Population: Adults with HTN.

See Ch 19, section “Hypertension” for guidance on management of HTN to prevent ASCVD.

Population: Adults with diabetes mellitus.

Organization

ADA 2019

Prevention Recommendations

–Lifestyle interventions:

Diet: Mediterranean or DASH-style diet; reduce saturated fat, trans fat, and cholesterol intake; increase n-3 fatty acids, viscous fiber, and plant stanols/sterols.

• Weight loss: if overweight or obese.

• Physical activity.

• Smoking cessation.

–Target BP goals:

• BP < 130/80 mmHg in patients with DM, HTN, and 10-y ASCVD risk > 15%.

• BP < 140/90 mmHg in patients with DM, HTN, and 10-y ASCVD risk < 15%.

–BP interventions:

• BP > 120/80: Lifestyle modifications.

• BP ≥ 140/90: Initiate/titrate pharmacotherapy.

• BP ≥ 160/100: Initiate/titrate 2-drug regimen.

–Antihypertensives should include classes demonstrated to reduce CV events in diabetic patients: angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, dihydropyridine calcium channel blockers (CCBs).

–Urinary albumin/Cr ratio ≥ 30 mg/gCr: first-line are ACE inhibitors or ARBs at maximum tolerated dose for BP treatment.

–Statin therapy:

• All ages with 10-y ASCVD risk > 20% or multiple ASCVD risk factors, use high-intensity statin. If LDL-C is still ≥70 mg/dL, consider adding ezetimibe (preferred) or PCSK9-I.

• Age < 40 y with ASCVD risk factors, consider moderate-intensity statin.

• Age ≥ 40 y without ASCVD risk factors, consider moderate-intensity statin.

–For patients who do not tolerate intended statin intensity, use maximally tolerated dose.

–Although statin use is associated with increased risk of incident diabetes, the CVD rate reduction with statins outweighed the risk of incident diabetes even for patients with the highest risk for diabetes.

–Aspirin therapy:

• Patients with ASCVD: Use aspirin (75–162 mg/d) for secondary prevention. Use clopidogrel 75 mg/d for patients with documented aspirin allergy. Consider ACE inhibitor to reduce risk of CV events. Use SGLT2 I or GLP1 A as part of diabetes regimen to reduce risk.

• Patients at increased ASCVD risk: Consider aspirin for primary prevention.

Source

–ADA. Diabetes Care. 2019;42(suppl 1):S103-S123.

Population: Adults who use tobacco.

Organizations

AHA/ACC 2019, USPSTF 2015

Prevention Recommendations

–Assess for tobacco use at every health care visit.

–Strongly advise cessation in all patients who use tobacco.

–Combine behavioral interventions and US FDA-approved pharmacotherapy to maximize cessation rates.

–Recommended pharmacotherapy options for smoking cessation:

• Nicotine replacement: Patch (7, 14, 21 mg), Gum (2, 4 mg), Lozenge (2, 4 mg), Nasal spray (10 × 10 mg), Inhaled Nicotine products.

• Drug: Bupropion 150 mg SR, Varenicline (0.5, 1 mg).

Sources

–AHA/ACC. J Am Coll Cardiol. 2019;73(24):e285-e350.

–USPSTF. Tobacco Smoking Cessation in Adults and Pregnant Women. 2015.

–http://rxforchange.ucsf.edu

Population: Women at risk¹for ASCVD.

Organizations

AHA 2011, AHA 2019, CCS 2021

Prevention Recommendations

–Limit alcohol consumption to ≤1 drink daily.

–Coronary artery calcium may further define risk in low-risk women (<7.5% 10 y).

–Substantial benefit of smoking cessation in pregnant women on perinatal outcomes.

–Statin therapy may be indicated for women with prior pregnancy-related conditions based on CV age over 10-y risk calculator.

Sources

–J Am Coll Cardiol. 2011;57(12):1404-1423.

–J Am Coll Cardiol. 2019;73(24):e285-e350.