2013;381:629 38. 4. Thalji NM, Suri RM, Daly RC, et al. The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era. J Thorac Cardiovasc Surg. 2015;149:451 60. 5. Faroux L, Guimaraes L, Wintzer-Wehekind J, et al. Coronary artery disease and transcatheter aortic valve replacement: JACC state-of-the-art review. J Am Coll Cardiol. 2019;74:362 72. 6. Goel SS, Ige M, Tuzcu EM, et al. Severe aortic stenosis and coronary artery disease implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol. 2013;62:1 10. 7. Sankaramangalam K, Banerjee K, Kandregula K, et al. Impact of coro- nary artery disease on 30-day and 1-year mortality in patients undergoing transcatheter aortic valve replacement: a meta-analysis. J Am Heart Assoc. 2017;6:e006092. 8. Millan-Iturbe O, Sawaya FJ, L nborg J, et al. Coronary artery disease, revascularization, and clinical outcomes in transcatheter aortic valve re- placement: real-world results from the East Denmark Heart Registry. Cath- eter Cardiovasc Interv. 2018;92:818 26. 9. Witberg G, Regev E, Chen S, et al. The prognostic effects of coronary disease severity and completeness of revascularization on mortality in pa- tients undergoing transcatheter aortic valve replacement. JACC Cardio- vasc Interv. 2017;10:1428 35. 10. Chieffo A, Giustino G, Spagnolo P, et al. Routine screening of coronary artery disease with computed tomographic coronary angiography in place of invasive coronary angiography in patients undergoing transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2015;8:e002025. 11. Rossi A, De Cecco CN, Kennon SRO, et al. CT angiography to evalu- ate coronary artery disease and revascularization requirement before trans-catheter aortic valve replacement. J Cardiovasc Comput Tomogr. 2017;11:338 46. 12. van den Boogert TPW, Vendrik J, Claessen B, et al.


12. van den Boogert TPW, Vendrik J, Claessen B, et al. CTCA for detection of significant coronary artery disease in routine TAVI work-up: A systematic review and meta-analysis. Neth Heart J. 2018;26:591 9. 13. Pesarini G, Scarsini R, Zivelonghi C, et al. Functional assessment of coro- nary artery disease in patients undergoing transcatheter aortic valve im- plantation: influence of pressure overload on the evaluation of lesions severity. Circ Cardiovasc Interv. 2016;9:e004088. 14. Ahmad Y, G tberg M, Cook C, et al. Coronary hemodynamics in patients with severe aortic stenosis and coronary artery disease undergoing trans- catheter aortic valve replacement: implications for clinical indices of coro- nary stenosis severity. JACC Cardiovasc Interv. 2018;11:2019 31. 15. Yamanaka F, Shishido K, Ochiai T, et al. Instantaneous wave-free ratio for the assessment of intermediate coronary artery stenosis in patients with severe aortic valve stenosis: comparison with myocardial perfusion scintig- raphy. JACC Cardiovasc Interv. 2018;11:2032 40. 14.1.2. Management of CAD in Patients Undergoing Valve Surgery 1. Graboys TB, Cohn PF. The prevalence of angina pectoris and abnormal coronary arteriograms in severe aortic valvular disease. Am Heart J. 1977;93:683 6. 2. Ramsdale DR, Bennett DH, Bray CL, et al. Angina, coronary risk factors and coronary artery disease in patients with valvular disease. A prospective study. Eur Heart J. 1984;5:716 26. CLINICAL STATEMENTS AND GUIDELINES 3. Dangas G, Khan S, Curry BH, et al. Angina pectoris in severe aortic steno- sis. Cardiology. 1999;92:1 3. 4. Basta LL, Raines D, Najjar S, et al. Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease. Br Heart J. 1975;37:150 7. 5. Thalji NM, Suri RM, Daly RC, et al. Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: when is preoperative coronary an- giography necessary? J Thorac Cardiovasc Surg.


Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: when is preoperative coronary an- giography necessary? J Thorac Cardiovasc Surg. 2013;146:1055 63, 64.e1. 6. Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: the Framingham Study. Am J Cardiol. 1976;38:46 51. 7. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350 8. 8. Heidenreich PA, Kapoor JR. Radiation induced heart disease: systemic dis- orders in heart disease. Heart. 2009;95:252 8. 9. Gahl K, Sutton R, Pearson M, et al. Mitral regurgitation in coronary heart disease. Br Heart J. 1977;39:13 8. 10. Enriquez-Sarano M, Klodas E, Garratt KN, et al. Secular trends in coronary atherosclerosis analysis in patients with valvular regurgitation. N Engl J Med. 1996;335:316 22. 11. Breisblatt WM, Cerqueira M, Francis CK, et al. Left ventricular function in ischemic mitral regurgitation a precatheterization assessment. Am Heart J. 1988;115:77 82. 12. Mark DB, Berman DS, Budoff MJ, et al. ACCF/ACR/AHA/NASCI/SAIP/ SCAI/SCCT 2010 expert consensus document on coronary computed to- mographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Car- diol. 2010;55:2663 99. 13. Opolski MP, Kim WK, Liebetrau C, et al. Diagnostic accuracy of computed tomography angiography for the detection of coronary artery disease in patients referred for transcatheter aortic valve implantation. Clin Res Car- diol. 2015;104:471 80. 14. Hamdan A, Wellnhofer E, Konen E, et al. Coronary CT angiography for the detection of coronary artery stenosis in patients referred for transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr. 2015;9:31 41. 15. Andreini D, Pontone G, Mushtaq S, et al. Diagnostic accuracy of multide- tector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement.


Diagnostic accuracy of multide- tector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement. Am Heart J. 2014;168:332 9. 16. Chieffo A, Giustino G, Spagnolo P, et al. Routine screening of coronary artery disease with computed tomographic coronary angiography in place of invasive coronary angiography in patients undergoing transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2015;8:e002025. 17. Matsumoto S, Yamada Y, Hashimoto M, et al. CT imaging before trans- catheter aortic valve implantation (TAVI) using variable helical pitch scan- ning and its diagnostic performance for coronary artery disease. Eur Ra- diol. 2017;27:1963 70. 18. Rossi A, De Cecco CN, Kennon SRO, et al. CT angiography to evaluate coro- nary artery disease and revascularization requirement before trans-catheter aortic valve replacement. J Cardiovasc Comput Tomogr. 2017;11:338 46. 19. Thalji NM, Suri RM, Daly RC, et al. The prognostic impact of concomitant coronary artery bypass grafting during aortic valve surgery: implications for revascularization in the transcatheter era. J Thorac Cardiovasc Surg. 2015;149:451 60. 20. Byrne JG, Leacche M, Vaughan DE, et al. Hybrid cardiovascular proce- dures. JACC Cardiovasc Interv. 2008;1:459 68. 21. Pontone G, Andreini D, Bartorelli AL, et al. Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for pa- tients referred for balloon-expandable transcatheter aortic valve implanta- tion. Am Heart J. 2011;161:1106 13. 22. Lund O, Nielsen TT, Pilegaard HK, et al. The influence of coronary artery disease and bypass grafting on early and late survival after valve replace- ment for aortic stenosis. J Thorac Cardiovasc Surg. 1990;100:327 37. 23. Beach JM, Mihaljevic T, Svensson LG, et al. Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2013;61:837 48. 14.2. Intervention for AF in Patients With VHD 1. Ad N, Henry L, Hunt S, et al.


Intervention for AF in Patients With VHD 1. Ad N, Henry L, Hunt S, et al. Do we increase the operative risk by add- ing the Cox Maze III procedure to aortic valve replacement and coronary artery bypass surgery? J Thorac Cardiovasc Surg. 2012;143:936 44. 2. Badhwar V, Rankin JS, Damiano RJ Jr, et al. The Society of Thoracic Sur- geons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg. 2017;103:329 41. 3. Ad N, Holmes SD, Pritchard G, et al. Association of operative risk with the outcome of concomitant Cox Maze procedure: a comparison of results across risk groups. J Thorac Cardiovasc Surg. 2014;148:3027 33. 4. Ad N, Holmes SD, Rongione AJ, et al. The long-term safety and efficacy of concomitant Cox maze procedures for atrial fibrillation in patients without mitral valve disease. J Thorac Cardiovasc Surg. 2019;157:1505 14. 5. Gillinov AM, Bakaeen F, McCarthy PM, et al. Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation? Ann Thorac Surg. 2006;81:19 26. 6. Gillinov AM, Gelijns AC, Parides MK, et al. Surgical ablation of atri- al fibrillation during mitral-valve surgery. N Engl J Med. 2015;372: 1399 409. 7. Abreu Filho CA, Lisboa LA, Dallan LA, et al. Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with per- manent atrial fibrillation and rheumatic mitral valve disease. Circulation. 2005;112:I20 5. 8. Akpinar B, Guden M, Sagbas E, et al. Combined radiofrequency modified maze and mitral valve procedure through a port access approach: early and mid-term results. Eur J Cardiothorac Surg. 2003;24:223 30. 9. Chua YL, Schaff HV, Orszulak TA, et al. Outcome of mitral valve repair in patients with preoperative atrial fibrillation. Should the maze proce- dure be combined with mitral valvuloplasty?


