Aspirin Use Recommendations for Aspirin Use Referenced studies that support recommendations are summarized in Online Data Supplements 17 and 18. COR LOE Recommendations IIb A Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding III: Harm B-R Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.S4.6-9 III: Harm C-LD Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of 5. COST AND VALUE CONSIDERATIONS The growing need to consider value stems directly from the goal of achieving the best possible health outcomes with finite healthcare resources in the pri- mary prevention of CVD.S5-1 Value in healthcare can be defined as the incremental health benefits of a therapy or procedure relative to its incremental net long-term costs.


COST AND VALUE CONSIDERATIONS The growing need to consider value stems directly from the goal of achieving the best possible health outcomes with finite healthcare resources in the pri- mary prevention of CVD.S5-1 Value in healthcare can be defined as the incremental health benefits of a therapy or procedure relative to its incremental net long-term costs. The consideration of cost and value in the guideline development process supports key goals, including: 1) enhancing overall value in the de- livery of cardiovascular care and 2) involving health- care professionals in the challenging care decisions that must be made to increase value in the US health- The integration of value assessments into our na- tional guidelines involves inherent methodological chal- lenges, including: 1) variability in costs across different healthcare settings; 2) variability in costs and benefits across different patient subgroups; 3) variability over time; 4) variability in who bears the burden of the health outcome (ie, typically the individual patient) ver- sus who bears the burden of the healthcare cost (eg, often spread beyond the individual to third-party pay- ers, taxpayers); and 5) an inadequate literature base on which to render a sound, evidence-based assessment of certain specific therapies.S5-1,S5-2 There are additional challenges specific to the pre- vention realm. As described in the 2011 AHA policy statement, Value of Primordial and Primary Prevention Table 7. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* Nonpharmacological Intervention Goal Approximate Impact on SBP Hypertension Normotension Reference Weight loss Weight/body fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight.


Expect about 1 mm Hg for every 1-kg reduction in body weight. Healthy diet DASH dietary pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Reduced intake of dietary sodium Dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. Enhanced intake of dietary potassium Dietary potassium Aim for 3500 5000 mg/d, preferably by consumption of a diet rich in potassium. Physical activity Aerobic 90 150 min/wk 65% 75% heart rate reserve Dynamic resistance 90 150 min/wk Isometric resistance 4 2 min (hand grip), 1 min rest between exercises, 30% 40% maximum voluntary contraction, 3 sessions/wk Moderation in alcohol intake Alcohol consumption In individuals who drink alcohol, reduce alcohol to: Men: 2 drinks daily Women: 1 drink daily *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. Detailed information about the DASH diet is available via the NHLBIS4.4-65 In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).S4.4-64 BP indicates blood pressure; DASH, Dietary Approaches to Stop Hypertension; NHLBI, National Heart, Lung, and Blood Institute; and SBP, systolic blood pressure. Reproduced with permission from Whelton et al.S4.4-1 Copyright 2017, American College of Cardiology Foundation and the American Heart Association, Inc. CLINICAL STATEMENTS AND GUIDELINES Assessing the value of prevention in appar- ently healthy patients is generally more difficult than evaluating therapy for established disease because the time horizon to the clinical mani- festation of disease is generally long many decades in the young.


Reproduced with permission from Whelton et al.S4.4-1 Copyright 2017, American College of Cardiology Foundation and the American Heart Association, Inc. CLINICAL STATEMENTS AND GUIDELINES Assessing the value of prevention in appar- ently healthy patients is generally more difficult than evaluating therapy for established disease because the time horizon to the clinical mani- festation of disease is generally long many decades in the young. Thus, it is difficult, per- haps impossible, to assess long-term effective- ness in terms of survival or quality-adjusted life-years (QALYs) or associated costs because of increasing uncertainty about outcome the fur- ther one tries to look into the future. Furthermore, the principle of discounting, which places relative emphasis on current costs and benefits while deemphasizing downstream costs and benefits, creates disadvantages for prevention because costs of- ten accrue in the present while the benefit may only be fully realized long into the future. These methodologi- cal challenges notwithstanding, prior AHA statements have highlighted the public policies, community efforts, and pharmacological interventions that are likely to be cost-effective and, at times, cost-saving prevention tac- tics compared with common benchmarks. For example, robust evidence suggests that both antihypertensive and statin therapy,S5-7 S5-9 particularly with low-cost generic drug formulations, are high-value inter- ventions across a wide spectrum of risk and age strata. The incorporation of the value category into clinical practice guidelines is one of several considerations in medical decision-making and resource allocation. Clini- cians, researchers, and policymakers alike must contin- ue to place cost-effective analyses in the proper context, extracting key value determinations while acknowledg- ing the challenges in fully characterizing and incorpo- rating the downstream benefits of a given therapeutic prevention tactic.


