Strategies*
- Prevent heart disease through lifestyle management, including smoking cessation (Appendix A in the original guideline document), increased physical activity, maintenance of a healthy weight and healthy eating habits.
- Assess the 10-year coronary heart disease (CHD) risk. This should be a part of a physical examination or done at intervals during other patient-physician interactions. CHD risk assessment charts are provided (Appendix B and C in the original guideline document).
- Provide tools for patient self-assessment and access to resources.
* Figure 1 (in the original guideline document) provides an overview of risk assessment and management strategies for cardiovascular disease.
Lifestyle Management
Heart disease and stroke are often caused by modifiable risk factors related to diet and lifestyle. These factors include smoking, lack of physical activity, unhealthy eating habits, and excess body weight. Excess body weight and lack of physical activity contribute to diabetes, increased blood pressure and dyslipidemia, which in turn significantly increase the risk of heart disease and stroke.
- Encourage all patients to adopt a healthy lifestyle to lower their risk of cardiovascular disease (CVD) (see the resources section at the end of this guideline and at the end of the associated patient guide).
- Provide adequate explanation and support to patients so that they clearly understand the nature and significance of CVD and that they have the primary responsibility for making the lifestyle changes required for reducing their risk.
- Provide patients with information, tools, resources and available supports, such as those offered by the Heart and Stroke Foundation of British Columbia and Yukon. These resources include self-assessment tools, personalized lifestyle management plans and self-management courses.
Offer and review the following lifestyle recommendations at each visit:
Smoking cessation: Cigarette smoking is responsible for approximately 30% of CHD deaths in North America. Complete cessation of smoking and exposure to second hand smoke is recommended. For assistance to quit, refer patients to QuitNow Services at 1 877 455-2233 (toll-free in BC; available 24/7/365) and at www.quitnow.ca to obtain self-help materials. Refer to Appendix A of the original guideline document for additional information.
Physical activity: A sedentary lifestyle is an important modifiable risk factor. Moderate intensity dynamic activity (such as walking 3 km [2 miles] in 30 minutes once per day or walking 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming) is beneficial for cardiac health and has been shown to reduce hypertension, prevent diabetes and improve survival. Writing a prescription for physical activity, such as walking (or another equivalent form of activity) for at least 30-60 minutes per day, 4-7 days per week, is an effective way to promote increased physical activity.
Weight reduction: A body-mass index (BMI) greater than 27 kg/m2 is associated with increased risk of hypertension, type 2 diabetes and dyslipidemia. Maintenance of a healthy body weight (BMI 18.5-24.9 kg/m2; waist circumference [Asian/Caucasian] <90 cm/102 cm [35"/40"] for men and <80 cm/88 cm [32"/35"] for women) is recommended. Advise all overweight individuals to lose weight. Weight loss strategies should be long-term and employ a multidisciplinary approach that includes dietary education, increased physical activity and behavioural intervention.
Dietary recommendations: Recommend a diet that emphasizes fruits, vegetables, low-fat dairy products, fibre, whole grains, and protein sources that are low in trans-fat, saturated fat and cholesterol. In addition to a well-balanced diet, a reduced dietary sodium intake of ≤1,500 milligrams per day (approximately 1 tsp of table salt) is recommended for everyone. Advise patients about the "hidden" salt content of processed foods, such as lunchmeat, canned soups and pasta. As well, increased consumption (at least 2 servings per week) of fish that are high in omega-3 fatty acids decreases cardiovascular risk.
Patients with CVD or identified risk factors such as diabetes, dyslipidemia, hypertension or obesity may benefit from personalized diet advice and may benefit from referral to a dietitian (see resources section on page 9 of the original guideline document for contact information for Dial-A-Dietitian). Disease-specific patient guides are provided at www.bcguidelines.ca.
Additional lifestyle management information, specifically on healthy eating, physical activity and smoking cessation, may be found at Act Now BC. ActNowBC recommends the following:
| 0 |
Smoking: Complete avoidance of tobacco smoke |
| 5 |
Servings of fruits and vegetables per day (minimum) |
| 30 |
Minutes of moderate-intensity activity per day (minimum) |
Cardiovascular Disease Risk Control
A number of clinical conditions, including hypertension, diabetes, dyslipidemia and kidney disease contribute significantly to the risk of developing cardiovascular disease. Effective long-term control of these conditions can substantially decrease the risk of CVD. Individual guidelines for the management of hypertension, diabetes and chronic kidney disease may be found at www.bcguidelines.ca. The management of dyslipidemia is covered in this guideline.
The following are considerations for cardiovascular disease risk control. Atherosclerosis and vascular damage that precede clinical CVD can also be prevented by reduction of the risk factors discussed below.
- Blood pressure (BP) control: Promote a healthy lifestyle through smoking cessation, weight reduction, increased physical activity, low-salt and low-fat food intake (DASH diet), and the use of antihypertensive medications where appropriate, with consideration for the presence of other CVD risk factors.
- Diabetes management: Promote a healthy lifestyle through smoking cessation, a healthful diet and increased physical activity, and use medications where appropriate to control blood glucose.
- Measure lipids under the following circumstances:
- Baseline full lipid profile (triglycerides [TG], total cholesterol [TC], high-density lipoprotein [HDL], low-density lipoprotein [LDL]) for men ≥40 yrs, women ≥50 yrs and postmenopausal women of any age. Reassess only if major CVD risk factors change.
- Full lipid profile if patient has hypertension, diabetes mellitus (type 1 or 2), chronic kidney disease or abdominal obesity, even if younger than 40 years-of-age.