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2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521 643. 5. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/ HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocar- diography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiog- raphy, American Heart Association, American Society of Nuclear Cardi- ology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, So- ciety for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2011;24:229 67. 15.2. Management of the Symptomatic Patient 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guide- line on perioperative cardiovascular evaluation and management of pa- tients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278 333. 2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521 643. 3. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic- valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790 8. 4. Reardon MJ, Adams DH, Kleiman NS, et al. 2-Year outcomes in patients undergoing surgical or self-expanding transcatheter aortic valve replace- ment. J Am Coll Cardiol. 2015;66:113 21. 5. Thyregod HGH, Steinbr chel DA, Ihlemann N, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve ste- nosis: 1-year results from the all-comers NOTION randomized clinical trial. J Am Coll Cardiol. 2015;65:2184 94. 6. Leon MB, Smith CR, Mack MJ, et al.


2015;65:2184 94. 6. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aor- tic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609 20. 7. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve re- placement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387:2218 25. 8. Okuno T, Yahagi K, Horiuchi Y, et al. The role of transcatheter aor- tic valve replacement in the patients with severe aortic stenosis re- quiring major non-cardiac surgery. Cardiovasc Interv Ther. 2019; 34:345 51. 9. Kogoj P, Devjak R, Bunc M. Balloon aortic valvuloplasty (BAV) as a bridge to aortic valve replacement in cancer patients who require urgent non- cardiac surgery. Radiol Oncol. 2014;48:62 6. 10. Calicchio F, Guarracino F, Giannini C, et al. Balloon aortic valvuloplasty before noncardiac surgery in severe aortic stenosis: a single-center experi- ence. J Cardiovasc Med (Hagerstown). 2017;18:109 13. 11. Kennon S, Archbold A. Expert opinion: guidelines for the management of patients with aortic stenosis undergoing non-cardiac surgery: out of date and overly prescriptive. Interv Cardiol. 2017;12:133 6. 15.3. Management of the Asymptomatic Patient 1. Agarwal S, Rajamanickam A, Bajaj NS, et al. Impact of aortic stenosis on postoperative outcomes after noncardiac surgeries. Circ Cardiovasc Qual Outcomes. 2013;6:193 200. 2. Zahid M, Sonel AF, Saba S, et al. Perioperative risk of noncardiac surgery associated with aortic stenosis. Am J Cardiol. 2005;96:436 8. 3. Tashiro T, Pislaru SV, Blustin JM, et al. Perioperative risk of major non- cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J. 2014;35:2372 81. 4. Bajaj NS, Agarwal S, Rajamanickam A, et al. Impact of severe mitral regur- gitation on postoperative outcomes after noncardiac surgery. Am J Med. 2013;126:529 35. 5. Lai H-C, Lai H-C, Lee W-L, et al.


2013;126:529 35. 5. Lai H-C, Lai H-C, Lee W-L, et al. Mitral regurgitation complicates postop- erative outcome of noncardiac surgery. Am Heart J. 2007;153:712 7. 6. Meyer S, McLaughlin VV, Seyfarth H-J, et al. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey. Eur Respir J. 2013;41:1302 7. 7. Klinger JR, Elliott CG, Levine DJ, et al. Therapy for pulmonary arterial hy- pertension in adults: update of the CHEST guideline and expert panel report. Chest. 2019;155:565 86. 8. Lai H-C, Lai H-C, Lee W-L, et al. Impact of chronic advanced aortic regur- gitation on the perioperative outcome of noncardiac surgery. Acta Anaes- thesiol Scand. 2010;54:580 8. 9. Goertz AW, Lindner KH, Seefelder C, et al. Effect of phenylephrine bolus administration on global left ventricular function in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology. 1993;78:834 41. 10. Goertz AW, Lindner KH, Sch tz W, et al. Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology. 1994;81:49 58. 11. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guide- line on perioperative cardiovascular evaluation and management of pa- tients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278 333. 12. Christ M, Sharkova Y, Geldner G, et al. Preoperative and perioperative care for patients with suspected or established aortic stenosis facing non- cardiac surgery. Chest. 2005;128:2944 53. 13. O Keefe JHJ, Shub C, Rettke SR. Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc. 1989;64:400 5. 14. Ho MC, Beathe JC, Sharrock NE. Hypotensive epidural anesthesia in pa- tients with aortic stenosis undergoing total hip replacement. Reg Anesth Pain Med. 2008;33:129 33. 15.


Hypotensive epidural anesthesia in pa- tients with aortic stenosis undergoing total hip replacement. Reg Anesth Pain Med. 2008;33:129 33. 15. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521 643. 16. Mittnacht AJ, Fanshawe M, Konstadt S. Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2008;12:33 59. 17. Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin. 2010;28:67 85. 18. Smilowitz NR, Armanious A, Bangalore S, et al. Cardiovascular outcomes of patients with pulmonary hypertension undergoing noncardiac surgery. Am J Cardiol. 2019;123:1532 7. 16. EVIDENCE GAPS AND FUTURE DIRECTIONS 16.1. Prevention of Valve Disease: Stage A 1. Nazarzadeh M, Pinho-Gomes A-C, Smith Byrne K, et al. Systolic blood pressure and risk of valvular heart disease: a mendelian randomization study. JAMA Cardiol. 2019;4:788 95. 2. Lindman BR, Clavel M-A, Mathieu P, et al. Calcific aortic stenosis. Nat Rev Dis Primers. 2016;2:16006. 3. Lindman BR. Aortic stenosis: moving from treatment to prevention. J Am Coll Cardiol. 2017;69:1533 5. CLINICAL STATEMENTS AND GUIDELINES 4. Atkins SK, Aikawa E. Valve under the microscope: shining a light on emerging technologies elucidating disease mechanisms. Heart. 2019;105:1610 1. 5. Peeters FECM, Meex SJR, Dweck MR, et al. Calcific aortic valve stenosis: hard disease in the heart: a biomolecular approach towards diagnosis and treatment. Eur Heart J. 2018;39:2618 24. 6. Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med. 2007;357:439 41. 7. Soler-Soler J, Galve E. Worldwide perspective of valve disease. Heart. 2000;83:721 5. 8. Nkomo VT, Gardin JM, Skelton TN, et al.


2000;83:721 5. 8. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368:1005 11. 9. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics 2013 update: a report from the American Heart As- sociation. Circulation. 2013;127:143 52. 10. Hagler MA, Hadley TM, Zhang H, et al. TGF- signalling and reactive oxy- gen species drive fibrosis and matrix remodelling in myxomatous mitral valves. Cardiovasc Res. 2013;99:175 84. 11. Miller JD, Weiss RM, Heistad DD. Calcific aortic valve stenosis: methods, models, and mechanisms. Circ Res. 2011;108:1392 412. 12. Lindman BR, Arnold SV, Bagur R, et al. Priorities for patient-centered re- search in valvular heart disease: a report from the National Heart, Lung, and Blood Institute Working Group. J Am Heart Assoc. 2020;9:e015975. 16.2. Medical Therapy to Treat or Prevent Disease Progression: Stage B 1. Park SJ, Dweck MR. Multimodality imaging for the assessment of severe aortic stenosis. J Cardiovasc Imaging. 2019;27:235 46. 2. Everett RJ, Dweck MR. Renin-angiotensin system inhibition in aortic ste- nosis: thinking beyond transcatheter aortic valve replacement. J Am Coll Cardiol. 2019;74:642 4. 3. Lindman BR, Otto CM, Douglas PS, et al. Blood pressure and arterial load after transcatheter aortic valve replacement for aortic stenosis. Circ Car- diovasc Imaging. 2017;10:e006308. 4. Thanassoulis G, Campbell CY, Owens DS, et al. Genetic associations with valvular calcification and aortic stenosis. N Engl J Med. 2013;368:503 12. 5. Lindman BR, Arnold SV, Bagur R, et al. Priorities for patient-cen- tered research in valvular heart disease: a report from the National Heart, Lung, and Blood Institute Working Group. J Am Heart Assoc. 2020;9:e015975. 16.3. Optimal Timing of Intervention: Stage C 1. Nicolau S, Ionescu T, Cleanoveanu G, et al.


