Experts have issued a new set of guidelines on the best ways to prevent first heart attacks, strokes and heart failure — and for the first time, they focus squarely on the patient. The new guidelines recognize how doctors can support people to not only address their medical risk factors, but also to change their behaviors and lifestyles in order to reduce their risk.
The latest revisions to the guidelines, issued by the American College of Cardiology (ACC) and the American Heart Association (AHA), were announced at the annual meeting of the ACC. They are intended to help doctors figure out a patient’s risk of having heart trouble and to navigate the best ways to treat those risk factors.
“It’s important for people to realize that more than 80% of heart attacks, strokes and peripheral arterial disease events are preventable, so early recognition of risk factors is important,” says Dr. Roger Blumenthal, director of the Johns Hopkins Ciccarone center for prevention of cardiovascular disease and co-chair of the ACC/AHA Prevention Writing Committee. “We want people to realize that it’s not rocket science on most of these things. It’s good common sense. And for doctors, it’s about motivating people when they come in for each and every visit — no matter what they come in to see us for.”
The recommendations, which are published in the AHA’s journal Circulation, reiterate previous advice on a number of measures but also propose new recommendations, including some that have not traditionally fallen within the realm of medicine.
Use aspirin — when appropriate
Until now, the ACC and AHA have recommended that most people at higher risk of having a first heart event take low-dose aspirin as a way to lower inflammation, which can prompt heart attacks and strokes.
But recent studies have questioned the safety of daily aspirin, even in low doses, and the latest guidelines back off that advice. Taking aspirin regularly can increase the risk of bleeding in the intestinal tract, especially for vulnerable people, like those with ulcers. Reflecting the latest data, the new guidelines recommend aspirin only after other heart disease risk factors — including cholesterol, blood pressure, diabetes, smoking, weight and exercise — have been addressed. Aspirin should not be recommended for people over 70, the new advice says, since the risk of bleeding outweighs any benefit the over-the-counter anti-inflammatory drug might provide.
Control Type 2 diabetes
The new advice also takes a stronger position on controlling blood sugar and recommends incorporating not just first-line drugs like metformin to treat diabetes, but also newer classes of medications, such as SGLT-2 inhibitors, which prevent the body’s cells from reabsorbing glucose and push them to excrete it instead, and GLP-1R agonists, which burn off more glucose in muscle cells and promote the pancreas to produce more insulin to break down blood sugar.
Steer clear of e-cigarettes
While the advice to quit smoking is familiar, the new guidelines also address the potential dangers of e-cigarettes. The guidelines do not recommend e-cigarettes as a strategy for quitting cigarette smoking and advise people to instead try proven smoking cessation options, including nicotine replacement patches, gums or smoking cessation medications.
Consider a patient’s environment
The new guidelines put a fresh emphasis on some of the non-medical factors that the latest research shows can be as important, if not more important, in affecting people’s health. These include whether people have stable housing and sources of food, as well as transportation to health care facilities. These so-called social determinants of health are emerging as a critical part to keeping people healthy, and the guidelines reflect that in urging doctors to engage with their patients about their social environments in order to better help them address challenges in finding healthy food, for example, or safe places to exercise. “If you want to change the risk for a patient, you cannot do that without the patient being front and center,” says Dr. Vera Bittner, professor of medicine at the University of Alabama at Birmingham who wrote a perspective accompanying the new guidelines. “So you need to take the patient’s circumstances, as well as his values and goals into account when you design a prevention strategy. It’s a more rational approach to the care paradigm.”
Keep blood pressure low
The guidelines continue to recommend that most people who have not yet had heart problems aim to keep their pressure below 130/80 mmHg, as the 2017 guidelines advised.
Lower cholesterol
The groups revised their cholesterol advice in November 2018, and not much has changed since; the new advice continues to recommend that in order to reduce risk of a first heart event, people should modify their diet and exercise and stop smoking first. If cholesterol levels remain high, then people should discuss with their doctors whether taking a statin could help. Since Type 2 diabetes is a risk factor for heart disease, people with diabetes should consider taking a statin to further lower their risk.
Maintain a reasonable weight
Experts continue to advise people to maintain their recommended weight by eating a diet rich in fruits, vegetables, grains and fish and avoid sugar and processed meats.
Move more
The new guidelines also support current advice for most people to get 150 minutes of moderate-intensity physical activity each week (or 75 minutes of vigorous exercise) in order to maintain healthy weight and keep blood pressure down. The more exercise, the greater the benefits, but any exercise, as the latest studies show, is better than none when it comes to protecting the heart.
