AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update
Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases
The initial Guide to the Primary Prevention of Cardiovascular Diseases was published in 1997 as an aid to healthcare professionals and their patients without established coronary artery disease or other atherosclerotic diseases.1 It was intended to complement the American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for Preventing Heart Attack and Death in Patients with Atherosclerotic Cardiovascular Disease (updated2) and to provide the healthcare professional with a comprehensive approach to patients across a wide spectrum of risk. The imperative to prevent the first episode of coronary disease or stroke or the development of aortic aneurysm and peripheral arterial disease remains as strong as ever because of the still-high rate of first events that are fatal or disabling or require expensive intensive medical care. The evidence that most cardiovascular disease is preventable continues to grow. Results of long-term prospective studies consistently identify persons with low levels of risk factors as having lifelong low levels of heart disease and stroke.3,4⇓ Moreover, these low levels of risk factors are related to healthy lifestyles. Data from the Nurses Health Study,5 for example, suggest that in women, maintaining a desirable body weight, eating a healthy diet, exercising regularly, not smoking, and consuming a moderate amount of alcohol could account for an 84% reduction in risk, yet only 3% of the women studied were in that category. Clearly, the majority of the causes of cardiovascular disease are known and modifiable.
This 2002 update of the Guide acknowledges a number of advances in the field of primary prevention since 1997. Research continues to refine the recommendations on detection and management of established risk factors, including evidence against the safety and efficacy of interventions once thought promising (eg, antioxidant vitamins).6 This, in turn, has stimulated a large number of additional guidelines for specific demographic groups (eg, women), on individual risk factors (eg, diabetes, smoking), and for the primary prevention of stroke. In all of these guidelines, there is an increasing emphasis on further stratifying patients by level of risk and matching the intensity of interventions to the hazard for cardiovascular disease events.7
Therefore, this 2002 update of the Primary Prevention Guide serves to integrate other guidelines and consensus statements developed since the initial Guide’s approval. This Guide might be viewed as the entry point to the more specific and detailed recommendations and the rationale behind them. The recommendations, as presented in the accompanying tables, are therefore consistent with the following recommendations: Agency for Healthcare Policy and Research Guidelines on Treating Tobacco Use and Dependence8; the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)9; the AHA Dietary Guidelines, Revision 200010; the AHA Statement on Alcohol and Heart Disease11; the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults12; American Heart Association Scientific Statements and Advisories on Physical Activity13,14⇓ and the American College of Sports Medicine Guidelines15; the Clinical Guidelines for the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults from the National Heart, Lung, and Blood Institute Expert Panel16 and an accompanying statement from the AHA Nutrition Committee17; the American Diabetes Association Standards of Medical Care for Patients with Diabetes18,19⇓ and the AHA Statement on Diabetes and Cardiovascular Disease20; the AHA Guidelines on the Primary Prevention of Stroke21; AHA Guidelines for Prevention of Cardiovascular Disease in Women22; ACC/AHA/European Society of Cardiology (ESC) Guidelines for the Management of Patients With Atrial Fibrillation23; the AHA Scientific Statement on Hormone Replacement Therapy and Cardiovascular Disease24; and the US Preventive Services Task Force evidence for use of aspirin in primary prevention.25 The aspirin guidelines recommended here agree with the Task Force Report in the use of aspirin in persons at high coronary and stroke risk but use a ≥10% risk per 10 years rather than >6% risk over 10 years. This improves the likelihood of a positive balance of coronary risk reduction over bleeding and hemorrhagic stroke caused by aspirin.26,27⇓
Although this Guide largely applies to adults, it does identify high-risk patients for whom screening and intervention in first-degree relatives (including children) would be an important aspect of primary prevention. However, this Guide will not provide specific recommendations for the reduction of cardiovascular risk in children and adolescents. This important issue will be the subject of a separate guide. However, a family-centered approach to primary prevention should be emphasized, inasmuch as it recognizes both the genetic and behavioral causes of the well-established familial aggregation of heart disease and stroke.
This Guide is intended to assist primary care providers in their assessment, management, and follow-up of patients who may be at risk for but who have not yet manifested cardiovascular disease. The continuing message is that adoption of healthy life habits remains the cornerstone of primary prevention, including the avoidance of tobacco (including secondhand smoke), healthy dietary patterns, weight control, and regular, appropriate exercise. An important role of healthcare providers is to support and reinforce these public health recommendations for all patients.
Table 1 is presented to guide the identification and assessment of modifiable risk. The assessment of absolute cardiac risk is increasingly advocated by international organizations and by individual risk factor guidelines in the United States.12,25,28⇓⇓ The Framingham database has been widely used, though we acknowledge that the multiple risk score may not apply equally to all sex, race, and ethnic groups.29,30⇓ The use of more sophisticated technologies than a risk factor inventory and global risk score has been addressed,31 and we conclude that most screening tests for occult atherosclerosis remain in the research arena, with the exception of the ankle-brachial blood pressure index. Similarly, those recommended interventions involving “nutriceutical” and pharmaceutical interventions in Table 2 have support from randomized clinical trials establishing their efficacy and safety. More controversial interventions, such as very low-fat diets,32 dietary supplements,6,33⇓ and potentially cardioprotective drugs other than aspirin require additional investigation in well-designed clinical trials in persons without established cardiovascular disease.
