Background

Cardiovascular disease does not discriminate. As the global impact of cardiovascular disease is more prevalent, action plans are necessary for prevention. Cardiovascular disease remains the top killer of Americans, second only to cancer.¹ Centers for Disease Control and Prevention reports that the leading driver of healthcare expenses are chronic diseases such as heart disease, cancer, stroke, and diabetes. These chronic diseases are preventable when considering modifiable risk factors. Lifestyle modification such as tobacco avoidance, healthy diet, and increasing physical activity will drastically reduce death from chronic disease. 

New Guideline

In March 2019, the American College of Cardiology and the American Heart Association released current guidelines for primary prevention of cardiovascular disease (PDF). Intended for primary prevention, the recommendations were based on the most recent clinical trial evidence.²  The guidelines covered nine categories:

• nutrition
• obesity
• physical activity
• diabetes, lipids
• statin therapy
• hypertension
• tobacco
• aspirin

The guidelines also emphasized the importance of shared decision-making in conjunction with a team-based approach for the implementation of lifestyle modification. Additionally, these prevention guidelines outline the significance of determining the social determinants and addressing barriers to healthcare. 

The prevention guidelines provided ten takeaway messages that depict a condensed summary of the recommendations.³ These takeaways help guide lifestyle change in clinical practice and initiating patient conversation. The major theme of the prevention guidelines enlists the importance of incorporating a healthy lifestyle across the lifespan and achieving change requires a team-based approach.  A ten-year atherosclerotic cardiovascular disease (ASCVD)  risk estimation and a coronary artery calcium scan should be completed in adults ages 40-75 in conjunction with a discussion of those risks prior to the implementation of any pharmacological therapy.

A diet rich in fruits, vegetables, legumes, nuts, whole grains, lean vegetable or animal protein, and fish but limited in trans fats, processed meats, refined carbohydrates, and sweetened beverages is encouraged for all adults. Physical activity for adults should be an engagement of 150 minutes weekly that is of moderate-intensity or 75 minutes weekly of vigorous-intensity. Lifestyle modification is also encouraged for adults with type 2 diabetes with metformin being the first-line therapy. It may be followed with a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. Tobacco use and cessation discussion should be assessed at every healthcare visit for all adults. Since there is a lack of net benefit, aspirin should be used sparingly in routine primary prevention of ASCVD.³ The recommended first-line therapy for primary prevention of ASCVD with elevated low-density lipoprotein (LDL) cholesterol in adults is statin therapy. This recommendation also encompasses adults ages 40 to 75 with diabetes and have been determined to be at risk for ASCVD.  Finally, non-pharmacological interventions are the standard therapy for adults with elevated blood pressure. For those populations requiring pharmacological therapy, the target blood pressure should be less than 130/80 mmHg.³

Implementing the Guidelines

One of the most effective tools for guideline implementation is education and raising awareness.⁴  The AHA/ACC guidelines (2019) on primary prevention for cardiovascular disease have indicated the importance of the advanced practice nurse (APN) placing an intensified focus on the importance of having crucial conversations regarding a healthy lifestyle with their patient population by empowering, educating, and engaging the patient.⁵  The key to guideline implementation is education; involve frontline nurses whenever possible and adapt the teaching to the individual circumstances. Explaining the benefits of lifestyle modification can help to motivate the patient to make healthy changes. Additionally, reassuring the patient that making small goals will lead to big changes is an effective strategy for long term success.  Finally, the APN should evaluate any social determinants that affect the individual from making healthy changes to define therapy decisions.² 

PCNA can help you when implementing these new guidelines, with the following items:

• Blood pressure patient education tools
• Cholesterol patient education tools
• Diabetes tools
• Heart Healthy Toolbox Lifestyle and Behavior Change Tools
• Webinar on the new Primary Prevention Guidelines

References

1. Center for Disease Control and Prevention. (2017). Heart Disease Facts. Retrieved from https://www.cdc.gov/heartdisease/facts.htm
2. American College of Cardiology (2019).  AHA/ACC Guidelines on the primary prevention of cardiovascular disease. Retrieved from http://www.onlinejacc.org/sites/default/files/additional_assets/guidelines/Prevention-Guidelines-Made-Simple.pdf
3. American Heart Association. (2019). Top Ten Things to Know: 2019 CVD primary prevention guidelines.  Retrieved from https://professional.heart.org/professional/ScienceNews/UCM_503728_Top-Ten-2019-CVD-Primary-Prevention-Guideline.jsp
4. Murphy, Staffileno, & Foreman. (2018) Research for Advanced Practice Nurses, Third Edition.
5. Roberts, M.E., Davis, L.L. (2013).  Cardiovascular disease in women: A Nurse Practitioner’s guide to prevention. Retrieved from https://doi.org/10.1016/j.nurpra.2013.08.018