Cardiovascular Preventive Care (Primary Prevention)

Basics

Description

Primary prevention focuses on individuals who have not had any clinical manifestation of disease in the coronary, cerebrovascular, and peripheral artery territories.
Primary prevention of CV diseases has public health priority as the 1st cause of disability adjusted years of life lost (DALYs) and associated impact on society.
Primary prevention aims to avoid the presence or harmful level of modifiable causal risk factors (also called primordial prevention), as well as their management once present.

Management of hyperlipidemia and HTN in pregnancy should avoid medications harmful to fetus: Statins, ACE inhibitors, ARBs. Aspirin should be avoided in 3rd trimester of pregnancy.

Epidemiology

In 2005, CV diseases accounted for 17.5 million deaths worldwide. It is truly a chronic pandemic that arises from changes in societal lifestyle.
Men have higher absolute risk for CV disease at any age than women. Conversely, risk from dying (case fatality) once disease manifests is higher for women until older age.
CV diseases have well-identified causal risk factors (see below) that allow effective prevention.

Incidence
At 40 yr, lifetime risk to develop clinical manifestations of CHD is 1 in 2 for men and 1 in 3 for women. At age 70, it is 1 in 3 for men and 1 in 4 for women.
Prevalence

Atherosclerotic plaque is present in most individuals in Westernized societies.
Significant coronary intraluminal obstruction in asymptomatic individuals is higher with male gender and increasing age.
Diabetes erases female advantage, increases plaque burden and risk for complications.

Risk Factors

Major modifiable risk factors:
- Smoking
- Elevated LDL cholesterol
- Low HDL cholesterol
- HTN
- Physical inactivity
- Type 2 diabetes (CHD risk equivalent)
- Obesity, particularly abdominal
Other risk factors:
- Age: Male >50 yr, female >60 yr
- Early CHD onset in 1st-degree relatives: Males <55, females <65
- Metabolic syndrome
- Male gender
- Low socioeconomic status
- Diet high in saturated fat and sodium
- Psychosocial factors (stress)
- LV hypertrophy
- Hypertriglyceridemia
- Microalbuminuria
Emerging risk factors:
- Lipid: Lipoprotein(a); Lipoprotein-associated phospholipase A2; small and dense LDL; HDL subspecies; apolipoproteins B and A1; lipoprotein remnant particles; oxidized LDL
- Thrombogenic: fibrinogen; homocysteine; tPA-PAI-1; D-dimer
- Inflammatory markers: High-sensitivity C-reactive protein (hsCRP) and others
- Vitamin D deficiency

Appropriate risk factor modification significantly reduces risk for CV disease in the population >65.
Genetics
Atherosclerotic vascular disease is mostly the result of adverse lifestyle (largely determined by society trends), with variable individual susceptibility that can have some contribution from genetic disorders through specific risk factors (dyslipidemia, thrombogenesis). The contribution from genetic disorders to the whole burden of CV atherosclerotic disease is small.

General Prevention

Atherosclerotic vascular disease accounts for the largest burden of CV disease.
At least 80 % of CV disease at middle and older age is potentially preventable with a desirable risk factor profile in younger age.
Intensity of the preventive effort should be commensurate with the individual person's risk for CV disease.
Physicians should lead in a societal effort to curb this epidemic by promoting:
- Public areas free of smoking
- Wide nutrient labeling in restaurants
- Greater public access to space for exercise
Optimal risk factor profile in young adulthood can prevent >80% of CV disease and substantial proportion of other chronic diseases.

Pathophysiology

The relation of BP, LDL cholesterol, HDL cholesterol, and glucose with CV disease is continuous and linear. The level where risk appears in large observational studies is 115 mm Hg for systolic BP, 150-160 mg/dL for total cholesterol, HbA1C of 5.0%, BMI of 25.
The basic pathophysiologic mechanism is atherothrombosis: Complex interaction of causal risk factors that lead to the formation of the atheromatous plaque and its eventual rupture/erosion with accompanying thrombotic occlusion of the involved artery. The acute/chronic manifestations of disease will vary according to the location of the artery predominantly involved:
- The desirable risk factor profile for asymptomatic young adults is a nonsmoking status; BP <120/80; total cholesterol <200 mg/dL; nondiabetic status and BMI <25

Etiology

Atherosclerotic CV disease is a multifactorial disorder that requires a comprehensive approach in its evaluation and management (see risk factors above).