Optimal Timing of Intervention: Stage C 1. Nicolau S, Ionescu T, Cleanoveanu G, et al. [National system for the reg- istration of congenital malformations and genetic diseases] [Article in Ro- manian]. Rev Pediatr Obstet Ginecol Pediatr. 1987;36:193 215. 2. Campo J, Tsoris A, Kruse J, et al. Prognosis of severe asymptomatic aortic stenosis with and without surgery. Ann Thorac Surg. 2019;108:74 9. 3. Kataruka A, Otto CM. Valve durability after transcatheter aortic valve im- plantation. J Thorac Dis. 2018;10:S3629 S36. 4. Lindman BR, Arnold SV, Bagur R, et al. Priorities for patient-centered re- search in valvular heart disease: a report from the National Heart, Lung, and Blood Institute Working Group. J Am Heart Assoc. 2020;9:e015975. 16.4. Better Options for Intervention: Stage D 1. Otto CM. Informed shared decisions for patients with aortic stenosis. N Engl J Med. 2019;380:1769 70. 2. Lindman BR, Clavel M-A, Mathieu P, et al. Calcific aortic stenosis. Nat Rev Dis Primers. 2016;2:16006. 3. Lindman BR, Arnold SV, Bagur R, et al. Priorities for patient-centered re- search in valvular heart disease: a report from the National Heart, Lung, and Blood Institute Working Group. J Am Heart Assoc. 2020;9:e015975. Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Catherine M. Otto (Co-Chair) University of Washington J.


Author Relationships With Industry and Other Entities (Relevant) 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section Catherine M. Otto (Co-Chair) University of Washington J. Ward Kennedy-Hamilton Endowed Chair in Cardiology and Professor of Medicine None None None None None None None Rick A. Nishimura (Co-Chair) Mayo Clinic Department of Cardiovascular Medicine and Judd and Mary Morris Leighton Professor of Cardiovascular Diseases and Hypertension None None None None None None None Robert O. Bonow Northwestern University, Feinberg School of Medicine Vice Chair for Development and Innovation, Department of Medicine; Max and Lilly Goldberg Distinguished Professor of Cardiology; and Professor of Medicine None None None None None None None Blase A. Carabello East Carolina Heart Institute at East Carolina University Professor and Chief, Division of Cardiology None None None Edwards Lifesciences (DSMB) John P. Erwin III Clinical Department Chair of Internal Medicine, NorthShore University Health System Clinical Professor, University of Chicago Pritzker School of Medicine None None None None None None None (Continued) CLINICAL STATEMENTS AND GUIDELINES Federico Gentile Centro Cardiologico Gentile, Naples, Italy None None None None None None None Hani Jneid Baylor College of Medicine Associate Professor of Medicine; The Michael DeBakey VA Medical Center Director of Interventional Cardiology Research None None None None None None None Eric V. Krieger University of Washington, School of Medicine Associate Professor of Medicine; Director, Seattle Adult Congenital Heart Disease Service None None None None None None None Michael Mack Baylor Scott & White Health Chair, Cardiovascular Service line None None None Abbott Vascular Edwards Lifesciences Medtronic Christopher McLeod Mayo Clinic Clinical Director for Cardiovascular Medicine (Jacksonville, FL) None None None None None None None Patrick T. O Gara Watkins Family Distinguished Chair in Cardiology, Brigham and Women s Hospital: Professor of Medicine Harvard Medical School None None None None Edwards Scientific Medtronic Vera H. Rigolin Northwestern University, Feinberg School of Medicine Professor of Medicine (Cardiology) None None AstraZeneca Merck/ Schering- Plough* Pfizer* Thoralf M. Sundt III Massachusetts General Hospital Chief, Division of Cardiac Surgery; Co-Director, Corrigan Minehan Heart Center None None None Thrasos* Edwards Lifesciences Medtronic Annemarie Thompson Duke University Medical Center Professor of Anesthesiology, Medicine, and Population Health Sciences, Director, Anesthesiology Residency Program None None None None None None None Christopher Toly Simulab Corporation Chief Executive Officer, Chief Technology Officer None None None None None None None This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document.


These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the Writing Committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Please refer to https://www.acc. org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Significant relationship. This disclosure was entered under the Clinical Trial Enroller category in ACC s disclosure system. To appear in this category, the author acknowledges that there is no direct or institutional relationship with the trial sponsor as defined in the (ACCF or ACC/AHA) Disclosure Policy for Writing Committees. ACC indicates American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; DSMB, Data and Safety Monitoring Board; FL, Florida; and VA, Veterans Affairs. Appendix 1. Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section CLINICAL STATEMENTS AND GUIDELINES Appendix 2.


Continued Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section CLINICAL STATEMENTS AND GUIDELINES Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Abigail M. Khan Official Reviewer AHA Oregon Health and Science University None None None None None None Andrew R. Waxler Official Reviewer Board of Governors Alternate Penn State Health None Amarin* Sanofi Regeron* None None DalCor Pharmaceutical Medicines Company Penn State St Joseph Medical Center Foundation Board Member Penn State St. Joseph Medical Center Pharmacy and Therapeutics Committee Member Pfizer Inc Regeneron Sanofi None Daniel M. Shindler Official Reviewer ACC Board of Governors University of Medicine and Dentistry, Robert Wood Johnson Medical School, New Brunswick, New Jersey None None None None None None William A. Zoghbi Official Reviewer ACC Clinical Policy Approval Committee Houston Methodist- Chairman, Department of Cardiology None None None None None None Y. Joseph Woo Content Reviewer Joint Committee on Clinical Practice Guidelines Stanford University School of Medicine None None None None NIH* None Adrian F. Hernandez Content Reviewer Joint Committee on Clinical Practice Guidelines Duke University School of Medicine Amgen Inc. AstraZeneca Pharmaceuticals Bayer Corporation U.S. Biofourmis Boehringer Ingelheim Pharmaceuticals, Inc Boston Scientific* Merck and Co., Inc. Novartis* Pfizer Relypsa Sanofi-Aventis* Xogenex None None American Regent AstraZeneca* Daiichi Sankyo Genentech, Inc Glaxo Smith Kline* Merck and Co., Inc. NIH Novartis* PCORI Verily* Eidos (DSMB) AHA Defendant, patent dispute, Anastasia L. Armbruster Content Reviewer Joint Committee on Clinical Practice Guidelines St. Louis College of Pharmacy None AstraZeneca Pharmaceuticals None None None None Andrew M. Kates Content Reviewer ACC/AHA Washington University School of Medicine- Professor of Medicine Director, Cardiovascular Fellowship Program None None None None None None Andrew Wang Official Reviewer AHA Duke University Medical Center-Professor of Medicine American College of Physicians* Cytokinetics RioVant UpToDate None None Myokardia* Abbott Vascular AHA, Circulation Journal* Medtronic MyoKardia, Inc Defendant, Diagnosis of Infective Endocarditis, Anita Deswal Content Reviewer Joint Committee on Clinical Practice Guidelines The University of Texas MD Anderson Cancer Center Department Chair, Cardiology, Ting Tsung and Wei Fong Chao Distinguished Chair, Professor of Medicine None None None NIH* ACC AHA Heart Failure Society of America None Ann Bolger Content Reviewer ACC/AHA University of California, San Francisco-Professor of Medicine General Electric None None None None None (Continued) CLINICAL STATEMENTS AND GUIDELINES (Continued) Brian R. Lindman Content Reviewer ACC/AHA Vanderbilt University Medical Center None None None Edwards Lifesciences* None None Bulent Gorenek Content Reviewer Joint Committee on Clinical Practice Guidelines Eskisehir Osmangazi University School of Medicine Professor of Cardiology AstraZeneca Sandoz None None None None None Carole A. Warnes Content Reviewer ACC/AHA Mayo Clinic-Professor of Medicine None None None None None None Cheryl Batzing Content Reviewer ACC/AHA Lay Reviewer Church Ministries International Donor Relations Manager None None None None None None Christine C. Rekash Content Reviewer ACC/AHA Lay Reviewer U.S. Department of Justice Paralegal Heart Valve Voice Advocate Good Samaritan Hospital AHA Bluhm Cardiovascular Institute at Northwestern Hospital None None Edwards Life Sciences Heart Valve Voice PCORI None Daniel B.