- Full lipid profile if patient has a family history of premature CHD (onset before age 55 for men, and before age 65 for women), hypercholesterolemia, or signs of hyperlipidemia (for example, tendon xanthoma).
- Consider apolipoprotein B (apoB) for follow-up testing in high-risk patients who are undergoing treatment for hypercholesterolemia (but not for other dyslipidemias). Other lipid tests are not required if using apoB for follow-up. ApoB is a more accurate measurement of atherogenic particles than LDL. Fasting is not required for apoB measurement. See Appendix D of the original guideline document for more information.
- Lipid management: Recommend lifestyle management (reduced dietary intake of saturated and trans-fats and cholesterol, increased physical activity) as first-line treatment for patients in all risk categories. If lifestyle management is insufficient in achieving desirable lipid levels, consider therapy with lipid-lowering medications, especially for patients at high risk (see Table 1 below). A decrease of 30-40% in lipids leads to sufficiently reduced CHD risk for most patients, including those with metabolic syndrome and diabetes.
- Global risk assessment*
- Framingham risk chart for patients without diabetes: The Framingham risk assessment chart (Appendix B in the original guideline document) is helpful in estimating the 10-year CHD risk for adults who do not have CVD or diabetes. The risk factors included in the Framingham calculation are: gender, age, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking.
- UKPDS risk chart for patients with diabetes: The United Kingdom Prospective Diabetes Study (UKPDS) risk assessment chart (Appendix C in the original guideline document) is helpful in estimating the 10-year CHD risk for adults with diabetes. The risk factors included in the UKPDS risk assessment are: gender, age, hemoglobin A1c, total cholesterol, HDL cholesterol, systolic blood pressure and cigarette smoking. Refer to the BC diabetes guideline for further information on the UKPDS risk calculator. *
*This excludes high-risk patients with known CVD.
Table 1. Framingham Risk Levels and Desirable Lipid Results
| Classification |
Risk Level |
LDL (mmol/L)
| ApoB (g/L)
| TC/HDL Ratio
|
| High * |
≥20% without CHD |
<2.5 |
<0.85 for follow-up |
<4.0 |
| Moderate ** |
10% - 19% |
<3.5 |
<1.05 |
<5.0 |
| Low *** |
<10% |
<5.0 |
<1.25 |
<6.0 |
Abbreviations: Apo B, apolipoprotein B; CHD, coronary heart disease; LDL, low-density lipoprotein; TC/HDL, total cholesterol/high-density lipoprotein ratio.
* Adults with diabetes or chronic renal disease should not automatically be considered high risk. Use the UKPDS risk assessment chart to determine the level of risk for patients with diabetes. Use the Framingham risk assessment charts to determine the level of risk for patients with chronic renal disease.
** Patients in the moderate risk category may be at high long-term CVD risk. This group includes many patients with abdominal obesity (metabolic syndrome).
*** Patients with severe genetic lipoprotein disorders, such as familial hypercholesterolemia or type III dyslipidemia should be treated regardless of their Framingham risk score.
Note: Although triglyceride levels are no longer indicated as a primary treatment target, the optimal level of triglycerides for high-risk patients is <1.5 mmol /L.
- Albumin/creatinine ratio: In most patients with diabetes or hypertension, measurement of the albumin/creatinine ratio is recommended (for details, refer to the BC diabetes and hypertension guidelines). An elevated albumin/creatinine ratio (men: >2.0 mg/mmol, women: >2.8 mg/mmol) is associated with an increased risk of heart disease and stroke. Angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) can be used to manage proteinuria, including microalbuminuria.
- Kidney function: Impaired kidney function (eGFR <60 mL/min) is associated with an increased risk of heart disease and stroke. ACEI and ARBs are effective in improving outcomes related to cardiovascular disease and kidney disease in patients with impaired kidney function. The benefits of statin therapy have not been fully evaluated in this patient group.
Additional Considerations
- Women: Statins do not appear to prevent heart disease or improve survival for most women without known heart disease (primary prevention), based on a large subset of women (5052) in the North American ALLHAT-LLT trial and a meta-analysis of more than 11,000 women.
- Older adults: The PROSPER trial found that statins did not reduce CHD and stroke events in men and women over age 69 without heart disease. There was a significant reduction in cardiovascular events for individuals with coronary heart disease (secondary prevention).
Overall (mixed primary and secondary prevention), there was a significant reduction in cardiovascular events, but a corresponding increase in major adverse events, such as cancer and hemorrhagic stroke. There is currently insufficient evidence for the safety of statins and improved overall outcomes in older adults.
- Aspirin therapy: Low-dose aspirin (e.g., 81 mg) to prevent platelet aggregation is recommended for people under age 70 who are not aspirin intolerant and who have a ten-year CHD risk ≥ 20% (no known CHD). Blood pressure must be well controlled. Low-dose aspirin therapy for patients (men and women) over age 70 is not recommended at this time due to insufficient evidence.
- Metabolic syndrome: Metabolic syndrome includes three or more of the following criteria:
- Abdominal obesity (waist circumference: men >102 cm, women >88 cm)
- Triglycerides ≥1.7 mmol/L
- HDL (men <1.0 mmol/L, women <1.3 mmol/L)
- BP >130/85 mm Hg
- Fasting glucose 5.7-6.9 mmol/L
The American Heart Association recommends lifestyle intervention as first-line therapy for the management of metabolic syndrome as there is insufficient evidence to recommend the use of drugs as first-line therapy for treating the underlying causes.
- Socioeconomic factors: Socioeconomic factors may play a role in exacerbating risk and should be considered.
