primary prevention of cardiovascular disease

Management

• counselling may be of some benefit to some patients (grade C recommendation) USPSTF
• minimize cardiac risk factors
• role of statins & antiplatelet agents controversial
• USPSTF recommended aspirin prophylaxis (primary prevention) for:
  • prevention of both cardiovascular disease & colorectal cancer in adults 40-59 years of age with a 10-year cardiovascular risk of >= 10%
    • small net benefit at best, shared decision making indicated
      • adults >= 60 years no net benefit (see aspirin)
  • men age 45-79 years when the potential benefitb due to a reduction in myocardial infarctions outweighs the potential harm (GI bleed)
  • women age 55-79 years when the potential benefit due to a reduction in strokes outweighs the potential harm (GI bleed)
  • insufficient evidence to recommend aspirin for patients > 79 years of age or in men < 45 or women < 55 years of age
  • risk for nontrivial bleeding roughly equals benefit in primary prevention of nonfatal myocardial infarction
  • no benefit in primary prevention of fatal myocardial infarction
• FDA & AHA/ACC recommend against aspirin for primary prevention
• statins for primary prevention
  • statins are recommended with lifestyle changes for patients with elevated LDL cholesteroal (>= 190 mg/dL), type 2 diabetes, or other cardiovascular risk factors
  • benefit of statins for primary prevention confirmed
    • benefits in patients with low cardiovascular risk (5 year risk < 10%) similar to benefits in high-risk patients
      • use cardiovascular risk calculator
    • suggestion is made that everyone over 50 years of age should take a statin: allegedly, benefits of statins outweigh risks, even in the healthiest patients
    • no reduction in mortality
  • no mortality benefit for primary prevention
  • benefit for primary prevention in the elderly (73 +/- 3 years); does not reduce all-cause mortality
• in older adults with at least one risk factor*, rosuvastatin 10 mg/day lowers mean LDL cholesterol level by 35 mg/dL, & reduces combined outcomes of CV-related death, nonfatal stroke, or nonfatal myocardial infarction vs placebo (3.7 vs 4.8%)
  • rosuvastatin does not lower all-cause mortality
  • financial incentives associated with statin recommendations for primary prevention rarely (if ever) discussed
  • statins never compared directly with Mediterranean diet
• candesartan/HCTZ (16/12.5 mg) reduced combined outcome vs placebo only in a subgroup with baseline systolic BP > 143 mm Hg (4.8 vs 6.5%)
• soluble (viscous) fiber lowers LDL cholesterol & estimated 10-year cardiovascular risk
• meditation may reduce cardiovascular mortality
• no benefit for vitamins & antioxidants

* elevated waist-hip ratio, low HDL cholesterol, current smoking, or diet-controlled diabetes

Additional terms

• cardiovascular disease (CVD)
• cardiovascular risk calculator; cardiovascular risk score
• cardiovascular risk factor
• coronary artery disease; coronary atherosclerosis (CAD)
• ischemic stroke
• peripheral vascular disease (PVD)
• secondary prevention in patients with cardiovascular disease