimise his lifestyle by way of physical activity. (He should spend no less than 150 minutes every week on moderate-intensity exercise or 75 minutes every week on vigorous-intensity aerobic exercise.)

What else can he do to cut back his risk of ASCVD? Should he start taking diabetes medications?

• No, right now it doesn’t meet medical therapy guidelines. HgA1C ≥ 6.5 is taken into account diabetes.

What about aspirin?

• He is within the medium risk group and doesn’t currently meet the factors to start out taking aspirin.