Mark Content Reviewer Joint Committee on Clinical Practice Guidelines Duke Clinical Research Institute Professor of Medicine None None None HeartFlow* Merck and Co., Inc.* Merck and Co., Inc.* None Dave L. Dixon Content Reviewer Joint Committee on Clinical Practice Guidelines Virginia Commonwealth University School of Pharmacy None None None Centers for Disease Control and Prevention* Community Pharmacy Foundation* Accreditation Council for Clinical Lipidology American Pharmacists Association American College of Pharmacy Cardiology Practice Research Network National Lipid Association None David H. Adams Content Reviewer ACC/AHA Mt. Sinai Medical Center None None None Abbott Medtronic NeoChord Edwards Lifesciences* Medtronic* None David E. Newby Content Reviewer ACC/AHA University of Edinburgh Chancellor s Building Professor of Cardiology AstraZeneca* Bristol-Myers Squibb Company* CellProthera Eli-Lilly Glaxo Smith Kline* Jansen Oncoarendi Pfizer Reckitt Benckiser Pharmaceuticals Inc. Roche Toshiba None None AstraZeneca* Boehringer Ingelheim* Bristol-Myers Squibb Company* GlaxoSmithKline* Merck and Co., Inc.* Pfizer* UCB Inc. (DSMB) AstraZeneca Pharmaceuticals Bristol-Myers Squibb Company CellProthera Esperion Infraredx None Jacqueline E. Tamis-Holland Content Reviewer Joint Committee on Clinical Practice Guidelines Mount Sinai Saint Luke s Hospital None None None Internal- Minneapolis Heart Institute-North American Covid STEMI Registry Abbott Vascular AHA Bronx Lebanon Hospital, Cardiology Fellowship Program Director Medscape/Heart. org Merck and Co., Inc. NIH The NGS Predict Study None Appendix 2. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness CLINICAL STATEMENTS AND GUIDELINES Jeanne M. DeCara Content Reviewer ACC/AHA University of Chicago Medicine None None None None Intersocietal Accreditation Commission None Jos A. Joglar Content Reviewer Joint Committee on Clinical Practice Guidelines UT Southwestern Medical Center Professor, Internal Medicine.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness CLINICAL STATEMENTS AND GUIDELINES Jeanne M. DeCara Content Reviewer ACC/AHA University of Chicago Medicine None None None None Intersocietal Accreditation Commission None Jos A. Joglar Content Reviewer Joint Committee on Clinical Practice Guidelines UT Southwestern Medical Center Professor, Internal Medicine. Program Director, Clinical Cardiac Electrophysiology Fellowship Program Professor None None None None None None Joseph Edward Marine Content Reviewer Joint Committee on Clinical Practice Guidelines Johns Hopkins University School of Medicine ACC* None None None UpToDate None Kim K. Birtcher Content Reviewer Joint Committee on Clinical Practice Guidelines University of Washington Director, Adult Congenital Heart Disease Program Jones & Bartlett Learning None None None None None Larry M. Baddour Content Reviewer ACC/AHA Mayo Clinic, Rochester, MN Boston Scientific* None None None UpToDate, Inc.* None Latha Palaniappan Content Reviewer Joint Committee on Clinical Practice Guidelines Stanford Medicine 23 and me National Minority Cardiovascular Alliance None None NIH* None None Lisa de las Fuentes Content Reviewer Joint Committee on Clinical Practice Guidelines Washington University, School of Medicine, Department of Medicine, Cardiovascular Division Acceleron Altavant Arena Bayer Healthcare Pharmaceuticals Express Scripts Johnson & Johnson Mentor Planning and Consulting Phase Bio V-wave WebMD, LLC* Bayer Healthcare Pharmaceuticals* Simply Speaking* None Acceleron* Altavant* Bayer Healthcare Pharmaceuticals Complexa* Johnson & Johnson* Liquidia* Medtronic* NIH* Reata Trio Analytics* United Therapeutics* University of Kentucky (DSMB) University of Toronto ACC AHA Circulation Journals, Editorial Board Ironwood Pulmonary Hypertension Association* None Mariann Piano Content Reviewer Joint Committee on Clinical Practice Guidelines Vanderbilt University None None None None None None Mark Reisman Content Reviewer ACC/AHA University of Washington Medical Center-Section Head, Interventional Cardiology Boston Scientific None None None None None Milind Y. Desai Content Reviewer ACC/AHA Cleveland Clinic None None None None None None Patrick Collier Content Reviewer AHA Cleveland Clinic None None None None None None Philippe Pibarot Content Reviewer ACC/AHA Professor, Department of Medicine, Laval University Head of Cardiology Research, Institut Universitaire de Cardiologie et de Pneumologie de Qu bec / Qu bec Heart & Lung Institute None None None Canadian Institutes of Health Research* Cardiac Phoenix* Edwards Lifesciences* Medtronic* V-Wave Ltd.* None None Rebecca T. Hahn Content Reviewer ACC Professor of Medicine at Columbia University Medical Center Edwards Lifesciences Medtronic Philips Healthcare Abbott Vascular Baylis Medical Siemens Healthineers NaviGate None Director of the Echo Core Lab None (Continued) Appendix 2.


Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness CLINICAL STATEMENTS AND GUIDELINES Sandra Lauck Content Reviewer ACC/AHA University of British Columbia, Vancouver, Canada None Abbott Edwards Lifesciences* None None None None Suzanne Arnold Content Reviewer ACC/AHA St. Luke s Mid America Heart Institute None None None None Abbott Laboratories None Terrence D. Welch Content Reviewer ACC/AHA Dartmouth-Hitchcock Medical Center None None None None None None Vinod H. Thourani Content Reviewer ACC Piedmont Heart Institute Abbott Vascular Boston Scientific Edwards Lifesciences Gore Medical Jenavalve None None None Abbott Medical Medtronic None Wendy Tsang Content Reviewer ACC/AHA Toronto General Hospital UpToDate None None Heart and Stroke Foundation of Canada* Peter Munk Cardiac Center Innovation Committee* Heart and Stroke Foundation of Canada* None William F. Armstrong Content Reviewer ACC/AHA University of Michigan Professor of Medicine, Division of Cardiovascular Disease None None None None None Defendant, medical malpractice, William Schuyler Jones Content Reviewer Joint Committee on Clinical Practice Guidelines Duke University Health System Bayer Healthcare Pharmaceuticals* Janssen Pharmaceuticals, Inc* None None Bristol Myers Squibb PCORI None None Zachary D. Goldberger Content Reviewer Joint Committee on Clinical Practice Guidelines University of Wisconsin School of Medicine and Public Health, Associate Professor of Medicine None None None None None None Stephan Windecker Content Reviewer ACC/AHA Inselspital Universit tsspital Bern Direktor und Chefarzt, Universit tsklinik f r Kardiologie None None None None Abbott* Amgen* Bayer* Biotronik* Boston Scientific* Bristol-Myers Squibb CSL Behring Edwards Lifesciences* Medtronic* Polares Medical SINO Medical Technologies, Inc None This table represents all relationships of reviewers with industry and other entities that were reported at the time of peer review, including those not deemed to be relevant to this document, at the time this document was under review.


The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $5000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Please refer to https://www.acc.org/guidelines/about-guidelines- and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *Significant relationship. No financial benefit. ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, Data and Safety Monitoring Board; NIH, National Institutes of Health; PCORI, Patient-Centered Outcomes Research Institute; and UT, University of Texas. Appendix 2. Continued Reviewer Representation Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness


2019 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA CLINICAL PRACTICE GUIDELINE 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Circulation https://www.ahajournals.org/journal/circ WRITING COMMITTEE MEMBERS Donna K. Arnett, PhD, MSPH, FAHA, Co-Chair Roger S. Blumenthal, MD, FACC, FAHA, Co-Chair Michelle A. Albert, MD, MPH, FAHA* Andrew B. Buroker, Esq Zachary D. Goldberger, MD, MS, FACC, FAHA Ellen J. Hahn, PhD, RN* Cheryl Dennison Himmelfarb, PhD, RN, ANP, FAHA* Amit Khera, MD, MSc, FACC, FAHA* Donald Lloyd-Jones, MD, SCM, FACC, FAHA* J. William McEvoy, MBBCh, MEd, MHS* Erin D. Michos, MD, MHS, FACC, FAHA* Michael D. Miedema, MD, MPH* Daniel Mu oz, MD, MPA, FACC* Sidney C. Smith Jr, MD, MACC, FAHA* Salim S. Virani, MD, PhD, FACC, FAHA* Kim A. Williams Sr, MD, MACC, FAHA* Joseph Yeboah, MD, MS, FACC, FAHA* Boback Ziaeian, MD, PhD, FACC, FAHA *ACC/AHA Representative. Lay Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Task Force Performance Measures Representative. The American Heart Association requests that this document be cited as follows: Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Mu oz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e563 e595. DOI: 10.1161/CIR.0000000000000677.


