(Circulation. 2002;106:388.)
© 2002 American Heart Association, Inc.
AHA Scientific Statement |
Key Words: AHA Scientific Statements prevention risk factors cardiovascular disease stroke
Introduction |
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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 Guides 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.
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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 physicians 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 AHAs 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.
Footnotes |
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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 kbradle@lww.com. 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.
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J. K. Pai, T. Pischon, J. Ma, J. E. Manson, S. E. Hankinson, K. Joshipura, G. C. Curhan, N. Rifai, C. C. Cannuscio, M. J. Stampfer, et al. Inflammatory Markers and the Risk of Coronary Heart Disease in Men and Women N. Engl. J. Med., December 16, 2004; 351(25): 2599 - 2610. [Abstract] [Full Text] [PDF] |
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T. Psaltopoulou, P. Orfanos, A. Naska, D. Lenas, D. Trichopoulos, and A. Trichopoulou Prevalence, awareness, treatment and control of hypertension in a general population sample of 26 913 adults in the Greek EPIC study Int. J. Epidemiol., December 1, 2004; 33(6): 1345 - 1352. [Abstract] [Full Text] [PDF] |
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P. van der Harst, M. Volbeda, A. A. Voors, H. Buikema, S. Wassmann, M. Bohm, G. Nickenig, and W. H. van Gilst Vascular Response to Angiotensin II Predicts Long-Term Prognosis in Patients Undergoing Coronary Artery Bypass Grafting Hypertension, December 1, 2004; 44(6): 930 - 934. [Abstract] [Full Text] [PDF] |
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K.-T. Khaw, S. Bingham, A. Welch, R. Luben, E. O'Brien, N. Wareham, and N. Day Blood pressure and urinary sodium in men and women: the Norfolk Cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk) Am. J. Clinical Nutrition, November 1, 2004; 80(5): 1397 - 1403. [Abstract] [Full Text] [PDF] |
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E. A. Meagher Addressing Cardiovascular Disease in Women: Focus on Dyslipidemia J Am Board Fam Med, November 1, 2004; 17(6): 424 - 437. [Abstract] [Full Text] [PDF] |
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C. H. Hennekens, G. L. Knatterud, and M. A. Pfeffer Use of Aspirin to Reduce Risks of Cardiovascular Disease in Patients With Diabetes: Clinical and research challenges Diabetes Care, November 1, 2004; 27(11): 2752 - 2754. [Full Text] [PDF] |
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S. Ornstein, R. G. Jenkins, P. J. Nietert, C. Feifer, L. F. Roylance, L. Nemeth, S. Corley, L. Dickerson, W. D. Bradford, and C. Litvin A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care: A Cluster Randomized Trial Ann Intern Med, October 5, 2004; 141(7): 523 - 532. [Abstract] [Full Text] [PDF] |
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G. J. Balady, M. G. Larson, R. S. Vasan, E. P. Leip, C. J. O'Donnell, and D. Levy Usefulness of Exercise Testing in the Prediction of Coronary Disease Risk Among Asymptomatic Persons as a Function of the Framingham Risk Score Circulation, October 5, 2004; 110(14): 1920 - 1925. [Abstract] [Full Text] [PDF] |
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Stroke Obstet. Gynecol., October 1, 2004; 104(4_suppl): 97S - 105S. [Full Text] [PDF] |
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K.-T. Khaw, N. Wareham, S. Bingham, R. Luben, A. Welch, and N. Day Association of Hemoglobin A1c with Cardiovascular Disease and Mortality in Adults: The European Prospective Investigation into Cancer in Norfolk Ann Intern Med, September 21, 2004; 141(6): 413 - 420. [Abstract] [Full Text] [PDF] |
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I. Meissner, B. K. Khandheria, S. G. Sheps, G. L. Schwartz, D. O. Wiebers, J. P. Whisnant, J. L. Covalt, T. M. Petterson, T. J.H. Christianson, and Y. Agmon Atherosclerosis of the aorta: Risk factor, risk marker, or innocent bystander?: A prospective population-based transesophageal echocardiography study J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1018 - 1024. [Abstract] [Full Text] [PDF] |
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C. Patrono, B. Coller, G. A. FitzGerald, J. Hirsh, and G. Roth Platelet-Active Drugs: The Relationships Among Dose, Effectiveness, and Side Effects: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 234S - 264S. [Abstract] [Full Text] [PDF] |
