Updated Cardiovascular Disease Prevention Guidelines (2020)

The American Heart Association and the American College of Cardiology released updated information on how best to prevent heart disease and strokes. 

As in the recent past, the majority of the information stressed a heart-healthy eating plan, exercise and the management of known risk factors. Avoiding tobacco usage also remains a pillar of preventing cardiovascular disease. 

New information has altered the recommendations of daily aspirin use in adults; it is now only rarely recommended to prevent heart and attacks and strokes for use in adults without known heart disease or stroke risk factors.

The comprehensive yet practical information from two leading authorities in the fight against heart disease should be heeded by most Americans. Cardiovascular disease, which can lead to a deadly sudden cardiac arrest, remains the leading cause of death for both men and women in the United States. It accounts for nearly one in three deaths in the U.S. every year.

The Role of the Guidelines

The updated prevention guidelines seek to address multiple issues, according to Roger S. Blumenthal, MD, co-chair of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. The main goals are as follows:

• To help people without a history of heart disease remain heart healthy
• To identify personal or social barriers that prevent people from staying heart healthy
• To promote awareness of heart-healthy lifestyle choices

Blumenthal, the Kenneth Jay Pollin Professor of Cardiology at John Hopkins Medicine, said that more than 80 percent of all cardiovascular events are preventable through lifestyle changes. He said we often fall short of implementing best strategies and controlling important risk factors.

“The most important way to prevent cardiovascular disease,” Blumenthal said, “whether it is a build-up of plaque in the arteries, heart attack, stroke, heart failure or issues with how the heart contracts and pumps blood to the rest of the body, is by adopting heart-healthy habits and to do so over one’s lifetime.”

The guidelines are based on rigorous, comprehensive, systematic evidence reviews. The American Heart Association and the American College of Cardiology worked with other professional groups in finalizing these guidelines. Multiple stakeholder organizations were invited to review and endorse the final documents.

The Importance of Risk Assessment

The updated guidelines stress that preventing a first instance of cardiovascular disease (called primary prevention) should ideally start with a thorough assessment of one’s risk. This act, Blumenthal said, estimates how likely someone is to develop blockages in their arteries and have a heart attack or stroke or die as a result. 

All patients should openly talk with their care team about their current health habits and personal risk for cardiovascular disease and, together, determine the best way to prevent it based on current evidence and personal preferences.

“We have good evidence now for how to identify these very high risk individuals with a physical exam and a good history, and for those at borderline risk there are additional factors that can help us determine who is at greater risk and should, for example, be on a medication like a statin earlier to prevent a cardiovascular event,” Blumenthal said. 

“In the past, a lot of people may have had a fatalistic attitude that they were going to develop heart problems sooner or later but, in reality, most cardiovascular events can be prevented.”

The document synthesizes the best data and proven interventions for improving diet and exercise and refraining from tobacco use. The guideline also address strategies for optimal control of four main factors that affect one’s likelihood of heart problems and stroke:

1. Obesity
2. Diabetes
3. High cholesterol
4. High blood pressure

In addition, the document discusses the challenges that may interfere with individuals being able to integrate better lifestyle habits. These challenges involve education and income levels, cost concerns, lack of insurance, inadequate access to healthy foods and safe places to exercise and life stresses

The Role of Aspirin

Aspirin use is still recommended for people who’ve had a heart attack, stroke, open heart surgery or stents placed to open clogged arteries. In these situations, aspirin use can be lifesaving. However, regular use of aspirin to prevent heart attacks and stroke in healthy people isn’t as clear-cut.

ACC/ AHA experts offer science-based guidance that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. Recent research suggests that the chance of bleeding, given the blood-thinning effect of aspirin, may be too high and the evidence of benefit—the number of heart attacks or strokes that are actually prevented—is not sufficient enough to make a daily aspirin worth taking for most adults in this setting.

“Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease,” Blumenthal said. “It’s much more important to optimize lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin. Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”

The Prescription of Statins

Stains are drugs that lower the amount of cholesterol circulating in the bloodstream. A number of statin drugs are currently in use in the United States. In general, the use of statins lowers the risk of cardiovascular disease in most patients, often dramatically. The general trend has been in the direction of more use of this class of drug.

Based on a simplified synopsis of the latest ACC/AHA cholesterol guideline, for primary prevention, statins should be commonly recommended with lifestyle changes to prevent cardiovascular disease among the following groups:

• people with elevated low density lipoprotein (LDL) cholesterol levels (≥ 190 mg/dl)
• those with Type 2 diabetes
• those deemed to have a high likelihood of having a stroke or heart attack based on medical history and other risk factors

The use of statins has been shown to help specific groups of people at risk for cardiovascular disease. This includes white women over age 60 who smoke and African-American men over age 50 with high blood pressure.

The Risk Factor of Diabetes

People with Type 2 diabetes are among the highest category of risk for cardiovascular disease. New data shows that two classes of diabetes medications, which work to lower blood sugar levels, can also cut the risk of heart attack, stroke and related deaths.

The Primacy of Lifestyle

A healthy lifestyle remains the cornerstone of preventing heart disease. 

The updated report provides practical advice based on the latest research. Some of the key lifestyle recommendations include:

• Eating healthier – choosing more vegetables, fruits, legumes, nuts, whole grains, and fish, and limiting salt, saturated fats, fried foods, processed meats, and sweetened beverages; specific eating plans like the Mediterranean, DASH and vegetarian diets are reviewed.
• Engaging in regular exercise – experts advise aiming for at least 150 minutes of moderate-intensity exercises such as brisk walking, swimming, dancing or cycling each week. For people who are inactive, some activity is better than none; 10-minute bursts of activity throughout the day can add up for those with hectic schedules. Currently, only half of American adults are getting enough exercise; prolonged periods of sitting can counteract the benefits of exercise.
• Aiming for and keeping a healthy weight – for people who are overweight or obese, losing just five to 10% of their body weight can markedly cut their risk of heart disease, stroke and other health issues.
• Avoiding tobacco by not smoking, vaping or breathing in smoke – one in three deaths from heart disease is attributable to smoking or exposure to secondhand smoke. Every effort to try to quit through counseling and/or approved cessation medications should be supported and tailored to each individual.