Home Books CURRENT Practice Guidelines in Primary Care 2019

Previous Chapter

Next Chapter

CURRENT Practice Guidelines in Primary Care 2019

Chapter 2: Cardiovascular Disorders

ABDOMINAL AORTIC ANEURYSM

Listen

Population

–Men age ≥ 65 y.

Recommendation

USPSTF 2014, ACC/AHA 2006, Canadian Society for Vascular Surgery 2006, Society for Vascular Surgery 2018

–Screen once before age 75, with ultrasound, if they have ever smoked.

ESVS 2011

–Screen once with ultrasound at age 65 y if have smoked >100 cigarettes lifetime or have a family history of AAA.

ESVS 2014

–Screen with ultrasound all men > 65 y of age.

ACRa/AIUM/SRU 2014

–Screen with ultrasound all men ≥65 y (or ≥50 y with family history of aneurysmal disease) and women ≥ 65 y with cardiovascular risk factors.
–Patients ≥ 50 y with a family history of aortic and/or peripheral vascular aneurysmal disease.
–Patients with a personal history of peripheral vascular aneurysmal disease.
–Groups with additional risk include patients with a history of smoking, hypertension, or certain connective tissue diseases (eg, Marfan syndrome).
–ACR-AIUM-SRU Practice Parameter for the Performance of Diagnostic and Screening Ultrasound of the Abdominal Aorta in Adults. 2014.

Society for Vascular Surgery 2018

–Screen once with ultrasound between age 65 and 75 if ever smoked, or after 75 if in “good health” and never screened previously.

Sources

–Ann Intern Med. 2014;161(4):281-290.
–J Vasc Surg. 2007;45:1268-1276.
–Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011;(41):S1-S58.
–Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. doi:10.1093/eurheartj/ehu281
–ACR-AIUM-SRU Practice Parameter for the Performance of Diagnostic and Screening Ultrasound of the Abdominal Aorta in Adults. 2014.
–J Vasc Surg. 2018;67(1):2-77.

Population

–Men/women at high risk.

Recommendations

Canadian Society for Vascular Surgery 2008

–Individual selective screening for those at high risk for AAA:
1. Women older than 65 y at high risk secondary to smoking, cerebrovascular disease, and family history.
2. Men younger than 65 y with positive family history.

Source

–Can J Surg. 2008;51(1):23-34.

Population

–Women age ≥65 y.
–Abdominal echocardiography used for mass screening in subgroups at risk was associated with a significant 45% decreased risk of AAA-related mortality at 10 y.

CAROTID ARTERY STENOSIS (CAS) (ASYMPTOMATIC)

Listen

Population

–Asymptomatic adults.

Recommendations

ASN 2007, USPSTF 2014, AHA/ASA 2011, ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2011, AAFP 2013

–Do not screen the general population or a selected population based on age, gender, or any other variable alone.
–Do not screen asymptomatic adults.

Sources

–J Neuroimaging. 2007;17:19-47.
–USPSTF. Carotid Artery Stenosis: Screening. 2014.
–J Am Coll Cardiol. 2012;60(3):242-276.
–Choosing Wisely: American Academy of Family Physicians. 2013.
–Stroke. 2011;42(2):e26.

Recommendation

ACR–AIUM–SRU 2016, ACC/AHA/ASA/ACR/SVS 2011

–Indications for carotid ultrasound: evaluation of patients with a cervical bruit, not routine screening.

Sources

–Stroke. 2011;42(8):e464-e540.
–ACR–AIUM–SPR–SRU Practice Parameter for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular System. 2016. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Extracranial_Cerebro.pdf

Recommendation

Society of Thoracic Surgeons 2013

–Do not routinely evaluate for carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.

Source

–Choosing Wisely: Society of Thoracic Surgeons. 2013.

Comments

The prevalence of internal CAS of ≥70% varies from 0.5% to 8% based on population-based cohort utilizing carotid duplex ultrasound. For population age >65 y, estimated prevalence is 1%. No risk stratification tool further distinguishes the importance of CAS. No evidence suggests that screening for asymptomatic CAS reduces fatal or nonfatal strokes.
Carotid duplex ultrasonography to detect CAS ≥60%; sensitivity, 94%; specificity, 92%. (Ann Intern Med. 2007;147(12):860)
If true prevalence of CAS is 1%, number needed to screen to prevent 1 stroke over 5 y = 4368; to prevent 1 disabling stroke over 5 y = 8696. (Ann Intern Med. 2007;147(12):860)

CHOLESTEROL AND LIPID DISORDERS

Listen

Population

–Asymptomatic adults 40–79 y.