2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e563 e595. DOI: 10.1161/CIR.0000000000000677. Key Words: AHA Scientific Statements guidelines antihypertensive agents aspirin atherosclerosis atherosclerotic cardiovascular disease atrial fibrillation behavior modification behavior therapy blood cholesterol blood pressure body mass index cardiovascular team-based care cardiovascular cardiovascular disease cholesterol chronic kidney disease coronary artery calcium score coronary disease coronary heart disease cost diet dietary patterns dietary fats dietary sodium dyslipidemia e-cigarettes exercise healthcare disparities health services accessibility heart failure hypertension LDL cholesterol diabetes mellitus lifestyle lipids measurement myocardial infarction nicotine nonpharmacological treatment nutrition physical activity prejudice primary prevention psychosocial deprivation public health quality indicators quality measurement risk assessment risk- enhancing factors risk factors risk reduction risk reduction discussion risk treatment discussion secondhand smoke sleep smoking smoking cessation social determinants of health socioeconomic factors statin therapy systems of care tobacco tobacco smoke pollution treatment adherence treatment outcomes type 2 diabetes mellitus waist circumference weight loss Endorsed by the American Associa- tion of Cardiovascular and Pulmo- nary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association ACC/AHA Task Force Members, see page e577 CLINICAL STATEMENTS AND GUIDELINES TABLE OF CONTENTS Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease e564 Preamble e564 1. Introduction e565 1.1. Methodology and Evidence Review e566 1.2. Organization of the Writing Committee e566 1.3. Document Review and Approval e566 1.4. Scope of the Guideline e567 1.5. Class of Recommendation and Level of Evidence e567 1.6. Abbreviations e568 2. Overarching Recommendations for ASCVD Prevention Efforts e568 2.1. Patient-Centered Approaches to Comprehensive ASCVD Prevention e568 2.2. Assessment of Cardiovascular Risk e569 3. Lifestyle Factors Affecting Cardiovascular Risk e570 3.1.


Assessment of Cardiovascular Risk e569 3. Lifestyle Factors Affecting Cardiovascular Risk e570 3.1. Nutrition and Diet e570 3.2. Exercise and Physical Activity e570 4. Other Factors Affecting Cardiovascular Risk e570 4.1. Adults With Overweight and Obesity e570 4.2. Adults With Type 2 Diabetes Mellitus e570 4.3. Adults With High Blood Cholesterol e571 4.4. Adults With High Blood Pressure or Hypertension e573 4.5. Treatment of Tobacco Use e574 4.6. Aspirin Use e575 5. Cost and Value Considerations e575 6. Conclusion e576 References e578 Appendix 1: Search Criteria e585 Appendix 2: Author Relationships With Industry and Other Entities (Relevant) e589 Appendix 3 Reviewer Relationships With Industry and Other Entities (Comprehensive) e591 TOP 10 TAKE-HOME MESSAGES FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE 1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2. A team-based care approach is an effective strat- egy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treat- ment decisions. 3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovas- cular disease (ASCVD) risk estimation and have a clinician patient risk discussion before starting on pharmacological therapy, such as antihyperten- sive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interven- tions in select individuals, as can coronary artery calcium scanning. 4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohy- drates, and sweetened beverages.


All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohy- drates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-inten- sity physical activity. 6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium- glucose cotransporter 2 inhibitor or a glucagon- like peptide-1 receptor agonist. 7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels ( 190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician patient risk discussion. 10. Nonpharmacological interventions are recom- mended for all adults with elevated blood pressure or hypertension. For those requiring pharmaco- logical therapy, the target blood pressure should generally be <130/80 mm Hg. PREAMBLE Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health.


PREAMBLE Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic meth- ods to evaluate and classify evidence, provide a founda- tion for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publica- tion of clinical practice guidelines without commercial support, and members volunteer their time to the writ- ing and review efforts. CLINICAL STATEMENTS AND GUIDELINES Clinical practice guidelines provide recommenda- tions applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the goals are to improve quality of care and align with patients interests. Guidelines are intended to define practices meeting the needs of patients in most but not all circumstances and should not replace clinical judgment. Recommendations for guideline-directed manage- ment and therapy, which encompasses clinical evalua- tion, diagnostic testing, and both pharmacological and procedural treatments, are effective only when adopted by both practitioners and patients. Adherence to rec- ommendations can be enhanced by shared decision- making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated condi- tions and comorbidities. The ACC/AHA Task Force on Clinical Practice Guide- lines strives to ensure that the guideline writing com- mittee includes requisite expertise and is representative of the broader medical community by selecting experts from a broad array of backgrounds, representing dif- ferent geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and scopes of clinical practice.


The ACC/AHA Task Force on Clinical Practice Guide- lines strives to ensure that the guideline writing com- mittee includes requisite expertise and is representative of the broader medical community by selecting experts from a broad array of backgrounds, representing dif- ferent geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and scopes of clinical practice. The ACC and AHA have rigorous policies and methods to ensure that documents are developed with- out bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found online. Beginning in 2017, numerous modifications to the guidelines have been and continue to be implemented to make guidelines shorter and enhance user friendli- ness. Guidelines are written and presented in a modu- lar knowledge chunk format, in which each chunk in- cludes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyper- linked references are provided for each modular knowl- edge chunk to facilitate quick access and review. More structured guidelines including word limits ( tar- gets ) and a web guideline supplement for useful but noncritical tables and figures are 2 such changes. This Preamble is an abbreviated version, with the detailed version available online. Patrick T. O Gara, MD, MACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines Although there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of morbidity and mortality globally.S1-1 S1-3 In the Unit- ed States, it is also the leading cause of death for peo- ple of most racial/ethnic groups, with an estimated cost of >$200 billion annually in healthcare services, medications, and lost productivity.


Patrick T. O Gara, MD, MACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines Although there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of morbidity and mortality globally.S1-1 S1-3 In the Unit- ed States, it is also the leading cause of death for peo- ple of most racial/ethnic groups, with an estimated cost of >$200 billion annually in healthcare services, medications, and lost productivity. Much of this is at- tributable to suboptimal implementation of preven- tion strategies and uncontrolled ASCVD risk factors in Most Americans who have had a myocardial infarc- tion (MI) had unfavorable levels of at least 1 cardiovas- cular risk factor before their ASCVD event.S1-4 the AHA defined a new model of ideal cardiovascular health, referred to as Life s Simple 7.S1-5 Clinicians will find the 2018 Journal of American College of Cardiol- ogy (JACC) Cardiovascular Health Promotion Series very helpful in approaching the various aspects of preven- tion with patients.S1-6 An increasing number of ideal cardiovascular health factors have been associated with a lower prevalence and incidence of ASCVD events, heart failure, atrial fibrillation, cancer, depression, and Therefore, moving individuals toward ideal cardiovascular health is critically important for prevention of many important health conditions. The ACC/AHA Task Force on Clinical Practice Guide- lines has commissioned this guideline to consolidate existing recommendations and various recent scientific statements, expert consensus documents, and clinical practice guidelines into a single guidance document fo- cused on the primary prevention of ASCVD.


The ACC/AHA Task Force on Clinical Practice Guide- lines has commissioned this guideline to consolidate existing recommendations and various recent scientific statements, expert consensus documents, and clinical practice guidelines into a single guidance document fo- cused on the primary prevention of ASCVD. However, this guideline also includes newly generated recom- mendations for aspirin use, exercise and physical activ- ity, and tobacco use, in addition to recommendations related to team-based care, shared decision-making, and assessment of social determinants of health, to cre- ate a comprehensive yet targeted ACC/AHA guideline on the prevention of ASCVD. This guideline has been formatted in the modular chunk format to facilitate readability and future updating. Prevention strategies occur at the population level but must also engage individual adults to slow the de- velopment of ASCVD. The most important way to pre- vent ASCVD is to promote a healthy lifestyle through- out life. Prevention strategies must include a strong focus on lifestyle optimization (improvements in diet, physical activity, and avoidance of tobacco use and ex- posure to secondhand smoke) to minimize the risk of future ASCVD events. A comprehensive patient-centered approach that addresses all aspects of a patient s lifestyle habits and estimated risk of a future ASCVD event is the first step in deciding on where there may be a need for pharmacotherapy. Even if a blood pressure (BP) reduc- ing medication, lipid-lowering medication, or diabe- tes medication is ultimately prescribed, lifestyle goals should be emphasized on a regular basis. Only when a CLINICAL STATEMENTS AND GUIDELINES person s risk is sufficiently high should medications to reduce ASCVD risk be considered as part of a shared decision-making process for optimal treatment. In summary, clinicians and individuals should focus at- tention on living a healthy lifestyle by referring to these evidence-based recommendations to help pre- vent ASCVD.