Clini- cians, researchers, and policymakers alike must contin- ue to place cost-effective analyses in the proper context, extracting key value determinations while acknowledg- ing the challenges in fully characterizing and incorpo- rating the downstream benefits of a given therapeutic prevention tactic. Further research and methodological advances are needed to comprehensively characterize the full spectrum of benefits produced by the preven- tion approach, thereby rendering cost-effectiveness as- sessments more consequential to clinical practice. Most ASCVD events are avoidable through primordial prevention (ie, the prevention of risk factor develop- ment) and control of traditional cardiovascular risk factors. Tobacco avoidance is critically important for ASCVD prevention, and all adults should strive to en- gage in regular brisk physical activity most days of the Table 8. Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers* Timing of Behavioral Interventions <3 min of tobacco status assessment with cessation counseling at each clinic encounter >3-10 min of tobacco status assessment with cessation counseling at each clinic encounter >10 min of tobacco status assessment with cessation counseling at each clinic encounter Treatment Dosing Precautions NRT* Patch 21 mg, 14 mg, or Starting dose: 21 mg for 10 CPD; 14 mg for <10 CPD Local irritation possible; avoid with skin disorders; may remove for sleep if needed Gum 2 mg or 4 mg Starting dose: 4 mg if first tobacco use is 30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d.


Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers* Timing of Behavioral Interventions <3 min of tobacco status assessment with cessation counseling at each clinic encounter >3-10 min of tobacco status assessment with cessation counseling at each clinic encounter >10 min of tobacco status assessment with cessation counseling at each clinic encounter Treatment Dosing Precautions NRT* Patch 21 mg, 14 mg, or Starting dose: 21 mg for 10 CPD; 14 mg for <10 CPD Local irritation possible; avoid with skin disorders; may remove for sleep if needed Gum 2 mg or 4 mg Starting dose: 4 mg if first tobacco use is 30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum* Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use Lozenge 2 mg or 4 mg Nasal spray 10 mg/mL Starting dose: maximum of 40 doses/d Local irritation possible; avoid with nasal or reactive airway disorders Oral inhaler 10-mg cartridge Starting dose: Puff for 20 min/cartridge every 1-2 h; maximum 16 cartridges/d Cough possible; avoid with reactive airway disorders Other Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKline]) 150 mg SR 150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination with NRTS4.5-9 Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor Varenicline (Chantix [Pfizer]) 0.5 mg or 1 mg 0.5 mg once daily (am) for 3 d; then 0.5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3-6 mo Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance. *CPD can guide dosing. 1 CPD is 1-2 mg of nicotine.


*CPD can guide dosing. 1 CPD is 1-2 mg of nicotine. Note: Use caution with all NRT products for patients with recent ( 2 wk) MI, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents. Timing of assessment relates to ICD-10 coding. Dose and duration can be titrated on the basis of response.S4.5-9 The FDA has issued a removal of black box warnings about neuropsychiatric events.S4.5-8,S4.5-9 am indicates morning; CPD, cigarettes smoked per day; FDA, US Food and Drug Administration; ICD-10, International Classification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release. CLINICAL STATEMENTS AND GUIDELINES week and adhere to a healthy dietary pattern to help lower future ASCVD risk. A diet high in fruits, veg- etables, and whole grains is best. Fish, legumes, and poultry are the preferred sources of protein. Minimizing the consumption of trans fats, added sugars (includ- ing sugar-sweetened beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in partnership with patients to assess their readi- ness for sustained lifestyle improvements, identify po- tential barriers to change, and encourage them to try to achieve measurable goals and continue to monitor Finally, social determinants of ASCVD risk and their impact on the patient s ability to prevent or treat risk factors must be taken into account. Clini- cians need to consider patients health literacy and edu- cation levels and assess patients motivation to improve their lifestyle habits. The goal of the clinician is to match the intensity of preventive efforts with an individual s absolute risk of a future ASCVD event and with the individual s willing- ness and capacity to implement preventive strategies. Risk estimation is imperfect and based on group aver- ages that are then applied to individual patients.