Recommendations

ACC/AHA 2013

–Perform 10-y ASCVD Risk Score.
–High-risk categories include:
1. Primary elevation of LDL-C ≥ 190 mg/dL.
2. Diabetes (type 1 or 2) with LDL-C 70–189 mg/dL and without clinical ASCVD.
3. Without clinical ASCVD or diabetes with LDL-C 70–189 mg/dL and estimated 10-y ASCVD Risk Score ≥7.5%.

ESC 2016

–Perform SCORE risk assessment tool available at: www.heartscore.org
–Secondary hyperlipidemia should be ruled out.
–Total cholesterol and LDL-C primary target: goal LDL ≤70 mg/dL in patients with very high CV risk, LDL ≤100 mg/dL in patients with high CV risk.
–Secondary targets are non-HDL-C and ApoB.
–HDL is not recommended as a target for treatment.

Canadian Cardiovascular Society 2016

–Screen all men/women over age 40, or those of any age at high risk (clinical evidence of atherosclerosis, AAA, DM, HTN, cigarette smoking, stigmata of dyslipidemia, family history of early CVD or dyslipidemia, CKD, BMI >30, inflammatory bowel disease, HIV, erectile dysfunction, COPD, hypertensive diseases of pregnancy).
–Nonfasting lipid tests are acceptable.
–Repeat a risk assessment using Framingham or Cardiovascular Life Expectancy Model every 5 y or as clinical circumstances dictate.

Sources

–Circulation. 2013;2013;01.cir.0000437738.63853.7a.
–European Society of Cardiology. Dyslipidaemias 2016.
–Canadian Journal of Cardiology. 2016;32(11):1263-1282.

Comment

Prior to initiating statin therapy, perform lipid panel, ALT, HgbA1c to R/O DM, and baseline CK (if patient is at increased risk for muscle events based on personal or family history of statin intolerance).

Population

–Adults with diabetes.

Recommendations

ADA 2013

–Measure fasting lipids at least annually in adults with diabetes.
–Every 2 y for adults with low-risk lipid values (LDL-C <100 mg/dL, HDL-C >50 mg/dL, TG <150 mg/dL).

Source

–Diabetes Care. 2013;36(suppl 1):S11-S66.

Population

–Adults >20 y.

Recommendations

NLA 2014

–Fasting lipid profile (LDL-C and TG) or nonfasting lipid panel (non-HDL-C and HDL-C) should be measured at least every 5 y.
–Also assess ASCVD risk.
–Non-HDL-C (primary target), ApoB (secondary target) have more predictive power than LDL-C.
–Apolipoprotein B (ApoB) is considered an optional, secondary target for therapy. More predictive power than LDL-C, but not consistently superior to non-HDL-C.
–HDL-C is not recommended as a target therapy.

Source

–J Clin Lipidol. 2014;8:473-488.

Comment

Non-HDL-C values:
1. Desirable <130 mg/dL.
2. Above desirable 130–159.
3. Borderline high 160–189.
4. High 190–219.
5. Very high ≥ 220.

| Download (.pdf) | Print

CHOLESTEROL GUIDELINES

Source

Recommended Lipoprotein Measurements for Risk Assessment

Recommended Lipoprotein Targets of Therapy

Recommended Risk Assessment Algorithm

National Cholesterol Education Program

Adult Treatment Panel III

Fasting lipid panel

Calculation of non-HDL-C when TG >200 mg/dL

Primary target: LDL-C

Secondary target: non-HDL-C

Identify number of CHD risk factors

Framingham 10-y absolute CHD risk

International Atherosclerosis Society

Fasting lipid panel with calculation of non-HDL-C

Non-HDL-C

LDL-C is considered alternative target of therapy

Lifetimes risk of total ASCVD morbidity/mortality (by Framingham, CV Lifetime Risk pooling project, or QRisk)

European Society of Cardiology/European Atherosclerosis Society

Fasting lipid panel with calculation of non-HDL-C and TC/HDL-C ratio ApoB or ApoB/apoA1 ration are considered alternative risk markers

Primary target: LDL-C

Secondary targets: non-HDL or ApoB in patients with cardiometabolic risk

10-y risk of total fatal ASCVD by the Systematic Coronary Risk Evaluation (SCORE) system