Associated Conditions

Atherosclerotic CV disease shares common risk factors with other chronic diseases such as type 2 diabetes, certain cancers (breast, prostate, esophagus, colon) and Alzheimer dementia
Erectile dysfunction
Chronic kidney dysfunction
Nonalcoholic steatohepatitis
Obstructive sleep apnea

Diagnosis

Asymptomatic in primary prevention.

History

Premature CV disease in 1st-degree relatives
Nutritional and physical activity habits
Tobacco products exposure
Weight fluctuation

Physical Exam

BMI; waist measurement
BP in both arms
Xanthoma, xanthelasma, lipemia retinalis, arcus senilis
Funduscopic exam: Retinal arteriolar narrowing, hypertensive or diabetic changes
Carotid, abdominal, or femoral bruits

Tests

Lab

In all adults ≥18 yr, a fasting lipoprotein profile, total cholesterol, LDL-C, HDL-C, and triglycerides should be obtained once every 5 yr.
Fasting blood glucose, serum creatinine
Microalbumin in urine
Additional tests under validation:
- Lipoprotein (a); apolipoproteins B and A1 (individuals with family history of early CHD)
- hsCRP (individuals with intermediate risk category at 10 yr; see below)
Resting EKG
Calculation of global CV risk in 10 yr with the use of standardized formulas is paramount to determine candidacy and intensity of risk factor management (see Framingham risk calculator reference). Young and middle-age adults may benefit from 30-yr or lifetime risk calculation:
- High risk: ≥20%/10 yr
- Intermediate risk: 10-19%/10 yr
- Low risk: <10%/10 yr

Imaging
Individuals with intermediate risk by a global score can be tested for measures of subclinical atherosclerosis or evidence of inflammation to further stratify their risk (strategy currently under validation):

Coronary calcium score
B-Mode carotid US for intima-media thickening
Ankle-brachial index
Stress tests for myocardial ischemia and functional capacity
hsCRP (hsCRP reclassifies ~5% of individuals to a lower or higher category of risk with uncertain cost-benefit)

Treatment

Therapeutic goals:
- Optimal levels of continuous risk factors (BP, LDL cholesterol, HDL cholesterol, glucose, BMI) have shifted recently towards lower (higher HDL-C) values in the normal distribution. The implication is that greater numbers of individuals are now in the borderline range, making them candidates for therapeutic lifestyle changes (TLC). Simultaneously, evidence is accumulating that in high-risk groups, achieving lower targets of the risk factor with TLC and medications has a superior preventive effect for CV disease
- High risk (global risk >20%/10 yr; diabetes; chronic kidney disease):
  - Nonsmoking status
  - BP <130/80
  - LDL-C <100 mg/dL (optional <70)
  - HDL-C > 40 mg/dL (optional >60?)
  - Triglycerides <150 mg/dL (optional <100?)
  - Non-HDL-C <130 mg/dL (optional <100?)
  - Glucose <100 mg/dL (diabetics <120)
  - HbA1C <6% (diabetics <7 %)
  - BMI <25
- Intermediate risk (global risk 10-20 %/10 yr):
  - Nonsmoking status
  - BP <135/85
  - LDL-C <130 mg/dL (optional <100?)
  - HDL-C, triglycerides, non-HDL-C, glucose, HbA1C, BMI same goals as high-risk group
- Low risk (Global risk <10%/10 yr):
  - Nonsmoking status
  - BP <140/90
  - LDL-C <130 mg/dL (<160 if 0-1 risk factors)
  - HDL-C, triglycerides, non-HDL-C, glucose, HbA1C, BMI same goals as high-risk group
The use of medications in the intermediate- and low-risk groups is recommended when TLC have not achieved the therapeutic goals after a reasonable time interval (3-6 mo in middle-aged and older individuals, 1-2 yr in younger ages).