Risk estimation is imperfect and based on group aver- ages that are then applied to individual patients. The clinician must balance an understanding of a patient s estimated ASCVD risk with potential benefits and ad- verse risk from pharmacological therapy in the context of a risk discussion. To determine the appropriateness of pharmacological therapy after quantitative risk estima- tion in cases that are unclear, risk-enhancing factors or selective use of a coronary artery calcium measurement can inform decision-making for cholesterol-lowering or antihypertensive medication use in intermediate-risk in- dividuals. This primary-prevention guideline strives to provide clinicians with the information they need to help their patients reduce their risk of ASCVD and encourage them to make healthier lifestyle changes when needed.


This primary-prevention guideline strives to provide clinicians with the information they need to help their patients reduce their risk of ASCVD and encourage them to make healthier lifestyle changes when needed. ACC/AHA TASK FORCE MEMBERS Patrick T. O Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Joaquin E. Cigarroa, MD, FACC; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Mark A. Hlatky, MD, FACC, FAHA; John Iko- nomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD PRESIDENTS AND STAFF American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice Presi- dent, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Educa- tion, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S.D.


ACC/AHA TASK FORCE MEMBERS Patrick T. O Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Joaquin E. Cigarroa, MD, FACC; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Mark A. Hlatky, MD, FACC, FAHA; John Iko- nomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD PRESIDENTS AND STAFF American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice Presi- dent, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Educa- tion, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S.D. Getchius, Manager, Guideline Operations American Heart Association Ivor Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Cammie Marti, PhD, MPH, RN, Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science Operations ARTICLE INFORMATION This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the American Heart Association Executive Committee in February 2019.


Getchius, Manager, Guideline Operations American Heart Association Ivor Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Cammie Marti, PhD, MPH, RN, Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science Operations ARTICLE INFORMATION This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the American Heart Association Executive Committee in February 2019. Supplemental materials are available with this article at https://www. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org/). A copy of the document is also available at https:// professional.heart.org/statements by selecting the Guidelines & Statements button. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guide- lines development, visit https://professional.heart.org/statements. Select the Guidelines & Statements drop-down menu near the top of the web page, then click Publication Development. Permissions: Multiple copies, modification, alteration, enhancement, and/ or distribution of this document are not permitted without the express permis- sion of the American Heart Association. Instructions for obtaining permission are are located at https://www.heart.org/permissions. A link to the Copyright Permissions Request Form appears in the second paragraph (https://www. heart.org/en/about-us/statements-and-policies/copyright-request-form). * Former Task Force member; current member during the writing effort. CLINICAL STATEMENTS AND GUIDELINES REFERENCES S1-1.