Canadian Cardiovascular Society

European Society of Cardiology/European Atherosclerosis Society

Primary target: LDL-C

Secondary targets: non-HDL-C and ApoB

10-y risk of total ASCVD events by the Framingham Risk Score

American Association of Clinical Endocrinologists

Fasting lipid panel

Calculation of non-HDL-C is a more accurate risk assessment if TG is between 200 and 500 mg/dL, diabetes, insulin resistance, or established CAD

Primary targets: LDL-C

Secondary targets: non-HDL-C in patients with cardiometabolic risk or established CAD ApoB recommended to assess success of LDL-C-lowering therapy

Men: Framingham Risk Score (10-y risk of coronary event)

Women: Reynolds Risk Score (10-y risk of coronary event, stroke, or other major heart disease)

American Diabetes Association/ American Heart Association Statement on Cardiometabolic Risk

Stronger risk discrimination provided by non-HDL-C, ApoB, LDL-P

Strong recommendation for ApoB and non-HDL-C as secondary targets

30-y/lifetime global ASCVD risk

American Diabetes Association: Standards of Medical Care in Diabetes

Fasting lipid panel

LDL-C

Not applicable in setting of diabetes (CHD risk equivalent)

Kidney Disease: Improving Global Outcomes: Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease

Fasting lipid panel to screen for more severe forms of dyslipidemia and secondary causes of dyslipidemia

None: therapy guided by absolute risk of coronary event based on age, and stage of CKD or eGFR

CKD considered CHD risk equivalent

Treatment with evidence-based statins/statin doses based on age, and stage of CKD or eGFR

Secondary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults: A Scientific Statement from the American Heart Association

Fasting lipid panel

Calculation of non-HDL-C when TG >200 mg/dL

Primary target: LDL-C

Secondary target: non-HDL-C

N/A

National Lipid Association: Familial Hypercholesterolemia

Fasting lipid panel

LDL-C

Not applicable due to extremely high lifetime risk

Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents

Fasting lipid panel with calculation of non-HDL-C

Primary target: LDL-C

Secondary target: non-HDL-C

No risk algorithm, treatment based on the number of ASCVD risk factors

AHA Women’s Cardiovascular Disease Prevention Guidelines

Fasting lipid panel

Consider hs-CRP in women >60 y and CHD risk >10%

LDL-C

Updated Framingham risk profile (coronary, cerebrovascular, and peripheral arterial disease and heart failure events)

Reynolds Risk Score (10-y risk of coronary event, stroke, or other major heart disease)

2013 American College of Cardiology/American Heart Association: Blood Cholesterol Guidelines for ASCVD Prevention

Fasting lipid panel to screen for more severe forms of dyslipidemia and secondary causes of dyslipidemia

LDL-C measured for assessment of therapeutic response and compliance

Therapy guided by identification of 40 categories of patients who benefit from high- or moderate-dose statin therapy

CV Risk Calculator based on Pooled Risk Equations (10-y risk of total ASCVD events)

Lifetime risk provided for individuals 20–59 y of age

apoA1, apolipoprotein A1; ApoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; CHD, coronary heart disease; CKD, chronic kidney disease; CV, cardiovascular; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein-cholesterol; LDL-P, low-density lipoprotein particle; TC, total cholesterol; TG, triglycerides.

Source: Morris PB, Ballantyne CM, et al. Review of clinical practice guidelines for the management of LDL-related risk. JACC. 2014;64(2):196–206.

CORONARY ARTERY DISEASE

Listen

Population

–Adults at low risk of CHD events.^a

Recommendations

AAFP 2012, USPSTF 2012, American College of Physicians 2012, American Society of Echocardiography 2013, American College of Cardiology 2013.

–Do not routinely screen men and women at low risk for CHD risk^b with resting electrocardiogram (ECG), exercise treadmill test (ETT), stress echocardiogram, or electron-beam CT for coronary calcium.
–Do not screen with stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms, unless high-risk markers are present.
–Do not perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.

Sources

–AAFP Clinical Recommendation: Coronary Heart Disease. 2012.
–Choosing Wisely: American College of Physicians. 2012. http://www.choosingwisely.org/societies/american-college-of-physicians/
–Choosing Wisely: American Academy of Family Physicians. 2013. http://www.choosingwisely.org/societies/american-academy-of-family-physicians/
–Choosing Wisely. American Society of Echocardiography. 2012. http://www.choosingwisely.org/societies/american-society-of-echocardiography/
–Choosing Wisely: American College of Cardiology. 2014. http:/www.choosingwisely.org/societies/american-college-of-cardiology/
–Ann Intern Med. 2012;157:512-518.

