NEW ORLEANS — Aspirin got downgraded while heart-beneficial diabetes medications got a boost in updated primary prevention of atherosclerotic cardiovascular disease (ASCVD) guidelines.
Other key additions to the American College of Cardiology (ACC)/American Heart Association guidelines were prominent endorsements of team-based care, shared-decision making, and considering social determinants of health.
However, most sections largely pooled together existing recommendations on primary prevention from prior guidelines, such as 2017 and 2018 updates on cardiovascular risk assessment, cholesterol, and hypertension, writing committee co-chair Donna Arnett, PhD, MSPH, and colleagues noted.
The document was released here at the ACC annual meeting and simultaneously published in the Journal of the American College of Cardiology and Circulation.
“One really has to be comprehensive if you want to make an impact on ASCVD risk,” said Amit Khera, MD, of UT Southwestern Medical Center in Dallas at an ACC press conference. “For busy clinicians, for people who are out there, this is a one-stop-shop, a central source for clinicians putting it all together…and hopefully that will help in the effectiveness of implementation.”
Perhaps one of the most impactful changes, Khera said, would be changes to the aspirin recommendations.
“Historically, we’ve always been trying to find this balance between lowering ASCVD risk, but aspirin always causes bleeding,” he said. “In the past, in the right groups — those at higher ASCVD risk — it was felt that that balance favored taking aspirin in the right situation. Well, as of late, there have been some new studies involving data that suggest that balance has tipped the other way.”
“We’ve had three trials in last year (ARRIVE, ASCEND, and ASPREE) which really have shown us that the place for aspirin has diminished in terms of primary prevention, and that bleeding will be outweighing the benefit in our modern era with all of our recommended therapies,” he added.
The guidelines now recommend that prophylactic low-dose aspirin:
- “Might be considered” for select patients, ages 40-70, at higher ASCVD risk but not at increased bleeding risk (IIb recommendation)
- Should not routinely be used for adults age >70 (class III, a warning of harm)
- Should not be given at any age among people at increased risk of bleeding (class III)
“Generally no, occasionally yes,” was how Khera summed up the recommendations. But he also cautioned against conflating these primary prevention recommendations to secondary prevention, for which aspirin still is recommended for use.
A 2018 consensus document from the ACC recommended considering addition of a glucose-lowering drug proven to have cardiovascular benefits for all type 2 diabetes patients with ASCVD.
The new guideline suggests “it may be reasonable to initiate a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) agonist to improve glycemic control and reduce CVD risk,” in patients without established ASCVD as well. This got a IIb recommendation, although Khera noted that it’s in the context of a comprehensive approach with nutrition, exercise, and first-line metformin.
“Although most patients studied had established CVD at baseline, the reduction in heart failure has been shown to extend to primary prevention populations,” the document noted.
Global Care Issues
Among the overarching recommendations were class I recommendation for team-based care to control ASCVD risk factors, shared decision-making, and having social determinants of health inform implementation of treatment.
Multidisciplinary team-based care may not be feasible in every practice, but it improves risk factor control, Arnett noted. Consider it an inducement to join such a setting, she told reporters.
However, an accompanying editorial in Circulation by Vera Bittner, MD, MSPH, of the University of Alabama at Birmingham, cautioned that broad implementation in outpatient settings may take more than emphasis in guidelines: “To achieve wider implementation, greater flexibility in reimbursement paradigms by third party payers will be necessary.”
The guidelines suggested using the Centers for Medicare & Medicaid’s screening tool for socioeconomic barriers to care, such as lack of transportation to visits and food insecurity, and then tailoring advice to fit patients’ circumstances.
“It is up to us to develop multidisciplinary models of care to implement these guidelines in our individual practices and to engage our patients to become our partners in this lifelong process,” concluded Bittner.
The guideline also was endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association.
Bittner disclosed a relevant relationships with Sanofi and institutional relationships with Sanofi, Amgen, Astra Zeneca, Bayer, DalCor, and Esperion.