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S4.5-5. Mons U, M ezzinler A, Gellert C, et al. Impact of smoking and smok- ing cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium. BMJ. 2015;350:h1551. S4.5-6. Lv X, Sun J, Bi Y, et al. Risk of all-cause mortality and cardiovascular disease associated with secondhand smoke exposure: a systematic review and meta-analysis. Int J Cardiol. 2015;199:106 15. S4.5-7. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC Expert Consensus Decision Pathway on Tobacco Cessation Treatment: A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2018;72:3332 65. S4.5-8. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387:2507 20. S4.5-9. Prochaska JJ, Benowitz NL. The past, present, and future of nicotine addiction therapy. Annu Rev Med. 2016;67:467 86. 4.6. Aspirin Use S4.6-1. Guirguis-Blake JM, Evans CV, Senger CA, et al. Aspirin for the pri- mary prevention of cardiovascular events: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med. 2016;164:804 13. S4.6-2. Whitlock EP, Burda BU, Williams SB, et al. Bleeding risks with aspirin use for primary prevention in adults: a systematic review for the US Preventive Services Task Force. Ann Intern Med. 2016;164:826 35. S4.6-3. Lotrionte M, Biasucci LM, Peruzzi M, et al. Which aspirin dose and preparation is best for the long-term prevention of cardiovascular disease and cancer? Evidence from a systematic review and network meta-analysis. Prog Cardiovasc Dis. 2016;58:495 504. S4.6-4. Raju N, Sobieraj-Teague M, Bosch J, et al. Updated meta-analysis of aspirin in primary prevention of cardiovascular disease. Am J Med. 2016;129:e35 6. S4.6-5.


Updated meta-analysis of aspirin in primary prevention of cardiovascular disease. Am J Med. 2016;129:e35 6. S4.6-5. Ogawa H, Nakayama M, Morimoto T, et al. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2008;300:2134 41. S4.6-6. Belch J, MacCuish A, Campbell I, et al. The prevention of progres- sion of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ. 2008;337:a1840. S4.6-7. Fowkes FGR, Price JF, Stewart MCW, et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA. 2010;303:841 8. S4.6-8. Ikeda Y, Shimada K, Teramoto T, et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: a randomized clinical trial. JAMA. 2014;312:2510 20. S4.6-9. McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardio- vascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379:1509 18. S4.6-10. Garc a Rodr guez LA, Mart n-P rez M, Hennekens CH, et al. Bleeding risk with long-term low-dose aspirin: a systematic review of observa- tional studies. PLoS ONE. 2016;11:e0160046. CLINICAL STATEMENTS AND GUIDELINES 5. COST AND VALUE CONSIDERATIONS S5-1. Weintraub WS, Daniels SR, Burke LE, et al. Value of primordial and pri- mary prevention for cardiovascular disease: a policy statement from the American Heart Association. Circulation. 2011;124:967 90. S5-2. Anderson JL, Heidenreich PA, Barnett PG, et al. ACC/AHA state- ment on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation. 2014;129:2329 45. S5-3.


ACC/AHA state- ment on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation. 2014;129:2329 45. S5-3. Bress AP, Bellows BK, King JB, et al. Cost-effectiveness of inten- sive versus standard blood-pressure control. N Engl J Med. 2017;377:745 55. S5-4. Moran AE, Odden MC, Thanataveerat A, et al. Cost-effectiveness of hypertension therapy according to 2014 guidelines. N Engl J Med. 2015;372:447 55. S5-5. Park C, Wang G, Durthaler JM, et al. Cost-effectiveness analyses of antihypertensive medicines: a systematic review. Am J Prev Med. 2017;53:S131 42. S5-6. Richman IB, Fairley M, J rgensen ME, et al. Cost-effectiveness of intensive blood pressure management. JAMA Cardiol. 2016;1:872 9. S5-7. Heller DJ, Coxson PG, Penko J, et al. Evaluating the impact and cost- effectiveness of statin use guidelines for primary prevention of coro- nary heart disease and stroke. Circulation. 2017;136:1087 98. S5-8. Odden MC, Pletcher MJ, Coxson PG, et al. Cost-effectiveness and population impact of statins for primary prevention in adults aged 75 years or older in the United States. Ann Intern Med. 2015;162:533 41. S5-9. Heart Protection Study Collaborative Group. Statin cost-effective- ness in the United States for people at different vascular risk levels. Circ Cardiovasc Qual Outcomes. 2009;2:65 72. S6-1. Lehr AL, Driver SL, Stone NJ. The ABCDs of lifestyle counseling. JAMA Cardiol. 2016;1:505 6. APPENDIX 1. SEARCH CRITERIA 1. Patnode CD, Evans CV, Senger CA, et al. Behavioral counseling to pro- mote a healthful diet and physical activity for cardiovascular disease prevention in adults without known cardiovascular disease risk factors: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;318:175 93. 2. LeBlanc ES, Patnode CD, Webber EM, et al.


