Primary prevention of cardiovascular disease

Evidence supporting primary prevention of cardiovascular disease (CVD) has become more robust and nuanced. The American College of Cardiology and the American Heart Association in conjunction with several other medical professional societies recently published updated performance measures to guide quality improvement on this important health intervention.

CVD is responsible for more than one-third of all deaths in the United States and has been the leading cause of mortality in the country for the last century, with the exception of the 1918 influenza outbreak.

Primary prevention refers to interventions targeting the first occurrence of CVD. Global risk scores provide reliable estimations of high (more than 20 percent). Intermediate (10 percent-20 percent), and low (less than 10 percent) risk of CVD vents over the next 10 years and should be instrumental in decision making regarding initiation of medication for primary prevention.

The 1999-2002 National Health and Nutrition Examination Survey reported that only 63 percent of non-Hispanic whites with hypertension were aware they had it, that slightly fewer than 50 percent were receiving treatment, and that 30 percent had the condition under control.

While there is strong evidence that tight glucose control in type 1 diabetes reduces CVD risk, data regarding tight glucose control in type 2 diabetes are uncertain, if not contradictory.

There is strong support for aggressive management of blood pressure and cholesterol in type 2 diabetes. The measures panel elected to make diabetes a risk factor as opposed to a CVD equivalent.

Because of a lack of evidence supporting antioxidants, folic acid, coenzyme Q, and fish oil as effective methods of primary prophylaxis, they were not included in the performance measures for primary CVD prevention.

Assessment of risk factors should start at age 18 and be revised at a minimum, at five-year intervals.

A global risk score should be calculated and recorded at least every 5 years for men after age 35 and women after age 45. Although the Framingham risk score is preferred, alternatives include the offering from the National Cholesterol Education Program, the European Systematic Coronary Risk Evaluation for fatal CVD risk, and the Reynolds Risk Score for women’s risk for CVD events.

Although the Adult Treatment Panel III recommends screening at age 20, this report supports the older ages 35 for men and 45 for women put forth by the US Preventive Services Task Force for performance measures targeting fasting lipid screening in adults. Evidence remains uncertain as to the benefit of screening fasting lipid levels in younger patients.

For women with a risk score under 10 percent, target LDL cholesterol is 190 mg/dL. For men with low risk scores, LDL should be below 160 mg/dL. High-risk patients (risk greater than 20 percent) should have an LDL treatment target of 10 mg/dL. In addition, high-risk patients without active CVD should have documented recommendations to initiate daily aspirin prophylaxis.

Screening for hypertension should begin at age 18 patients with blood pressure of 120/80 mm Hg or lower should have their blood pressure recorded every 2 years, and patients with prehypertension should have annual assessments.

The panel recommends as an accountability performance measure that all patients have a blood pressure below 140/90 mm Hg or be prescribed at least two antihypertensive medications. Higher-risk patients (those with diabetes or renal failure) should have lower treatment targets.

Patients should have a documented review of dietary habits and exercise routine every 2 years. Dietary advice should include at least one of the following items: salt intake, low fat diet, dietician referral, weight reduction, alcohol intake, or avoidance of concentrated carbohydrates,

Target exercise goals should stress 30 minutes of moderate intensity activity 5 days a week or 20 minutes of vigorous activity 3 days a week.

All patients should be questioned about smoking habits at least every 2 years, and patients who are active smokers should receive documented interventions such as advice, referral for counseling, or pharmacologic support.

Body weight and body mass index (BMI) should be recorded at least every 2 years. For patients who weigh more than 350 pounds, it is acceptable to record BMI as over 40 kg/m2. All patients should have documented counseling about achievement or maintenance of appropriate weight and BMI at least every 2 years.