In summary, clinicians and individuals should focus at- tention on living a healthy lifestyle by referring to these evidence-based recommendations to help pre- vent ASCVD. 1.1. Methodology and Evidence Review This guideline continues the ACC and AHA effort to de- sign a comprehensive yet succinct compilation of practi- cal guidance for the primary prevention of ASCVD and to promote optimal dissemination of information by us- ing concise language and formatting. The recommen- dations listed in this guideline are evidence based and supported by an extensive evidence review. A search for literature derived from research involving human sub- jects, published in English, and indexed in Ovid MED- LINE, PubMed, Cochrane Library, National Institute for Health and Care Excellence (NICE), and other selected databases relevant to this guideline, was conducted be- tween May and July 2018. For specific search terms used and years searched per section, please see Appendix 1. Randomized controlled trials (RCTs), systematic re- views of RCTs, meta-analyses, and large, United States based, high-quality cohort studies, as well as observa- tional studies and systematic reviews of observational studies, were evaluated for their content on the pre- vention of ASCVD outcomes related to the following 9 topic areas: risk assessment, diet, exercise/physical ac- tivity, obesity and weight loss, type 2 diabetes mellitus (T2DM), blood cholesterol, hypertension, smoking ces- sation, and aspirin use. Previous ACC/AHA guidelines, as well as US Preventive Services Task Force (USPSTF) reviews and other guidance relevant to this guideline, were also assessed. The final evidence tables included in the Online Data Supplement summarize the evidence used to formulate recommendations. References se- lected and published in this document are representa- tive and not all-inclusive. Avalere Health, a healthcare advisory services firm contracted by ACC/AHA, served as the document manager for this guideline to facilitate its development process.


Avalere Health, a healthcare advisory services firm contracted by ACC/AHA, served as the document manager for this guideline to facilitate its development process. As document manager, Avalere facilitated the deliberations of the writing committee and led the modified Delphi process for establishing the Class of Recommendation and the Level of Evidence. In parallel, an independent health data and epidemiology expert, Lee Ann Prebil, conducted a systematic evidence review for the key topic of exercise and physical activity and conducted targeted literature searches to support this document s discussion of patient-centered approaches, including team-based care, shared decision-making, and assessment of social determinants of health. A targeted literature search was also conducted for this guideline s cost and value considerations. These search- es are available as downloadable Excel files. Recommendations and supportive text relevant to cardiovascular risk, blood cholesterol, and high BP were taken directly from 2 recently released ACC/AHA guide- lines, the 2017 Hypertension Clinical Practice Guideli- and the 2018 Cholesterol Clinical Practice and were adapted for the present guide- line, which aims to provide an overview of the primary prevention of ASCVD among adults. Recommendations that were adapted from previous publications are noted in the recommendation tables, and both the original published recommendation and the adapted version are provided in the guideline Web Supplement. The results of these evidence reviews were evalu- ated by the writing committee for incorporation into the present guideline. (See Table S1 in the Web Supple- ment for a list of relevant publications and statements used in support of the guideline s recommendations.) Each topic area was assigned a primary writer, as well as a primary, and sometimes secondary, reviewer. These assignments were based on areas of particular expertise of writing committee members.


These assignments were based on areas of particular expertise of writing committee members. All recommendations were fully reviewed and discussed among the full com- mittee to allow for diverse perspectives and consider- ations for this guideline. Recommendations were then voted upon, with a modified Delphi process used to reach consensus. 1.2. Organization of the Writing Committee The writing committee consisted of clinicians, cardi- ologists, health services researchers, epidemiologists, internists, nurses, and a lay representative. The writing committee included representatives from the ACC and AHA. Appendix 2 of the present document lists writing committee members relevant RWI. For the purposes of full transparency, the writing committee members com- prehensive disclosure information is available online. 1.3. Document Review and Approval This document was reviewed by 5 official reviewers nominated by the ACC and AHA (1 reviewer from the ACC/AHA Task Force for Practice Guidelines, 2 review- ers from the AHA, and 2 reviewers from the ACC); 3 reviewers on behalf of the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Society for Nutrition, and the American So- ciety of Preventive Medicine; and 23 individual con- tent reviewers. Reviewers RWI information was dis- tributed to the writing committee and is published in this document (Appendix 3). This document was ap- proved for publication by the governing bodies of the ACC and AHA. CLINICAL STATEMENTS AND GUIDELINES 1.4. Scope of the Guideline This guideline is intended to be a resource for the clinical and public health practice communities. It addresses the primary prevention of CVD in adults ( 18 years of age), focused on outcomes of ASCVD (ie, acute coronary syndromes, MI, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of ath- erosclerotic origin), as well as heart failure and atrial fibrillation.


It addresses the primary prevention of CVD in adults ( 18 years of age), focused on outcomes of ASCVD (ie, acute coronary syndromes, MI, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of ath- erosclerotic origin), as well as heart failure and atrial fibrillation. The guideline presents recommendations to prevent CVD that are related to lifestyle factors (eg, diet and exercise or physical activity), other factors af- fecting CVD risk (eg, obesity, diabetes, blood choles- terol, high BP, smoking, aspirin use), patient-centered approaches (eg, team-based care, shared decision- making, assessment of social determinants of health), and considerations of the cost and value of primary prevention. 1.5. Class of Recommendation and Level of Evidence Recommendations are designated with both a Class of Recommendation (COR) and a Level of Evidence (LOE). Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015) CLINICAL STATEMENTS AND GUIDELINES The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk.


Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015) CLINICAL STATEMENTS AND GUIDELINES The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the qual- ity of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).S1.5-1 Abbreviation Meaning/Phrase ASCVD atherosclerotic cardiovascular disease AU Agatston units BMI body mass index BP blood pressure CHD coronary heart disease CKD chronic kidney disease CVD cardiovascular disease DASH Dietary Approaches to Stop Hypertension DBP diastolic blood pressure DM diabetes mellitus ENDS electronic nicotine delivery systems FDA US Food and Drug Administration HDL-C high-density lipoprotein cholesterol LDL-C low-density lipoprotein cholesterol MI myocardial infarction PCE pooled cohort equations RCT randomized controlled trial SBP systolic blood pressure T2DM type 2 diabetes mellitus USPSTF US Preventive Services Task Force RECOMMENDATIONS FOR ASCVD PREVENTION EFFORTS 2.1. Patient-Centered Approaches to Comprehensive ASCVD Prevention Recommendations for Patient-Centered Approaches to Comprehensive ASCVD Prevention Referenced studies that support recommendations are summarized in Online Data Supplements 1 and 2. COR LOE Recommendations I A A team-based care approach is recommended for the control of risk factors associated with ASCVD.S2.1-1 S2.1-14 I B-R Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk.S2.1-15 S2.1-18 I B-NR Social determinants of health should inform optimal implementation of treatment recommendations for the prevention of Table 2 outlines key considerations related to social determinants of health and ASCVD prevention. Table 2.


COR LOE Recommendations I A A team-based care approach is recommended for the control of risk factors associated with ASCVD.S2.1-1 S2.1-14 I B-R Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk.S2.1-15 S2.1-18 I B-NR Social determinants of health should inform optimal implementation of treatment recommendations for the prevention of Table 2 outlines key considerations related to social determinants of health and ASCVD prevention. Table 2. Example Considerations for Addressing Social Determinants of Health to Help Prevent ASCVD Events Topic/Domain Example Considerations Cardiovascular risk Adults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.S2.1-26 Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.S2.1-27 Diet In addition to the prescription of diet modifications, body size perception, as well as social and cultural influences, should be assessed.S2.1-28,S2.1-29 Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age*.S2.1-30 Exercise and physical activity In addition to the prescription of exercise, neighborhood environment and access to facilities for physical activity should be Obesity and weight loss Lifestyle counseling for weight loss should include assessment of and interventional recommendations for psychosocial stressors, sleep hygiene, and other individualized barriers.S2.1-34 S2.1-36 Weight maintenance should be promoted in patients with overweight/obesity who are unable to achieve recommended weight loss.


Example Considerations for Addressing Social Determinants of Health to Help Prevent ASCVD Events Topic/Domain Example Considerations Cardiovascular risk Adults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.S2.1-26 Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.S2.1-27 Diet In addition to the prescription of diet modifications, body size perception, as well as social and cultural influences, should be assessed.S2.1-28,S2.1-29 Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age*.S2.1-30 Exercise and physical activity In addition to the prescription of exercise, neighborhood environment and access to facilities for physical activity should be Obesity and weight loss Lifestyle counseling for weight loss should include assessment of and interventional recommendations for psychosocial stressors, sleep hygiene, and other individualized barriers.S2.1-34 S2.1-36 Weight maintenance should be promoted in patients with overweight/obesity who are unable to achieve recommended weight loss. Diabetes mellitus In addition to the prescription of type 2 diabetes mellitus interventions, environmental and psychosocial factors, including depression, stress, self-efficacy, and social support, should be assessed to improve achievement of glycemic control and adherence to High blood pressure Short sleep duration (<6 h) and poor-quality sleep are associated with high blood pressure and should be considered.S2.1-41 Because other lifestyle habits can impact blood pressure, access to a healthy, low-sodium diet and viable exercise options should also be considered. Tobacco treatment Social support is another potential determinant of tobacco use. Therefore, in adults who use tobacco, assistance and arrangement for individualized and group social support counseling are recommended.S2.1-42,S2.1-43 *Advanced age generally refers to age 75 years. ASCVD indicates atherosclerotic cardiovascular disease.