2017;318:175 93. 2. LeBlanc ES, Patnode CD, Webber EM, et al. Behavioral and pharmaco- therapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320:1172 91. 3. Selph S, Dana T, Bougatsos C, et al. Screening for abnormal glucose and type 2 diabetes mellitus: a systematic review to update the 2008 US Preventive Services Task Force Recommendation. Report No. 13-05190- EF-1. 2015, US Agency for Healthcare Research and Quality:Rockville, MD. Available at: http://www.ncbi.nlm.nih.gov/books/NBK293871. Accessed January 5, 2019. 4. Patnode CD, Henderson JT, Thompson JH, et al. Behavioral counsel- ing and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: a review of reviews for the US Preventive Services Task Force. Ann Intern Med. 2015;163:608 21. 5. Guirguis-Blake JM, Evans CV, Senger CA, et al. Aspirin for the pri- mary prevention of cardiovascular events: a systematic evidence review for the US Preventive Services Task Force. Ann Intern Med. 2016;164:804 13. CLINICAL STATEMENTS AND GUIDELINES APPENDIX 1. SEARCH CRITERIA The rapid review conducted by the Evidence-based Practice Center to complete this literature search, in the limited timeframe provided, built on existing systematic reviews conducted on behalf of the USPSTF.


SEARCH CRITERIA The rapid review conducted by the Evidence-based Practice Center to complete this literature search, in the limited timeframe provided, built on existing systematic reviews conducted on behalf of the USPSTF. Medical Subject Headings (MeSH) Terms Key Words Nutrition and Diet Search since the 2017 review1 exp Diet/ diet* exp Diet Therapy/ cardiovascular Healthy Diet coronary Primary Prevention/ heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Obesity and Weight Loss Search since the 2018 review2 exp Obesity/ obes* exp Weight Loss overweight Primary Prevention/ weight cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Type 2 Diabetes Mellitus Search since the 2015 review3 exp Diabetes Mellitus, Type 2/ impaired fasting glucose Prediabetic State/ impaired glucose tolerance Glucose Intolerance/ Ifg Primary Prevention/ Igt prediabetes* type 2 diabet* DM cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Tobacco Use Search since the 2015 review4 Smoking/ smoking exp "Tobacco Use Cessation"/ cigarette* "Tobacco Use Disorder"/ tobacco Electronic Cigarettes/ nicotine Primary Prevention/ vape vaping e-cigarette electronic cigarette electronic nicotine delivery system* ENDS cardiovascular coronary heart myocardial infarction MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Aspirin Use Search since the 2016 review5 Aspirin aspirin exp Cerebrovascular Disorders/ acetylsalicylic acid exp Cardiovascular Diseases/ clopidogrel Primary Prevention/ cardiovascular coronary heart myocardial infarction Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES Primary Prevention/ MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Social Determinants of Health Search limited to English.


Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES Primary Prevention/ MI CVD CHD cerebrovascular stroke microvascular mortality prevent* Social Determinants of Health Search limited to English. No date restrictions (conducted 7/11/2018) Similar articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED Social determinants of health Equity Social status Social deprivation Neighborhood Neighborhood conditions Uninsured Housing Immigration Adverse childhood events Social gradient Educational status Inequalities Sexuality Atherosclerosis cardiovascular Team Based Care Search limited to English, 1/1/2010-10/14/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN EMPLOYED team Team care Collaborative care Multidisciplinary team based team approach prevention Primary prevention Cardiovascular disease, Cholesterol Aspirin Smoking Obesity Heart disease Atherosclerosis stroke Shared Decision Making Search limited to English, 1/1/2010-10/24/2018 (though earlier articles may have been identified through related articles search) Related articles searches were also conducted where potentially highly relevant papers were found NONE SPECIFIED, BUT DUE TO AUTOMATIC TERM MAPPING IN PUBMED, SOME MeSH TERMS MAY HAVE BEEN AUTOMATICALLY EMPLOYED Shared decision making Prevention Cardiovascular Atherosclerosis Stroke Heart Hypertension Lipids Cholesterol diabetes Exercise & Physical Activity Search limits: Not ACP Journal Club OR Summaries for patients OR Editorial OR case-report OR letter OR letter OR abstract OR newspaper article OR comment OR baseline characteristics OR study design OR methodology Terms to identify clinical trials/SRs/Mas: Filters: Meta-Analysis, Systematic Reviews, Clinical Trial, Controlled Clinical Trial, Randomized Controlled Trial, From 2011/01/01 to 2018/05/25, Humans, English, Adult: 19+ years Terms to identify observational studies: 2011/01/01 to 2018/12/31, Humans, English, Epidemiologic Studies, Case- Control Studies, Cohort Studies, Cross-Sectional Studies, epidemiolog* AND stud*, case control, cohort stud*, cross sectional, cohort analys*, follow up stud*, longitudinal, retrospective, prospective, observational AND stud* Filters: Adult: 19+ years Waist Circumference Search limited to adult populations, 01/01/2010-10/3/18, English language Acute Coronary Syndrome Acute coronary syndromes Angina Unstable Unstable angina?


, Angina Unstable Myocardial infarction Myocardial infarctions Shock cardiogenic shock cardiogenic Myocardial Stunning myocardial stunning No Reflow Phenomenon Heart Arrest St elevation myocardial infarction STEMI Non-st elevated myocardial infarction NSTEMI death/sudden cardiac Stroke Brain Infarction Brain Stem Infarctions Lateral Meduallary Syndrome Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty "angioplasty transluminal percutaneous coronary" Heart failure Hospitalization Hospitalization? OR rehospitalization? atherectomy coronary Coronary stent CABG bypass grafts Carotid pathology physiopathology Non-coronary revascularization procedure Carotid revascularization? Lower extremity revascularization? Percutaneous transluminal angioplast? Stent placement? Abdominal aortic aneurysm repair? AAA repair? complications Event? OR outcome? OR episode? Risk score Coronary risk modification Cardiovascular diseases Cardiovascular OR CVD Cardiovascular disease Coronary disease coronary Coronary artery disease Myocardial infarction Heart failure CHF OR CHD Cerebrovascular disorders dyspnea paroxysmal edema cardiac Physical fitness Motor activity Exercise tolerance Metabolic equivalent Metabolic equivalent Exercise test Graded exercise test OR gxt Life style or lifestyle Exercise Training Walking Maximal met Mets Physical activity Maximal metabolic? Acute Coronary Syndrome Acute coronary syndromes Angina Unstable Unstable angina?, Angina Unstable Myocardial infarction Myocardial infarctions Shock cardiogenic shock cardiogenic Myocardial Stunning myocardial stunning No Reflow Phenomenon Heart Arrest St elevation myocardial infarction STEMI Non-st elevated myocardial infarction NSTEMI death/sudden cardiac Stroke Brain Infarction Brain Stem Infarctions Lateral Meduallary Syndrome Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty "angioplasty transluminal percutaneous coronary" Heart failure Hospitalization Hospitalization? OR rehospitalization?


, Angina Unstable Myocardial infarction Myocardial infarctions Shock cardiogenic shock cardiogenic Myocardial Stunning myocardial stunning No Reflow Phenomenon Heart Arrest St elevation myocardial infarction STEMI Non-st elevated myocardial infarction NSTEMI death/sudden cardiac Stroke Brain Infarction Brain Stem Infarctions Lateral Meduallary Syndrome Cerebral Infarction Myocardial ischemia Dementia Multi infarct infarction anterior cerebral artery infarction middle cerebral artery infarction posterior cerebral artery Myocardial revascularization Coronary artery bypass Internal mammary coronary artery anastomosis Angioplasty "angioplasty transluminal percutaneous coronary" Heart failure Hospitalization Hospitalization? OR rehospitalization? atherectomy coronary Coronary stent CABG bypass grafts Carotid pathology Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) (Continued) CLINICAL STATEMENTS AND GUIDELINES physiopathology Non-coronary revascularization procedure Carotid revascularization? Lower extremity revascularization? Percutaneous transluminal angioplast? Stent placement? Abdominal aortic aneurysm repair? AAA repair? complications Event? OR outcome? OR episode? Risk score Coronary risk modification Cardiovascular diseases Cardiovascular OR CVD Cardiovascular disease Coronary disease coronary Coronary artery disease Myocardial infarction Heart failure CHF OR CHD Cerebrovascular disorders dyspnea paroxysmal edema cardiac Because of automatic term mapping in PubMed, some MeSH terms may have been used even when not explicitly specified. Appendix 2.