Comment

USPSTF recommends against screening asymptomatic individuals because of the high false-positive results, the low mortality with asymptomatic disease, and the iatrogenic diagnostic and treatment risks.

Populations

–All asymptomatic adults age ≥20 y.
–Risk score assessment.

Recommendations

ACC/AHA 2013, ESC 2012

–ASCVD Risk Score has replaced the FRS in the United States for patients age 40–79 y.
–Assess 10-y ASCVD Risk Score every 4–6 y.
–Framingham Risk Score (FRS), including blood pressure (BP) and cholesterol level, should be obtained in asymptomatic adults age ≥20 y.
–The SCORE Risk Score remains the screening choice in Europe.
–No benefit in genetic testing, advanced lipid testing, natriuretic peptide testing, high-sensitivity C-reactive protein (CRP), ankle-brachial index, carotid intima-medial thickness, coronary artery score on electron-beam CT, homocysteine level, lipoprotein (a) level, CT angiogram, MRI, or stress echocardiography regardless of CHD risk.

Sources

–Circulation. 2007;115:402-426.
–J Am Coll Cardiol. 2010;56(25): 2182-2199.

Population

–Adults at intermediate risk of CHD events.

Recommendations

ACC/AHA 2013, ESC 2012

–May be reasonable to consider use of coronary artery calcium and high-sensitivity CRP (hs-CRP) measurements in patients at intermediate risk.
–hs-CRP is not recommended in low- or high-risk individuals.

Sources

–Eur Heart J. 2007;28(19): 2375-2414.
–Eur Heart J. 2012;33:1635-1701.
–J Am Coll Cardiol. 2007;49:378-402.
–Circulation. 2013;2014;129(25 Suppl 2):S49-73.

Comment

10-y ASCVD risk calculator (The Pooled Cohort Equation) can be found at: http://tools.acc.org/ASCVD-Risk-Estimator/

Population

–Adults at high risk of CHD events.

Recommendations

AAFP 2012, AHA 2007, USPSTF 2012

–Insufficient evidence to recommend for or against routine screening with ECG, ETT.
–In addition, there is insufficient evidence to recommend routine MRI.

Sources

–Arch Intern Med. 2011;171(11): 977-982.
–AAFP Clinical Recommendations: Coronary Heart Disease. 2012.
–Ann Intern Med. 2012;157:512-518.

Population

–Men and Women with no History of CHD.

Recommendation

USPSTF 2009

–Insufficient evidence to assess the balance of benefits and harms of using the nontraditional risk factors to prevent CHD events (hs-CRP, ankle-brachial index [ABI], leukocyte count, fasting blood glucose level, periodontal disease, carotid intima-media thickness, coronary artery calcification [CAC] score on electron-beam computed tomography, homocysteine level, and lipoprotein[a] level).

Source

–USPSTF. Coronary Heart Disease: Screening Using Non-Traditional Risk Factors. 2009.

Comment

–10-y ASCVD risk calculator (The Pooled Cohort Equation) can be found at: http://tools.acc.org/ASCVD-Risk-Estimator/

Population

–Women.

Recommendations

ACCF/AHA 2011

–Cardiac risk stratification by the Framingham Risk Score should be used. High risk in women should be considered when the risk is ≥10% rather than ≥20%.
–An alternative 10-y risk score to consider is the Reynolds Risk Score, although it requires measurement of hs-CRP.

Source

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

Population

–Adults with stable CAD.

Recommendation

CCS 2013

–Risk assessment by Framingham Risk Score should be completed every 3–5 y for men age 40–75 y and women age 50–75 y. Frequency of measurement should increase if history of premature cardiovascular disease (CVD) is present. Calculate and discuss a patient’s “cardiovascular age” to improve the likelihood that the patient will reach lipid targets and that poorly controlled hypertension will be treated.

Source

–Can J Cardiol. 2013;29:151-167.

Recommendation

AAFP 2009, AHA/APA 2008

–All patients with acute myocardial infarction (MI) to be screened for depression at regular intervals during and post hospitalization.

Sources

–Circulation. 2008;118:1768-1775.
–Ann Fam Med. 2009;7(1):71-79.

HYPERTENSION (HTN), ADULTS

Listen

Population

–Adults age >18 y.