Medication

Smoking cessation (2-4 yr after complete cessation risk of CHD and stroke approaches the risks seen in never smokers of the same age):
- Nicotine replacement therapy*, bupropion**, varenicline**
Lipid management:
- - Statins *, fibrates *, nicotinic acid"‚*, ezetimibe**, colesevelam"‚**, cholestyramine**, Colestid **
BP management:
- Thiazide diuretics*, β-blockers *, ACE inhibitors*, ARBs*, calcium channel blockers*, vasodilators**, antiadrenergic drugs**
Antiplatelet therapy (high- and intermediate-risk groups):
- Aspirin*, clopidogrel**, ticlopidine**
Î©3-Fatty acid supplementation (high-risk group needs further validation)

Additional Treatment

General Measures
Effective primary prevention of CV disease requires both a whole population approach as well as evaluation of the risk of individuals in order to tailor the intensity of their preventive effort. Instead of focusing on isolated levels of risk factors, the calculation of a global risk at 10 yr is most appropriate to classify the person's candidacy and intensity of therapy:

Low risk (<10% at 10 yr): Advice on low-saturated fat, low-sodium, low-simple sugar and high-fiber nutrition; advice on ≥30 min of daily physical activity; avoidance to any tobacco exposure; counseling on stress management; TLC
Intermediate risk (10-20% at 10 yr): A recent large trial (Jupiter) that used 20 mg rosuvastatin in subjects that had an average traditional risk score of 14% in 10 yr and hsCRP >2 mg/dL showed a large (47%) relative risk reduction in primary CV outcome, albeit a small absolute risk reduction (1.2%). Possible overestimation of effect, cost to implement hsCRP to reclassify risk, and wider statin prescription remains to be clarified in upcoming ATP IV guidelines
High risk (>20% at 10 yr): Emphasis on TLC, intense risk factor modification with the use of medications to lower the level of risk factors to the range demonstrated in clinical trials to provide benefit.

Issues for Referral
Refractory management of HTN, dyslipidemia, obesity, and tobacco addiction should be referred to specialists.

Surgery

Surgery is only indicated in carefully selected individuals with obesity stage IV (BMI >40 or >35 with associated diseases)

Ongoing Care

Follow-Up Recommendations

Frequency of risk profile monitoring: Every 3-6 mo for high-risk; every 6-12 mo for intermediate and low risk to monitor achievement of therapeutic goals
Patient Monitoring
Home BP monitoring with calibrated equipment can help in decision-making for initiation and adjustment of medication

Diet

Less consumption of red meat, high-fat dairy products, fast foods, and simple sugars. Higher intake of fish and seafood, whole-grain cereals and breads, whole fruits, vegetables, and nuts (Mediterranean diet)

Patient Education

TLC have greater impact when adopted by the whole family, particularly children and adolescents
ACTIVITY: 30 min of moderate physical activity (eg, brisk walking) most days of the week

Primary prevention in children and youth
Low-saturated fat diet to all children >2 yr (<10% of total calories per day)
Favor less sodium consumption.
Limit TV time and sedentary activities.
Encourage at least 1 hr of playtime daily.
Give a clear message to abstain from any tobacco use.

Prognosis

Global risk score calculation provides an effective tool to communicate individualized prognosis and potential for preventive action.

Additional Reading

1 Framingham risk calculator: hp2010.nhlbihin.net/atpiii/calculator.asp2O'Keefe JH. Primary and secondary prevention of cardiovascular diseases: A practical evidence-based approach. Mayo Clin Proc. 2009;84(8):741-757. [View Abstract]3Pearson TA. AHA guidelines for primary prevention of CV disease and stroke: 2002 update. Circulation. 2002;106:388-391. [View Abstract]4Ridker PM, Danielson E, Fonseca FA. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med. 2008;359:2195-2207. [View Abstract]

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