Risk score Coronary risk modification Cardiovascular diseases Cardiovascular OR CVD Cardiovascular disease Coronary disease coronary Coronary artery disease Myocardial infarction Heart failure CHF OR CHD Cerebrovascular disorders dyspnea paroxysmal edema cardiac Because of automatic term mapping in PubMed, some MeSH terms may have been used even when not explicitly specified. Appendix 2. Author Relationships With Industry and Other Entities (Relevant) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Donna K. Arnett, Co-Chair University of Kentucky College of Public Health Dean and Professor of Epidemiology None None None None None None Roger S. Blumenthal, Co-Chair Johns Hopkins University Professor of Medicine and Director, Ciccarone Center for the Prevention of Heart Disease None None None None None None Michelle A. Albert UCSF School of Medicine Professor of Medicine and Director, UCSF NURTURE Center None None None None None None Andrew B. Buroker Faegre Baker Daniels LLP, Partner None None None None None None Zachary D. Goldberger University of Wisconsin School of Medicine and Public Health Associate Professor of Medicine, Division of Cardiology None None None None None None Ellen J. Hahn University of Kentucky College of Nursing Professor & Director, BREATHE, Deputy Director, UK-CARES & Leader, and Community Engagement Core; Marcia A. Dake Professor of Nursing None None None None None None Cheryl Dennison Himmelfarb Johns Hopkins School of Nursing Professor; Associate Dean Research, Office for Science and Innovation; and Deputy Director, Johns Hopkins Institute for Clinical and Translational Research None None None None None None Appendix 1.


Author Relationships With Industry and Other Entities (Relevant) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Committee Member Employment Consultant Speakers Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Donna K. Arnett, Co-Chair University of Kentucky College of Public Health Dean and Professor of Epidemiology None None None None None None Roger S. Blumenthal, Co-Chair Johns Hopkins University Professor of Medicine and Director, Ciccarone Center for the Prevention of Heart Disease None None None None None None Michelle A. Albert UCSF School of Medicine Professor of Medicine and Director, UCSF NURTURE Center None None None None None None Andrew B. Buroker Faegre Baker Daniels LLP, Partner None None None None None None Zachary D. Goldberger University of Wisconsin School of Medicine and Public Health Associate Professor of Medicine, Division of Cardiology None None None None None None Ellen J. Hahn University of Kentucky College of Nursing Professor & Director, BREATHE, Deputy Director, UK-CARES & Leader, and Community Engagement Core; Marcia A. Dake Professor of Nursing None None None None None None Cheryl Dennison Himmelfarb Johns Hopkins School of Nursing Professor; Associate Dean Research, Office for Science and Innovation; and Deputy Director, Johns Hopkins Institute for Clinical and Translational Research None None None None None None Appendix 1. Continued Medical Subject Headings (MeSH) Terms Key Words (Continued) CLINICAL STATEMENTS AND GUIDELINES Amit Khera UT Southwestern School of Medicine Professor of Internal Medicine and Director, Preventive Cardiology Program None None None None None None Donald Lloyd-Jones Northwestern University Eileen M. Foell Professor; Senior Associate Dean for Clinical and Translational Research; Chair, Department of Preventive Medicine; and Director, Clinical and Translational Sciences Institute None None None None None None J. William McEvoy National University of Ireland, Galway Campus Professor of Preventive Cardiology; National Institute for Preventive Cardiology, Galway Medical and Research Director; and University Hospital Galway, Ireland Consultant Cardiologist.