Recommendations

USPSTF 2015, AAFP 2009, CHEP 2015, ESH/ESC 2013, Canadian Task Force on Preventive Health Care 2013

–Screen for HTN.
–HTN is >140/90 mm Hg on two or more BP readings.
–All adults should have their BP assessed at all appropriate clinical visits.
–Ambulatory BP monitoring (ABPM) is the standard to confirm diagnosis.
–Annual F/U of patients with high-normal BP (2-y risk of developing HTN is 40%).

Sources

–Am Fam Physician. 2009;79(12): 1087-1088.
– http://www.aafp.org/online/en/home/clinical/exam.html
–USPSTF. High Blood Pressure in Adults: Screening. 2015.
–Hypertension Canada: http://www.hypertension.ca/en/chep
–Can Fam Physician. 2013;59(9): 927-933.
–J Hypertens. 2007;25:1105.
–Eur Heart J. 2013;34:2159–2219.

Recommendations

ESH/ESC 2013

–In cases of severe BP elevation, especially if associated with end-organ damage, the diagnosis can be based on measurements taken at a single visit.
–In asymptomatic subjects with hypertension but free of CVD, chronic kidney disease (CKD), and diabetes, total cardiovascular risk stratification using the SCORE model is recommended as a minimal requirement.

Sources

–J Hypertens. 2007;25:1105.
–Eur Heart J. 2013;34:2159-2219.

Comments

Electronic (oscillometric) measurement methods are preferred to manual measurements. Routine auscultatory Office BP Measurements (OBPMs) are 9/6 mm Hg higher than standardized research BPs (primarily using oscillometric devices). (CHEP, 2015)
Confirm diagnosis out-of-office before starting treatment.
ABPM has better predictive ability than OBPM.
Home BP Measurement (HBPM) is recommended if ABPM is not tolerated, not readily available, or due to patient preference; 15%–30% of elevations by OBPM will have lower BP at home. (USPSTF, 2015)
Assess global cardiovascular risk in all hypertensive patients. Informing patients of their global risk (“vascular age”) improves the effectiveness of risk factor modification.

Population

–Age >18 y.

Recommendation

JNC 8 2014

–Treatment thresholds:
- Age ≥ 60: 150/90.
- Age <60: 140/90.
- DM or CKD: 140/90.

Source

–JAMA. 2014;311(5):507-520.

Comment

“Hypertension” and “pre-hypertension” are no longer defined.

Population

–Age >65 y.

Recommendation

ACCF/AHA 2011

–Identification and treatment of systolic and diastolic HTN in the very elderly are beneficial in the reduction of all-cause mortality and stroke death.

Source

–J Am Coll Cardiol. 2011;57(20):2037-2110.

Comments

Increased frequency of systolic HTN compared with younger patients.
HTN is more likely associated with end-organ damage and more often associated with other risk factors.

SLEEP APNEA

Listen

Population

–Asymptomatic Adults

Recommendation

USPSTF 2017, AAFP 2017

–Insufficient evidence to recommend for or against routine screening.

Sources

–AAFP. Obstructive Sleep Apnea in Adults: Screening. 2017.
–JAMA. 2017;317(4):407-414.

TOBACCO USE

Listen

Population

–Adults.

Recommendation

AAFP 2015, USPSTF 2015, ICSI 2014

–Recommend screening all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.

Sources

–AAFP Clinical Preventive Service Recommendation: Tobacco Use. 2015.

–USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. 2015.
–ICSI. Preventive Services for Adults. 20th ed. 2014.

Comment

The “5-A” framework is helpful for smoking cessation counseling:
1. Ask about tobacco use.
2. Advise to quit through clear, individualized messages.
3. Assess willingness to quit.
4. Assist in quitting.
5. Arrange follow-up and support sessions.

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Send Email

Jump to a Section

Population

Recommendation

Population

Recommendations

Population

Population

Recommendations

Recommendation

Recommendation

Comments

Population

Recommendations

Comment

Population

Recommendations

Population

Recommendations

Comment

Population

Recommendations

Comment

Populations

Recommendations

Population

Recommendations

Comment

Population

Recommendations

Population

Recommendation

Comment

Population

Recommendations

Population

Recommendation

Recommendation

Population

Recommendations

Recommendations

Comments

Population

Recommendation

Comment

Population

Recommendation

Comments

Population

Recommendation

Population

Recommendation

Comment

Pop-up div Successfully Displayed