Therefore, in adults who use tobacco, assistance and arrangement for individualized and group social support counseling are recommended.S2.1-42,S2.1-43 *Advanced age generally refers to age 75 years. ASCVD indicates atherosclerotic cardiovascular disease. Abbreviation Meaning/Phrase CLINICAL STATEMENTS AND GUIDELINES 2.2. Assessment of Cardiovascular Risk Recommendations for Assessment of Cardiovascular Risk Referenced studies that support recommendations are summarized in Online Data Supplement 3.


Assessment of Cardiovascular Risk Recommendations for Assessment of Cardiovascular Risk Referenced studies that support recommendations are summarized in Online Data Supplement 3. COR LOE Recommendations I B-NR For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the pooled cohort equations (PCE).S2.2-1,S2.2-2 IIa B-NR For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to IIa B-NR In adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions (eg, statin IIa B-NR In adults at intermediate risk ( 7.5% to <20% 10-year ASCVD risk) or selected adults at borderline risk (5% to <7.5% 10- year ASCVD risk), if risk-based decisions for preventive interventions (eg, statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician patient risk IIb B-NR For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be Among adults at borderline (5% to <7.5%) and inter- mediate ( 7.5% to <20%) risk, one may consider ad- ditional individual risk-enhancing clinical factors (Table 3) that can be used to revise the 10-year ASCVD risk These factors may include having a fam- ily history of premature ASCVD,S2.2-5 chronic inflam- matory disease [rheumatoid arthritis,S2.2-6 or ], South Asian ancestry,S2.2-13 a his- tory of preeclampsiaS2.2-8 or preterm delivery,S2.2-9 early chronic kidney disease (CKD), metabolic syndrome, persis- tently elevated inflammatory markers,S2.2-14 or elevat- ed lipid biomarkers.S2.2-4 After these clinically available risk-enhancing factors have been considered, if there is still uncertainty about the reliability of the risk es- timate for individuals in the borderline- or interme- diate-risk categories, further testing to document subclinical coronary atherosclerosis is reasonable to more accurately reclassify the risk estimate upward or Table 3.


Risk-Enhancing Factors for Clinician Patient Risk Discussion Risk-Enhancing Factors Family history of premature ASCVD (males, age <55 y; females, age <65 y) Primary hypercholesterolemia (LDL-C 160 189 mg/dL [4.1 4.8 mmol/L]; non HDL-C 190 219 mg/dL [4.9 5.6 mmol/L])* Metabolic syndrome (increased waist circumference [by ethnically appropriate cutpoints], elevated triglycerides [>150 mg/dL, nonfasting], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 mg/dL in women] are factors; a tally of 3 makes the diagnosis) with or without albuminuria; not treated with dialysis or kidney transplantation) Chronic inflammatory conditions, such as psoriasis, RA, lupus, or HIV/AIDS History of premature menopause (before age 40 y) and history of pregnancy-associated conditions that increase later ASCVD risk, such as preeclampsia High-risk race/ethnicity (eg, South Asian ancestry) Lipids/biomarkers: associated with increased ASCVD risk Persistently elevated* primary hypertriglyceridemia ( 175 mg/dL, nonfasting); If measured: Elevated high-sensitivity C-reactive protein ( 2.0 mg/L) Elevated Lp(a): A relative indication for its measurement is family history of premature ASCVD. An Lp(a) 50 mg/dL or 125 nmol/L constitutes a risk- enhancing factor, especially at higher levels of Lp(a). Elevated apoB ( 130 mg/dL): A relative indication for its measurement would be triglyceride 200 mg/dL. A level 130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor *Optimally, 3 determinations. ABI indicates ankle-brachial index; AIDS, acquired immunodeficiency syndrome; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; HIV, human immunodeficiency virus; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein (a); and RA, rheumatoid arthritis. Reproduced with permission from Grundy et al.S2.2-4 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Assessment of Cardiovascular Risk (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES 3. LIFESTYLE FACTORS AFFECTING CARDIOVASCULAR RISK 3.1.


Recommendations for Assessment of Cardiovascular Risk (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES 3. LIFESTYLE FACTORS AFFECTING CARDIOVASCULAR RISK 3.1. Nutrition and Diet Recommendations for Nutrition and Diet Referenced studies that support recommendations are summarized in Online Data Supplements 4 and 5. COR LOE Recommendations I B-R A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk IIa B-NR Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD IIa B-NR A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk.S3.1-9,S3.1-14 S3.1-16 IIa B-NR As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk.S3.1-17 S3.1-23 III-Harm B-NR As a part of a healthy diet, the intake of trans fats should be avoided to reduce 3.2. Exercise and Physical Activity Recommendations for Exercise and Physical Activity Referenced studies that support recommendations are summarized in Online Data Supplements 6 and 7.


Exercise and Physical Activity Recommendations for Exercise and Physical Activity Referenced studies that support recommendations are summarized in Online Data Supplements 6 and 7. COR LOE Recommendations I B-R Adults should be routinely counseled in healthcare visits to optimize a physically I B-NR Adults should engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) to reduce ASCVD IIa B-NR For adults unable to meet the minimum physical activity recommendations (at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity), engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial to reduce ASCVD risk.S3.2-5,S3.2-6 IIb C-LD Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD Other activity states that comprise a 24-hour period for an average individual include sleep, light-intensity physical activity, and sedentary behavior (Figure 1). Sedentary behavior refers to waking behavior with an energy expenditure of 1.5 metabolic equivalents while in a sitting or reclining posture (Table 4).S3.2-12 4. OTHER FACTORS AFFECTING CARDIOVASCULAR RISK 4.1. Adults With Overweight and Obesity Recommendations for Adults With Overweight and Obesity Referenced studies that support recommendations are summarized in Online Data Supplements 8 and 9. COR LOE Recommendations I B-R In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.S4.1-1 I B-R Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.S4.1-1,S4.1-2 I C-EO Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations.


COR LOE Recommendations I B-R In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.S4.1-1 I B-R Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.S4.1-1,S4.1-2 I C-EO Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations. IIa B-NR It is reasonable to measure waist circumference to identify those at higher 4.2. Adults With Type 2 Diabetes Mellitus See Figure 2 for an algorithm for treatment of T2DM for primary prevention of cardiovascular disease. Figure 1. Hours per day spent in various states of activity. US adults spend >7 h/d on average in sedentary activities. Replacing sedentary time with other physical activity involves increasing either moderate- to vigorous-intensity physical activity or light-intensity physical activity. Data modified from Young et al.S3.2-12 CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With Type 2 Diabetes Mellitus Referenced studies that support recommendations are summarized in Online Data Supplement 10.


Data modified from Young et al.S3.2-12 CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With Type 2 Diabetes Mellitus Referenced studies that support recommendations are summarized in Online Data Supplement 10. COR LOE Recommendations I A For all adults with T2DM, a tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-1,S4.2-2 I A Adults with T2DM should perform at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous- intensity physical activity to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-3,S4.2-4 IIa B-R For adults with T2DM, it is reasonable to initiate metformin as first-line therapy along with lifestyle therapies at the time of diagnosis to improve glycemic control and reduce ASCVD risk.S4.2-5 S4.2-8 IIb B-R For adults with T2DM and additional ASCVD risk factors who require glucose-lowering therapy despite initial lifestyle modifications and metformin, 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.S4.2-9 S4.2-14 4.3. Adults With High Blood Cholesterol Recommendations from the 2018 Cholesterol Clini- cal Practice GuidelinesS4.3-1 are included and adapted below. Table 4. Definitions and Examples of Different Intensities of Physical Activity Intensity METs Examples Sedentary behavior* 1 1.5 Sitting, reclining, or lying; watching television Light 1.6 2.9 Walking slowly, cooking, light housework Moderate 3.0 5.9 Brisk walking (2.4 4 mph), biking (5 9 mph), ballroom dancing, active yoga, recreational swimming Vigorous 6 Jogging/running, biking ( 10 mph), singles tennis, swimming laps *Sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 METs while in a sitting, reclining, or lying posture.


