Let’s take what we learned in A Review of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease and apply the risk assessment tool in a real-life scenario. Remember that the following variables must be considered: age, gender, race, blood pressure, cholesterol profile, history of diabetes, tobacco use, and whether the patient is currently taking medication for blood pressure, cholesterol or coronary artery disease. 

A 53-year-old Caucasian male returns to your office after having bloodwork completed to discuss therapy options. His past medical history includes pre-diabetes (HgA1C 6.4); Class I obesity (BMI 31), a family history of premature CAD, daily tobacco smoker (1/2 PPD for 35 years), with blood pressure of 145/60 on today’s visit as well as last visit, and a cholesterol panel as follows: total cholesterol 189; HDL 31; LDL 141; triglycerides 87.

He seeks your professional opinion about whether he needs to take a statin, or any other medication.

What is his risk?

• The ASCVD Risk Estimator Plus places him at a 10-year ASCVD Risk of 16.3% (intermediate).
• His Lifetime ASCVD Risk is 50%
• His Optimal ASCVD Risk is 2.9%

Should he start a statin?

• Moderate intensity statin is recommended for patients with LDL-C 70-189 mg/dL. Presence of risk enhancing factors (in his case, metabolic syndrome and family history of premature ASCVD), favor initiation of statin therapy. LDL-C should be reduced by at least 30%.

If he is resistant to starting a statin, it is reasonable to use a coronary artery calcium (CAC) score in the decision to withhold, postpone or initiate statin therapy. In which case, the following applies:

• If the coronary calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5-10 years, as long as higher risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking).
• If CAC score is 1 to 99, it is reasonable to initiate statin therapy for patients ≥ 55 years of age.
• If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.

Should he be treated for hypertension at this visit?

• For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is recommended.
• Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within one month of the initial diagnosis, have a combination of nonpharmacological management and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in 1 month.
• For initiation of antihypertensive drug therapy, first-line agents include thiazide diuretics, calcium channel blockers (CCBs), and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).

What other counseling should occur at the time of this visit?

• Tobacco abstinence is recommended, and the patient should be firmly advised to quit.
• Offer a combination of behavioral interventions plus pharmacotherapy.
• Avoid exposure to secondhand smoke.
• Assess tobacco use at every visit.
• Make a follow-up plan.

What other behavioral modifications should he make?

• He should be counseled on the benefits of weight loss, and a healthy diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended.
• He should also be routinely counseled to optimize a physically active lifestyle. (Engage in at least 150 minutes per week of accumulated moderate intensity or 75 minutes per week of vigorous intensity aerobic physical activity).

What else can he do to reduce his ASCVD risk? Should he start a medication for diabetes?

• No, at this time, he does not fall into guidelines for medical therapy. HgA1C ≥ 6.5 is considered diabetes.

What about an aspirin?

• He falls into the intermediate risk category and would not meet criteria for starting an aspirin at this time.

Need to revisit the guidelines? Read this review or view our guideline summary.