Pathways Forward in Cardiovascular Disease Prevention One and a Half Years After Publication of the 2013 ACC/AHA Cardiovascular Disease Prevention Guidelines

Abstract

The 2013 American College of Cardiology / American Heart Association (ACC/AHA) prevention guidelines represent an important step forward in both the risk assessment and management of atherosclerotic cardiovascular disease in clinical practice. Differentiated risk prediction equations for women and African Americans were developed, and convenient 10-year and lifetime risk assessment tools were provided, facilitating their implementation. Lifestyle modification was portrayed as the foundation of preventive therapy. In addition, based on high-quality evidence from randomized controlled trials, statins were prioritized as the first lipid-lowering pharmacologic treatment, and a shared decision-making model between the physician and the patient was emphasized as a key feature of personalized care. After their publication, however, important limitations of the guidelines were also identified. This resulted in a constructive scientific debate yielding valuable insights into potential opportunities to refine recommendations, fill gaps in guidance, and better harmonize recommendations within and outside the US. The latter point deserves emphasis because when guidelines are in disagreement, this may result in non-action on the part of professional caregivers or non-adherence by patients. In this review, we discuss the key scientific literature relevant to the guidelines published in the year and a half after their release. We aim to provide cohesive, evidence-based views that may offer pathways forward in cardiovascular prevention towards greater consensus and benefit the practice of clinical medicine.

Cardiovascular Disease Risk Prediction in the HIV Outpatient Study

“…These risk prediction tools may provide accurate estimates of long-term risk [23], but the PCE particularly has been shown to overestimate CVD risk in general populations [33, 34]. In contrast, our findings support another recent study that reported that the FRS and PCE underestimate CVD risk in HIV-infected populations [35].…”

Providing Evidence for Subclinical CVD in Risk Assessment

“…43 The MESA study played a prominent role in describing how so-called “negative risk factors” can be used to down-classify risk in certain situations. 36,44-46 In a study of 13 negative risk factors, Blaha et al used risk factor-adjusted diagnostic likelihood ratios (DLRs) to demonstrate that a CAC score of zero was the strongest negative risk factor (0.41), followed by a normal carotid ultrasound (0.65) and a negative family history of CHD (0.76) (Figure 4).…”

LIFESTAT – Living with statins: An interdisciplinary project on the use of statins as a cholesterol-lowering treatment and for cardiovascular risk reduction

“…These treatment goals are based on the present evidence for reducing morbidity and mortality connected to different medical conditions. The goals have been sharpened in recent years, and experts recommend more aggressive treatment with statins [26], although full agreement has not been achieved [27]. Compared with primary prevention, statin therapy is more important in secondary prevention, e.g.…”