The gap between which evidence-based interventions are recommended and what is actualized is large.34,35⇓ Guidelines, even when based on the best available evidence from randomized, controlled trials, cannot be successfully implemented without acceptance by the entire healthcare team, including physicians, nurses, nutritionists, and other healthcare professionals. A physician-patient partnership must be forged, on the physician’s part by assessing and communicating risk and by codeveloping with the patient a plan of preventive action. New tools for providers are available to foster this partnership, such as the AHA’s Get With the Guidelines.36 Information for the public on cardiovascular and stroke risk factors is available on the AHA web site.37
The challenge for healthcare professionals is to engage greater numbers of patients, at an earlier stage of their disease, in comprehensive cardiovascular risk reduction with the use of interventions that are designed to circumvent or alleviate barriers to participation and adherence, so that many more individuals may realize the benefits that primary prevention can provide. The healthcare professional should create an environment supportive of risk factor change, including long-term reinforcement of adherence to lifestyle and drug interventions. Practice-based systems for risk factor monitoring, reminders, and support services need to be established, reimbursed, and otherwise supported by managed care organizations and third-party payers. Primary prevention, by its very nature, requires a lifetime of interactions that virtually define successful provider-patient relationships.
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 21, 2002. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0226. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail firstname.lastname@example.org. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
↵*From the Population Science Committee of the American Heart Association.
- ↵Grundy SM, Balady GJ, Criqui MH, et al. Guide to primary prevention of cardiovascular diseases: a statement for healthcare professionals from the Task Force on Risk Reduction. American Heart Association Science Advisory and Coordinating Committee. Circulation. 1997; 95: 2329–2331.
- ↵Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001; 104: 1577–1579.
- ↵Rosengren A, Dotevall A, Eriksson H, et al. Optimal risk factors in the population: prognosis, prevalence, and secular trends; data from Goteborg population studies. Eur Heart J. 2001; 22: 136–144.
- ↵Agency for Healthcare Policy and Research. Treating Tobacco Use and Dependence: US Department of Health and Human Services Public Health Services Report. Washington, DC: US Government Printing Office; 2000.
- ↵The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 1998.NIH Publication 98–4080.
- ↵Krauss RM, Eckel RH, Howard B, et al. AHA dietary guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American Heart Association. Circulation. 2000; 102: 2284–2299.
- ↵Pearson TA. Alcohol and heart disease. Circulation. 1996; 94: 3023–3025.
- ↵Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation. 1996; 94: 857–862.
- ↵Pollock ML, Franklin BA, Balady GJ, et al. AHA Science Advisory. Resistance exercise in individuals with and without cardiovascular disease: benefits, rationale, safety, and prescription: an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association; Position paper endorsed by the American College of Sports Medicine. Circulation. 2000; 101: 828–833.
- ↵American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 6th ed. Baltimore, Md: Lippincott Williams and Wilkins; 2000.
- ↵Eckel RH. Obesity and heart disease: a statement for healthcare professionals from the Nutrition Committee, American Heart Association. Circulation. 1997; 96: 3248–3250.
- ↵American Diabetes Association. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1999; 22 (suppl): S5–S19.
- ↵American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 1999; 22 (suppl 1): S32–S41.
- ↵Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation. 1999; 100: 1134–1146.
- ↵Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke: a statement for healthcare professionals from the Stroke council of the American Heart Association. Circulation. 2001; 103: 163–182.
- ↵Mosca L, Grundy SM, Judelson D, et al. Guide to preventive cardiology for women: AHA/ACC scientific statement consensus panel statement. Circulation. 1999; 99: 2480–2484.
- ↵Fuster V, Ryden LF, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001; 22: 1852-1923.
- ↵Mosca L, Collins P, Herrington DM, et al. Hormone replacement therapy and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation. 2001; 104: 499–503.
- ↵Collaborative meta-analysis of randomized trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Antithrombotic Trialists Collaboration. BMJ. 2002; 324: 71–86.
- ↵Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) full report: manuscript version. National Heart, Lung, and Blood Institute web site. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm. Pages III-3–III-8. Accessed June 1, 2002.
- ↵Wilson PW, D’Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation. 1998; 97: 1837–1847.
- ↵Grundy SM, Pasternak R, Greenland P, et al. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 1999; 100: 1481–1492.
- ↵Smith SC Jr, Greenland P, Grundy SM. AHA Conference Proceedings: Prevention Conference V: beyond secondary prevention: identifying the high-risk patient for primary prevention: executive summary. American Heart Association. Circulation. 2000; 101: 111–116.
- ↵Lichtenstein AH, Van Horn L. Very low fat diets. Circulation. 1998; 98: 935–939.
- ↵Tribble DL. AHA science advisory: antioxidant consumption and risk of coronary heart disease: emphasis on vitamin C, vitamin E, and beta-carotene: a statement for healthcare professionals from the American Heart Association. Circulation. 1999; 99: 591–595.
- ↵Burke LE, Ockene IS, eds. Compliance in Healthcare and Research. Armonk, NY: Futura Publishing Co; 2001.
- ↵American Heart Association. Get With the Guidelines. Available at: http://www.americanheart.org/getwiththeguidelines. Accessed June 1, 2002.
- ↵American Heart Association web site. Available at: http://www. americanheart.org. Accessed June 1, 2002.