I Heart My Heart - Part 2: Preventive Medications and Counseling

In part 1, screenings to prevent cardiovascular disease were discussed. These included screening for hypertension, and for abnormal blood glucose. Next, we’re going to talk about two medications that are recommended by the task force for people with elevated risk for heart disease. But before we address the medications, we first have to talk about a concept called the “10-year risk for atherosclerotic cardiovascular disease”, as defined by the American Heart Association and the American College of Cardiologists. This calculation uses age, gender, race, blood pressure, cholesterol numbers, diabetes history, and smoking history to estimate an individual's “10-year risk” for heart attack and stroke.¹ This was based off of a review of large cohort studies that looked for correlation between risk factors and disease in tens of thousands of people.¹ Now, this is a very imperfect estimate,² but it is helpful in identifying individuals who are at greater risk, and who may benefit from taking medication to reduce that risk.

The first recommended medications that we’re going to talk about are called statins. The task force recommends use of statins in individuals who are age 40-75, they have one or more risk factors for heart disease (like high blood pressure, high cholesterol, diabetes, or smoking), and their estimated 10-year risk (that we just discussed) is 10% or higher.³ Statins work primarily by blocking an enzyme in the liver that is responsible for cholesterol synthesis.⁴ They also stabilize atherosclerotic plaques, which are deposits of cholesterol on the inside of blood vessels that can lead to a blockage, and have anti-inflammatory effects.^5-6 Their use has shown to significantly decrease the risk of heart attack and stroke.³ 

The second of the medications recommended by the task force is a daily low-dose aspirin for adults aged 50 through 59 who have a 10-year heart disease risk of 10% or higher.^7-8 Aspirin helps to prevent heart attacks and strokes by decreasing blood clot formation, which can happen when plaques reduce normal blood flow.⁸ The risk reduction is maximized when the medication is taken for the full 10 years, so it only makes sense in people whose life expectancy is at least 10 years. And aspirin should not be taken by those who have an increased risk for bleeding, as its anti-clotting effects would exacerbate that bleeding risk. 

And this brings us to an important point, which is that these medications, like all medications, are not for everybody. Before starting either of these medications, you should always discuss with a trusted health care provider, even though aspirin is over-the-counter. On the other hand, there are many cases where people don’t fit the task force’s exact criteria but still could potentially benefit from the medication. In these cases it would also be a personal decision to make with your healthcare provider.

But just to review: statins are recommended for individuals aged 40-75, who have one or more risk factors for heart disease, and an estimated 10-year cardiovascular risk of 10% or higher. Low-dose aspirin is recommended for adults aged 50 through 59 with a 10% ten-year risk, who aren’t at an increased risk for bleeding and are willing to take the medication the full 10 years. 

The final two recommendations that we’re going to discuss are about counseling and interventions. They are actually quite similar, but have a couple of subtle differences. The first of these recommendations is to offer intensive behavioral counseling to promote physical activity and a healthful diet for adults are overweight or obese and have known cardiovascular risk factors.⁹ These risk factors mentioned here are the same ones that we’ve discussed before, like high blood pressure, high cholesterol, smoking, and diabetes. In this higher risk group, interventions to promote healthy lifestyle have shown a significant benefit.

The second recommendation is similar. This is to offer obese individuals, that is adults with a BMI over 30, intensive, multi-component behavioral interventions.¹⁰ The goal of these interventions was to help participants achieve a 5% or greater weight loss with dietary changes and physical activity. It also looked at behavioral interventions to combat other underlying barriers by focusing on self monitoring of weight, peer support, and relapse prevention.

So now you know why healthcare providers make this a focal issue. There’s really no intervention that is close to as effective as adopting a healthier lifestyle. That is always first line therapy. Every medication that we prescribe to help with high cholesterol, high blood pressure, or abnormal blood glucose metabolism is secondary to this. People who have a higher level of risk can be helped by being provided baseline, foundational knowledge, structure, peer support, and a variety of other success tools. This allows people to have the confidence to fight back; restoring vitality and lowering their risk. 

Please pass this article about medications and counseling on to those you care about, to help prevent cardiovascular disease. While you’re at it, pass on part 1 too!

References

1. Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 2014.
2. Lloyd-Jones MD, Donald M. Strengths and Limitations of the ASCVD Risk Score and What Should Go in the Risk Discussion. American College of Cardiologists. Jul 21, 2014 
3. US Preventive Services Task Force. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016
4. Stancu C, Sima A. Statins: mechanism of action and effects. Journal of Cellular and Molecular Medicine. 2001.
5. Kwon O, Kang SJ, Kang SH, Lee PH, Yun SC, Ahn JM, Park DW, Lee SW, Kim YH, Lee CW, Han KH, Park SW, Park SJ. Relationship between serum inflammatory marker levels and the dynamic changes in coronary plaque characteristics after statin therapy. Circulation: Cardiovascular Imaging. 2017.
6. Park SJ, Kang SJ, Ahn JM, Chang M, Yun SC, Roh JH, Lee PH, Park HW, Yoon SH, Park DW, Lee SW, Kim YH, Lee CW, Mintz GS, Han KH, Park SW. Effect of statin treatment on modifying plaque composition: a double-blind, randomized study. Journal of the American College of Cardiology. 2016.
7. Guirguis-Blake JM, Evans CV, Senger CA, Rowland MG, O'Connor EA, Whitlock EP. Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Evidence synthesis no. 131. AHRQ publication no. 13-05195-EF-1. Rockville, Md.: Agency for Healthcare Research and Quality; 2015.
8. Kirsten Bibbins-Domingo, PhD, MD, MAS, on behalf of the U.S. Preventive Services Task Force. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine.  21 June 2016
9. LeFevre ML; U.S. Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2014 Oct 21;161(8):587-93. doi: 10.7326/M14-1796. PMID: 25155419.
10. US Preventive Services Task Force. Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(11):1163–1171. doi:10.1001/jama.2018.13022