Image by AlexSecret
Image by AlexSecret

Take a tiered approach to CVD

Primary care physicians' efforts are paying off as they promote primary prevention of cardiovascular disease, even in a time-pressed visit.

Cardiovascular disease (CVD) claims more than 850,000 lives annually, according to the latest American Heart Association (AHA) data, and is the number one cause of death in the United States. But notable improvements have been seen in the past decade: From 2008 to 2018, the stroke death rate has declined by 11.9% and the death rate from heart disease has declined by 27.9%.

These improvements are due at least in part to primary care physicians' efforts, and there's a lot they can do to further promote primary prevention of CVD, even in a time-pressed visit, said Robert Kushner, MD, FACP, professor of medicine at Northwestern University Feinberg School of Medicine and director of The Center for Lifestyle Medicine at Northwestern Medicine in Chicago. One area to address is an increasingly common American risk factor: excess weight. He cited a recent analysis, published Nov. 23/30, 2021, in JAMA, which found that 32.7% of young adults ages 18 to 25 years were obese in 2017-2018 compared with 6.2% in the late 1970s.

It's important to ask patients' permission first, Dr. Kushner suggested. “You say, ‘Is this a good time to talk about your weight?’” Then take a few minutes to brainstorm several strategies that might fit with their lifestyle before considering referring them for additional support, whether to a registered dietitian or other outside resources, he said.

This message “coming from a voice of authority,” as patients often perceive physicians, can make an impression, he said. “That my doctor brought up my weight because he felt or she felt that it was important to my health, and actually spent five minutes talking to me about it in a very respectful way,” Dr. Kushner said, “that's very, very meaningful.”

To encourage healthier eating, physicians can refer patients to an expanding array of nutritional and wellness programs, including some offered through grocery store chains and employer programs, said Lawrence Appel, MD, MPH, FACP, a professor of medicine and a general internist at Baltimore's Johns Hopkins University and vice chair on the AHA's latest dietary guidance for cardiovascular health. The guidance, published Dec. 7, 2021, in Circulation, focuses on broad strategies to improve the quality of what someone eats and didn't delve into any specific diets, including fad diets, he said.

Simple reminders can help, such as advising patients to minimize processed food, avoiding “food in cellophane,” Dr. Appel said. Ask if they have a scale at home to monitor their own weight, he added. Also, patients can learn a lot about their own daily nutritional choices by using one of various phone applications, some of which are free, such as the MyPlate app, Dr. Kushner said.

Treating risk factors

Darren DeWalt, MD, FACP, John R. and Helen B. Chambliss Distinguished Professor and chief of the division of general medicine and clinical epidemiology at the University of North Carolina School of Medicine in Chapel Hill, said he typically starts talking about statins once a patient's 10-year atherosclerotic CVD risk estimation reaches the 7.5% to 10% range, spelling out what a one-third reduction in cardiovascular risk would mean. If a patient's score is 7.5%, for example, he explains that a statin will decrease the chance of a heart attack or stroke to roughly 5% over the next decade.

The thresholds to guide the initiation of statins vary. The U.S. Preventive Services Task Force (USPSTF) recommends a 10% risk score for adults ages 40 to 75 years with one or more risk factors. (The Task Force is in the process of updating those statin recommendations, published in 2016.) The American College of Cardiology/American Heart Association sets the bar at 7.5% and possibly as low as 5% if the patient has other risk-enhancing conditions, such as metabolic syndrome or a family history, according to their joint guideline on primary prevention, published in September 2019 by Circulation and the Journal of the American College of Cardiology.

ACP Member Jeremy Sussman, MD, will typically adjust his statin recommendation for primary prevention based on his patient's 10-year risk estimation, encouraging use at 5% to 10% and making a stronger case as risk increases. A borderline candidate might be a 50-year-old with a 10-year risk of 8%, said Dr. Sussman, an associate professor at the University of Michigan and a primary care physician and research scientist at the Veterans Affairs Ann Arbor Healthcare System. In cases such as these, Dr. Sussman will detail the potential benefits and downsides, including the addition of a daily medication and possible side effects, such as muscle aches.

Despite patients' concerns about potential side effects, a systematic review of 14 primary prevention trials comparing statins to placebo found no significant link. The review, published in 2014 in the European Journal of Preventive Cardiology, found that fatigue, muscle aches, and myopathy weren't any more common in those taking statins versus placebo. When statin-related myalgias do occur and if patients are bothered by them, the physician can suggest trying another statin, Dr. Sussman said.

Dr. DeWalt has learned over time that patients are more open to starting a preventive medication, such as a statin, if he lets them know upfront that they have an off ramp. For instance, he tells his patients that a statin “is an incredibly safe medication. It's safer than taking an aspirin a day, and it's more effective.’” Dr. DeWalt also emphasizes that the vast majority of people don't experience side effects, including muscle aches.

“I say, ‘Why don't you give it a try? And we can always stop it.’ Almost all of my patients are ready to try, when I offer it that way.”

To maximize cardiovascular protection, Dr. Sussman also suggested that physicians review blood pressure control in some patients, including older patients, in light of the cardiovascular benefits found in the Systolic Blood Pressure Intervention Trial (SPRINT), in which patients without diabetes received antihypertensive treatment with a systolic target of 120 mm Hg. “One of the lessons of SPRINT was that many things that we thought might prevent that [cardiovascular] benefit, like older age or kidney disease, patients with those [conditions] did benefit,” he said. Plus, the risk of falls in that study proved to be lower than anticipated, he said.

