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Chapter 207: Cardiovascular Disease Prevention

INTRODUCTION

Atherosclerotic cardiovascular disease is the leading cause of death worldwide; prevention is targeted at modifiable risk factors (Table 207-1). Identification and control of these attributes reduce cardiovascular event rates.

TABLE 207-1Atherosclerotic Risk Factors

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TABLE 207-1 Atherosclerotic Risk Factors

Modifiable Risk Factors

Cigarette smoking

Dyslipidemias (↑LDL or ↓HDL)

Hypertension

Diabetes mellitus

Obesity

Sedentary lifestyle

Unmodifiable Risk Factors

Premature coronary heart disease in first-degree relatives (age <55 in men, <65 in women)

Age (men ≥45 years; women ≥55 years)

Male sex

ESTABLISHED RISK FACTORS

Cigarette Smoking

Cigarette smoking increases the incidence of, and mortality associated with, coronary heart disease (CHD). Observational studies show that smoking cessation reduces the risk of coronary events within months. For pts who smoke, implement counseling and, as needed, pharmacologic therapy to assist cessation. Consider a one-time ultrasound study to screen for abdominal aortic aneurysm in men aged 65–75 who have ever smoked.

Lipid Disorders

(See Chap. 181) Both elevated LDL and low HDL cholesterol are associated with cardiovascular events. Each 1-mg/dL increase in serum LDL correlates with a 2–3% rise in CHD risk; each 1-mg/dL decrease in HDL heightens risk by 3–4%. A screening lipid profile in adults should include total cholesterol, triglycerides, HDL, and LDL (calculated or directly measured). Regular physical activity, dietary improvements, and achieving desirable body weight are recommended for all pts with dyslipidemia. Pharmacologic approaches depend on presence or risk of clinical atherosclerotic disease (ASCVD). Treatment should be most aggressive in pts with established disease and in those at the highest risk as shown in Table 207-2, the cornerstone of which is statin therapy. In pts with isolated low HDL, encourage beneficial lifestyle measures: smoking cessation, weight loss, and increased physical activity (see Chap. 181).

TABLE 207-2Guideline Recommendations for Lipid-Lowering Drug Therapy

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TABLE 207-2 Guideline Recommendations for Lipid-Lowering Drug Therapy

GROUP

RECOMMENDATION

Clinical atherosclerotic disease (ASCVD)

High-intensity statin^a to achieve ≥50% LDL reduction;

If LDL remains ≥70 mg/dL: Consider adding ezetimibe;

If very high risk^b and LDL still ≥70 mg/dL on maximally tolerated statin + ezetimibe: Consider adding PCSK9 inhibitor

LDL cholesterol ≥190 mg/dL

High-intensity statin^a to achieve ≥50% LDL reduction;

If <50% LDL reduction achieved, or LDL remains ≥100 mg/dL: Consider adding ezetimibe;

If LDL reduction still <50%: Consider adding bile acid sequestrant (do not add if triglycerides >300 mg/dL);

If pt has heterozygous familial hypercholesterolemia and LDL still ≥100 mg/dL (or if baseline LDL ≥220 mg/dL, age 40–75, and LDL still ≥130 mg/dL): Consider adding PCSK9 inhibitor

Diabetics

Age 40–75

• Regardless of ASCVD risk profile

Moderate-intensity statin^c

• Multiple ASCVD risk factors

High-intensity statin^a to achieve ≥50% LDL reduction

• 10-year ASCVD ...

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