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H. Eyre, R. Kahn, R. M. Robertson, and and the ACS/ADA/AHA Collaborative Writing Committe Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Stroke, August 1, 2004; 35(8): 1999 - 2010. [Abstract] [Full Text] [PDF] |
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H. Eyre, R. Kahn, R. M. Robertson, and the ACS/ADA/AHA Collaborative Writing Committe, N. G. Clark, C. Doyle, T. Gansler, T. Glynn, Y. Hong, R. A. Smith, et al. Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association CA Cancer J Clin, July 1, 2004; 54(4): 190 - 207. [Abstract] [Full Text] [PDF] |
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H. Eyre, R. Kahn, and R. M. Robertson Preventing Cancer, Cardiovascular Disease, and Diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Diabetes Care, July 1, 2004; 27(7): 1812 - 1824. [Abstract] [Full Text] [PDF] |
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H. Eyre, R. Kahn, R. M. Robertson, the ACS/ADA/AHA Collaborative Writing Committee, ACS/ADA/AHA Collaborative Writing Committee Member, N. G. Clark, C. Doyle, Y. Hong, T. Gansler, T. Glynn, et al. Preventing Cancer, Cardiovascular Disease, and Diabetes: A Common Agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Circulation, June 29, 2004; 109(25): 3244 - 3255. [Abstract] [Full Text] [PDF] |
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E. R. Cox, M. Frisse, A. Behm, and K. A. Fairman Over-the-Counter Pain Reliever and Aspirin Use Within a Sample of Long-term Cyclooxygenase 2 Users Arch Intern Med, June 14, 2004; 164(11): 1243 - 1246. [Full Text] [PDF] |
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M. J. LaMonte, M. Z. Nichaman, S. N. Blair, J. K. Ninomiya, M. H. Criqui, A. Gamst, G. L'Italien, J. L. Whyte, and R. S. Chen Physical Activity and the Metabolic Syndrome Association With Myocardial Infarction and Stroke * Response Circulation, June 8, 2004; 109(22): e314 - e314. [Full Text] [PDF] |
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J. Liu, Y. Hong, R. B. D'Agostino Sr, Z. Wu, W. Wang, J. Sun, P. W. F. Wilson, W. B. Kannel, and D. Zhao Predictive Value for the Chinese Population of the Framingham CHD Risk Assessment Tool Compared With the Chinese Multi-provincial Cohort Study JAMA, June 2, 2004; 291(21): 2591 - 2599. [Abstract] [Full Text] [PDF] |
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R. D. Brook, B. Franklin, W. Cascio, Y. Hong, G. Howard, M. Lipsett, R. Luepker, M. Mittleman, J. Samet, S. C. Smith Jr, et al. Air Pollution and Cardiovascular Disease: A Statement for Healthcare Professionals From the Expert Panel on Population and Prevention Science of the American Heart Association Circulation, June 1, 2004; 109(21): 2655 - 2671. [Abstract] [Full Text] [PDF] |
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N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Stroke, May 1, 2004; 35(5): 1230 - 1240. [Full Text] [PDF] |
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N. F. Gordon, M. Gulanick, F. Costa, G. Fletcher, B. A. Franklin, E. J. Roth, and T. Shephard Physical Activity and Exercise Recommendations for Stroke Survivors: An American Heart Association Scientific Statement From the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council Circulation, April 27, 2004; 109(16): 2031 - 2041. [Full Text] [PDF] |
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D. C. Anderson and L. B. Goldstein Aspirin: It's hard to beat Neurology, April 13, 2004; 62(7): 1036 - 1037. [Full Text] [PDF] |
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O. Honda, S. Sugiyama, K. Kugiyama, H. Fukushima, S. Nakamura, S. Koide, S. Kojima, N. Hirai, H. Kawano, H. Soejima, et al. Echolucent carotid plaques predict future coronary events in patients with coronary artery disease J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1177 - 1184. [Abstract] [Full Text] [PDF] |
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Expert Panel/Writing Group, L. Mosca, L. J. Appel, E. J. Benjamin, K. Berra, N. Chandra-Strobos, R. P. Fabunmi, D. Grady, C. K. Haan, S. N. Hayes, et al. Evidence-based guidelines for cardiovascular disease prevention in women J. Am. Coll. Cardiol., March 3, 2004; 43(5): 900 - 921. [Abstract] [Full Text] [PDF] |
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L. Mosca and for the Expert Panel/WritingGroup Summary of the American Heart Association's Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women Arterioscler. Thromb. Vasc. Biol., March 1, 2004; 24(3): 394 - 396. [Full Text] |
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L. Mosca, L. J. Appel, E. J. Benjamin, K. Berra, N. Chandra-Strobos, R. P. Fabunmi, D. Grady, C. K. Haan, S. N. Hayes, D. R. Judelson, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women Arterioscler. Thromb. Vasc. Biol., March 1, 2004; 24(3): e29 - 50. [Full Text] |
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