Definitions and Examples of Different Intensities of Physical Activity Intensity METs Examples Sedentary behavior* 1 1.5 Sitting, reclining, or lying; watching television Light 1.6 2.9 Walking slowly, cooking, light housework Moderate 3.0 5.9 Brisk walking (2.4 4 mph), biking (5 9 mph), ballroom dancing, active yoga, recreational swimming Vigorous 6 Jogging/running, biking ( 10 mph), singles tennis, swimming laps *Sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 METs while in a sitting, reclining, or lying posture. Standing is a sedentary activity in that it involves 1.5 METs, but it is not considered a component of sedentary behavior. MET indicates metabolic equivalent; mph, miles per hour. Figure 2. Treatment of T2DM for primary prevention of cardiovascular disease. type 2 diabetes mellitus. CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With High Blood Cholesterol Referenced studies that support recommendations are summarized in Online Data Supplements 11 and 12.


CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With High Blood Cholesterol Referenced studies that support recommendations are summarized in Online Data Supplements 11 and 12. COR LOE Recommendations I A In adults at intermediate risk ( 7.5% to <20% 10-year ASCVD risk), statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended.S4.3-2 S4.3-9 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I A year ASCVD risk) patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk ( 20% 10-year ASCVD risk), levels should be reduced by 50% or Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I A In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated.S4.3-11 S4.3-19 Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I B-R In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL ( 4.9 mmol/L) or higher, maximally tolerated statin therapy is Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIa B-R In adults with diabetes mellitus who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C levels by 50% Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Figure 3. Primary prevention. Colors correspond to Class of Recommendation in Table 1. ABI indicates ankle-brachial index; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coro- nary artery calcium; CHD, coronary heart disease; HIV, human immunodeficiency virus; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; and Lp(a), lipoprotein (a).


ABI indicates ankle-brachial index; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coro- nary artery calcium; CHD, coronary heart disease; HIV, human immunodeficiency virus; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; and Lp(a), lipoprotein (a). Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Adults With High Blood Cholesterol (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES IIa B-R year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIa B-NR ASCVD risk) adults or selected borderline-risk in whom a coronary artery calcium score is measured for the purpose of making a treatment decision, AND If the coronary artery calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (eg, diabetes, family history of premature CHD, cigarette smoking); If coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients 55 years of age; If coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.S4.3-28,S4.3-34 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIb B-R In patients at borderline risk (5% to <7.5% 10- year ASCVD risk), in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy.S4.3-28,S4.3-35 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Primary ASCVD prevention requires attention to AS- CVD risk factors beginning early in life (Figure 3).


Recommendations for Adults With High Blood Cholesterol (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES IIa B-R year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIa B-NR ASCVD risk) adults or selected borderline-risk in whom a coronary artery calcium score is measured for the purpose of making a treatment decision, AND If the coronary artery calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (eg, diabetes, family history of premature CHD, cigarette smoking); If coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients 55 years of age; If coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.S4.3-28,S4.3-34 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIb B-R In patients at borderline risk (5% to <7.5% 10- year ASCVD risk), in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy.S4.3-28,S4.3-35 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Primary ASCVD prevention requires attention to AS- CVD risk factors beginning early in life (Figure 3). The benefit from statin therapy is related to both global risk and intensity of treatment,S4.3-2 and no RCTs of high- intensity statin therapy have been carried out in cohorts of patients exclusively with diabetes. On the basis of these considerations and the fact that patients with dia- betes have a higher trajectory of lifetime risk than do those without diabetes, high-intensity statin therapy is preferred in patients with diabetes as they develop risk modifiers (Table 5).


On the basis of these considerations and the fact that patients with dia- betes have a higher trajectory of lifetime risk than do those without diabetes, high-intensity statin therapy is preferred in patients with diabetes as they develop risk modifiers (Table 5). Selected examples of candidates who might benefit from knowing their coronary artery calcium score is zero are listed in Table 6. 4.4. Adults With High Blood Pressure or Hypertension Recommendations from the 2017 Hypertension Clinical are adapted below. Recommendations for Adults With High Blood Pressure or Hypertension Referenced studies that support recommendations are summarized in Online Data Supplements 13 and 14. COR LOE Recommendations I A In adults with elevated blood pressure (BP) or hypertension, including those requiring antihypertensive medications nonpharmacological interventions are recommended to reduce BP. These include: ; a heart-healthy dietary patternS4.4-6 S4.4-8 ; ; dietary potassium supplementationS4.4-14 S4.4-18 ; increased physical activity with a structured ; and Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 I SBP:A In adults with an estimated 10-year ASCVD risk* of 10% or higher and an average systolic BP (SBP) of 130 mm Hg or higher or an average diastolic BP (DBP) of 80 mm Hg or higher, use of BP-lowering medications is recommended for primary prevention of Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO Table 5. Diabetes-Specific Risk Enhancers That Are Independent of Other Risk Factors in Diabetes Mellitus Risk Enhancers in Diabetic Patients Long duration ( 10 years for T2DMS4.3-36 or 20 years for type 1 diabetes ) Albuminuria 30 mcg albumin/mg creatinineS4.3-37 ABI indicates ankle-brachial index; eGFR, estimated glomerular filtration rate; and T2DM, type 2 diabetes mellitus. Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Table 6.


Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Table 6. Selected Examples of Candidates for Coronary Artery Calcium Measurement Who Might Benefit From Knowing Their Coronary Artery Calcium Score Is Zero Coronary Artery Calcium Measurement Candidates Who Might Benefit from Knowing Their Coronary Artery Calcium Score Is Zero Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms Older patients (men 55 80 y of age; women 60 80 y of age) with low burden of risk factorsS4.4-42 who question whether they would benefit from statin therapy Middle-aged adults (40 55 y of age) with PCE-calculated 10-year risk for ASCVD 5% to <7.5% with factors that increase their ASCVD risk, although they are in a borderline risk group. Caveats: If patient is at intermediate risk and if a risk decision is uncertain and a coronary artery calcium score is obtained, it is reasonable to withhold statin therapy unless higher-risk conditions, such as cigarette smoking, family history of premature ASCVD, or diabetes mellitus, are present and to reassess the coronary artery calcium score in 5 to 10 years. Moreover, if coronary artery calcium is recommended, it should be performed in facilities that have current technology and expertise to deliver the lowest radiation possible. ASCVD indicates atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; and PCE, pooled cohort equations. Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation.


Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Adults With High Blood Cholesterol (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES I SBP:B-RSR In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than 130/80 mm Hg is Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR In adults with T2DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher, with a treatment goal of less than 130/80 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I C-LD In adults with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher, initiation and use of BP-lowering medication Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 IIb SBP:B-NR In adults with confirmed hypertension without additional markers of increased ASCVD risk, a BP target of less than 130/80 mm Hg may be reasonable.S4.4-59 S4.4-62 Adapted from recommendations in the 2017 Hypertension Clinical Practice DBP:C-EO *ACC/AHA pooled cohort equations to estimate 10-year risk of ASCVD. See Figure 4 for the BP thresholds and treatment rec- ommendations algorithm and refer to the 2017 Hyper- tension Clinical Practice Guidelines for comprehensive See Table 7 for recommended dose and approximate impact on SBP. 4.5. Treatment of Tobacco Use Recommendations for Treatment of Tobacco Use Referenced studies that support recommendations are summarized in Online Data Supplements 15 and 16.


Treatment of Tobacco Use Recommendations for Treatment of Tobacco Use Referenced studies that support recommendations are summarized in Online Data Supplements 15 and 16. COR LOE Recommendations I A All adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.S4.5-1 I A To achieve tobacco abstinence, all adults who use tobacco should be firmly advised I A In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.S4.5-2,S4.5-3 I B-NR In adults who use tobacco, tobacco abstinence is recommended to reduce IIa B-R To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare III: Harm B-NR All adults and adolescents should avoid secondhand smoke exposure to reduce In alignment with previous expert consensus regard- ing strategies for tobacco cessation,S4.5-7 Table 8 sum- marizes recommended behavioral interventions and pharmacotherapy for tobacco treatment. There are 7 FDA-approved cessation medications, including 5 forms of nicotine replacement. Note that the black box warn- ings about neuropsychiatric events have been removed by the FDA.S4.5-8,4.5-9 Figure 4. BP thresholds and recommendations for treatment. Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; and CVD, cardiovascular disease. Adapted with permission from Whelton Copyright 2017, American College of Cardiology Foundation and the American Heart Association, Inc. Recommendations for Adults With High Blood Pressure or Hypertension (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES 4.6. Aspirin Use Recommendations for Aspirin Use Referenced studies that support recommendations are summarized in Online Data Supplements 17 and 18.