Dr. Sussman will recommend antihypertensive drugs in patients with readings exceeding 130/80 mm Hg who have a 10-year cardiovascular risk estimation of 10%. Once that risk approaches or surpasses 15%, he will more strongly encourage medication.

Dr. DeWalt agreed that SPRINT's findings changed his discussions with some patients ages 65 years and older. He will more frequently propose, “Rather than going for [a systolic reading of] 140, let's see if we can get it down closer to 120, as long as you're not having side effects.”

Still, he noted, the greatest cardiovascular benefit is achieved by reducing someone's systolic reading from 160 mm Hg to 140 mm Hg, rather than pushing from 140 mm Hg to 120 mm Hg. Taking medication to strive for that lower 120 mm Hg target is very much a shared decision-making conversation, Dr. DeWalt said. He stresses that patients should alert him if they develop any dizziness or lightheadedness on the new medication regimen.

If patients have not taken any antihypertensive medication previously, Dr. DeWalt will consider their blood pressure level and their cardiovascular risk in weighing whether to prescribe. If blood pressure exceeds 130/80 mm Hg and the cardiovascular risk exceeds 10%, he will suggest antihypertensive medication and/or a statin. But if a patient's cardiovascular risk exceeds 10% and blood pressure is below 130/80 mm Hg, he's more likely to prescribe a statin first to bring down the risk, he said.

Aspirin guidance, smoking cessation

In regard to primary cardiovascular prevention, the USPSTF continues to shift away from recommending low-dose aspirin, based on its draft guidance published in October 2021. In 2016, the Task Force had recommended aspirin in adults ages 50 to 59 years with at least a 10% cardiovascular risk, assigning that recommendation a B grade based on aspirin's potential to reduce CVD and colorectal cancer. The Task Force guidance at that time was more equivocal, with a C recommendation, for adults ages 60 to 69 years with the same cardiovascular risk.

In the U.S., 61.7% of adults with diabetes ages 60 years and older take aspirin for primary prevention, as well as 42.2% without diabetes, according to a cross-sectional analysis of data from the National Health and Nutrition Examination Survey published June 21, 2021, in JAMA Network Open.

But the latest research review by the Task Force, which included more recent studies, indicates that the potential harms of aspirin, most notably gastrointestinal and other bleeding, largely cancel out the cardiovascular benefits for adults ages 60 years and older, said John Wong, MD, MACP, a Task Force member and chief of the division of clinical decision making in the department of medicine at Tufts Medical Center in Boston. The draft statement assigned a D rating, recommending not starting aspirin in this age group for primary prevention.

More recent studies have not identified as great a cardiovascular benefit from aspirin, likely due in part to other prevention successes, such as a reduction in smoking rates and better treatment of hypertension and hypercholesterolemia, Dr. Wong said. Another factor the Task Force considered is that bleeding risk can develop in the short term, he said.

“And the potential benefits in preventing a first stroke or heart attack are downstream or later in life,” Dr. Wong said. “So, you've got this upfront risk, yet a delayed benefit.”

Among individuals in their 40s and 50s, the Task Force gave a C rating for starting aspirin, allowing physicians and their patients to sort out the individual risks and benefits, Dr. Wong said. Physicians may want to have a similar conversation for patients of all ages who are already taking aspirin for primary cardiovascular prevention, he said.

Michael Pignone, MD, MPH, MACP, a Task Force member when the 2016 aspirin recommendations were developed, agreed that the bleeding risk is too great a concern to suggest aspirin in adults ages 70 years and older. But he questioned whether the draft guidance went too far by opposing aspirin among adults ages 60 to 69 years. “That feels to me like it's expressing more certainty about net harm than there is,” said Dr. Pignone, a professor of medicine and chair of the department of internal medicine at The University of Texas at Austin Dell Medical School.

Key areas of research uncertainty persist, including to what extent aspirin reduces fatal cardiovascular events among adults in their 60s, said Dr. Pignone, adding that even a small benefit could help many people. There's also not enough high-quality evidence isolating the relative risk of fatal gastrointestinal bleeds, he said.

Moreover, Dr. Pignone disagreed with the Task Force describing the level of evidence for aspirin and colon cancer outcomes “to be insufficient to very low strength.” While that might be true in the context of the prevention studies assessed by the Task Force, Dr. Pignone said, the totality of aspirin-colorectal cancer research, including its use in individuals at higher risk or with a history of polyps, paints a different picture. “I think it's very hard-pressed to believe that aspirin doesn't have a beneficial effect on colorectal cancer incidence over extended periods of time,” he said.

Dr. Pignone noted, however, that he would treat a patient's elevated blood pressure or cholesterol levels first before considering aspirin as an option. Dr. DeWalt also pursues that multitiered prescribing approach. But first on his primary cardiovascular prevention list is to check in with his patients who smoke to see if they are ready to try to quit.

If they are, Dr. DeWalt will discuss prescription medications as well as nicotine patches and other over-the-counter options, along with providing resources such as the quitline 1-800-QUIT-NOW. Most patients opt to try bupropion or varenicline, he said. “If a patient is ready to have that conversation to work on smoking, then I see that as a really good use of my time with them.”

When discussing behavioral changes, Dr. DeWalt doesn't necessarily talk up their cardiovascular benefits if he feels like other approaches might resonate more. For example, he reminds his patients that more exercise now will boost their chances of being mobile and energetic later in life.

“I say, ‘When you lose muscle mass as an elderly person, or anywhere past middle age, it's really hard to get it back,’” he said. “And they're nodding. They know.”