Q&A: Aspirin, nutrition among highlights of primary prevention guideline
NEW ORLEANS — One of the biggest stories from the American College of Cardiology Scientific Session was the presentation of a new primary prevention guideline from the ACC and the American Heart Association that has the potential to make physicians rethink their prevention approaches and strategies for their patients.
In addition to recommending against aspirin for primary prevention in most patients and endorsing in appropriate patients certain diabetes drugs that have demonstrated CV benefits, the guideline emphasizes shared decision-making and careful consideration of social determinants of health.
Cardiology Today spoke with 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, and is a member of the writing committee for the guideline, about the major take-home messages of the guideline and their implications for clinical practice.
Question: How do you hope this guideline is used?
Answer: This guideline was highly anticipated and exciting. For those of us in the prevention world, this offers us a great opportunity.
The guideline is comprehensive. There is not just one thing that will prevent disease down the road. We included multiple domains such as BP, cholesterol, obesity, smoking, diabetes and exercise. For clinicians, this is a one-stop shop, which is important because there are so many different guidances out there. Having all of this information in one place is critical.
Q: What are some of the major themes of the guideline?
A: It is important to remember that lifestyle is the foundation of the guideline. There are specific recommendations about exercise, nutrition and smoking cessation. Lifestyle underpins all that we do for risk factors.
A major theme of the guidelines is team-based care. Primary prevention is not an individual sport. Rather, it’s about the team of health care providers and patients all working together to help improve risk factors. All throughout the document, there are references to social determinants of health. We have to remind ourselves that you can give people guidance, but to actually incorporate these lifestyle changes, we have to think about a patient’s cultural factors, economic factors and other factors that come in to play. We give specific guidances on how to think about these topics. At the end of the day, it’s about shared decision-making. The patient must agree with what you are recommending, and must take on those behaviors and activities.
Q: Is there anything in the document that might inspire a change in clinical practice around the country?
A: Yes. While the exercise and nutrition recommendations are going to have the greatest impact, the aspirin recommendations are also notable. In primary prevention, the pendulum has swung. Aspirin for primary prevention is now a class IIb recommendation, meaning occasionally it is appropriate, but generally it is not. In the past, it was the other way around and we were more frequently giving aspirin. We also advise that people over age 70 years generally should not be receiving aspirin for primary prevention. That came from the ASPREE trial. It is a pretty big deal because patients ask us about that all the time and we are now able to incorporate the newest data.
Also of note is that we recognized that there are new agents available to treat diabetes that have shown CV benefits in patients with diabetes at high risk for CVD. Those were mostly studied in secondary prevention, but we acknowledged that after metformin, there are other drugs that appear to have beneficial CV effects and can be considered. This could lead to changes in how we prescribe these medications.
Q: Many U.S. adults have poor nutritional habits. What are some of the suggestions for improvement?
A: Nutrition is a tough subject because it is not just a matter of writing a prescription. If you look at the sum total of what are considered heart-healthy nutritional patterns, prominent components include vegetables, nuts, fish, whole grains and other foods typically included in a Mediterranean-style diet. The guideline also discusses avoiding simple carbohydrates and sweetened beverages, processed meats and trans fats. We think the guideline puts all the relevant information there. There is so much controversy today about diet with most information focusing on weight loss, but what constitutes a heart-healthy diet is now well-described in this document. This guideline discusses the overall heart-healthy eating pattern, as opposed to the lifestyle component of the 2013 ACC/AHA cholesterol guidelines, which discussed it in terms of effect on BP and cholesterol. – by Erik Swain
Arnett DK, et al. All you needed to know about cardiovascular disease prevention guidelines; well — almost all. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Disclosure : Khera reports no relevant financial disclosures.