The first in a five-part series of articles that explain the new heart disease and stroke prevention guidelines.
Obesity should be treated like a disease and cholesterol-lowering drugs could prevent cardiovascular disease in more Americans than previously thought, according to new cardiovascular prevention guidelines released Tuesday by the American Heart Association and American College of Cardiology.
The updated guidelines for healthcare providers also urge overall healthy diets rather than stressing about occasional indulgences. And they give doctors the first-ever formulas to calculate heart and stroke risk specifically for African-Americans – who face disproportionate risks for these diseases.
These cardiovascular prevention guidelines reflect the latest views of scientific and medical experts on how to prevent heart disease and stroke, the No. 1 and 4 killers in the U.S. These guidelines are the result of experts poring over hundreds of clinical research studies and then developing recommendations about what works best, equipping doctors across the country to provide the most up-to-date care.
“These new guidelines represent the best of what scientific research can tell us about how to prevent heart disease and stroke,” said American Heart Association president Mariell Jessup, M.D., medical director of the Penn Medicine Heart and Vascular Center at the University of Pennsylvania in Philadelphia. “These recommendations will help guide the clinical decisions doctors make every day to protect their patients from two of the nation’s biggest killers.”
The guidelines are based on rigorous, comprehensive, systematic evidence reviews originally sponsored by the federal National Heart, Lung, and Blood Institute. The American Heart Association and the American College of Cardiology worked with other professional groups in finalizing these guidelines, and multiple stakeholder organizations were invited to review and endorse the final documents.
Below is a brief look at the new guidelines in obesity, cholesterol, risk assessment and lifestyle.
Obesity should be managed and treated like a disease
The best strategy to lose weight and keep it off requires a three-pronged approach: Eat fewer calories than your body needs, exercise more and change unhealthy behaviors.
Patients are more likely to stay on track when guided by a trained professional in a healthcare setting.
That’s why healthcare providers are now urged to actively help patients achieve and maintain a healthier body weight, said Frank Hu, M.D., Ph.D., a professor of nutrition and epidemiology at Harvard School of Public Health in Boston.
Hu is an American Heart Association volunteer who sat on a 27-member expert committee that wrote the new Guideline for the Management of Overweight and Obesity in Adults, from the American Heart Association, American College of Cardiology and The Obesity Society.
“Clinicians should not just think of obesity as a lifestyle issue. They should treat obesity as a disease,” Hu said. “Providing preventive care services such as obesity screening and behavioral counseling are critically important.”
Included in the new guideline is a first-of-its-kind roadmap to help patients lose weight and keep it off. It starts with finding out who would benefit from weight loss by calculating at least once a year every American’s body mass index, which is an indicator of obesity based on height and weight. Patients with a BMI of 30 or higher are considered obese and need treatment. In the U.S., nearly 78 million adults are obese.
For the overweight, the new guidelines found that more people can reap rewards from weight loss than previously thought. In 1998, federal guidelines suggested that overweight people must have at least two risk factors for obesity-related health problems to benefit from weight loss. But the revised guidelines find weight-loss dividends for people that have even just one risk factor, such as elevated blood pressure or high triglycerides (blood fats).
“The key message here is that we know weight loss isn’t just about will power,” said Donna Ryan, M.D., co-chair of the committee that wrote the guideline and professor emeritus at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge. “It’s about behaviors around food and physical activity, and getting the help you need to change those behaviors.”
More Americans could benefit from statins
Cholesterol-lowering statin drugs could be prescribed to an estimated 33 million Americans without cardiovascular disease who have a 7.5 percent or higher risk for a heart attack or stroke within the next 10 years. That’s according to a new cholesterol guideline from the American Heart Association and American College of Cardiology.
This is a dramatic change from the 2002 federal cholesterol guideline, which recommended that people should only take a statin if their 10-year risk level exceeded 20 percent. The old guideline only considered a person’s risk for heart disease, leaving out the risk for stroke.
Statins are drugs that lower the amount of cholesterol circulating in the blood. Seven statin drugs are currently available in the U.S.
“We’ve been undertreating people who need statin therapy in this country,” said American Heart Association volunteer Donald Lloyd-Jones, M.D., one of 20 experts on the committee that wrote the new guideline.
Examples of groups that would exceed the 7.5 percent risk threshold and therefore benefit from statin therapy include white women over 60 who smoke and have high blood pressure and African-American men over 50 with high blood pressure.
“Statins lower cholesterol levels, but what they really target is overall cardiovascular risk,” said Lloyd-Jones, a preventive cardiologist and chair of the Department of Preventive Medicine at Northwestern University Feinberg School of Medicine in Chicago.
Ideally, the level of bad (LDL) cholesterol should be below 100 milligrams per deciliter of blood (mg/dL). It is considered high at 160 mg/dL. For someone taking a statin, the risk for a heart attack or stroke drops by about 20 percent for each 39 mg/dL reduction in bad (LDL) cholesterol, according to the guideline. Bad cholesterol is considered high at 160 mg/dL.
The guideline recommends statin therapy for the following groups:
- People without cardiovascular disease who are 40 to 75 years old and have a 7.5 percent or higher risk for heart attack or stroke within 10 years.
- People with a history of heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization.
- People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher).
- People with Type 1 or Type 2 diabetes who are 40 to 75 years old.
New risk equations add African-Americans and stroke risk
Doctors can now calculate cardiovascular risk in African-Americans for the first time ever. The new equations offer greater accuracy in predicting the chances of heart attack or stroke in African-Americans, whose risk levels are higher than whites.
But the new risk equations actually benefit everyone. That’s because for the first time, stroke risk has been added to the equation, giving patients a two-in-one assessment of their future cardiovascular health.
The updated risk equations for white men and women – and the brand-new risk equations for African-American men and women – were published in the risk assessment guideline from the American Heart Association and American College of Cardiology.
For decades, health providers have had to rely on risk equations based on long-term research in a white population – a group less at risk for heart attack and stroke than African-Americans. Doctors also often had to assess heart disease and stroke risk separately.
Healthcare systems and providers should adopt the new risk equations as soon as possible, said David Goff, Jr., M.D., Ph.D., who co-chaired a 17-member expert committee that wrote the guideline and an American Heart Association volunteer. “We believe the new equations are better because they are based on a broader, more current set of research data and assess both heart attack and stroke risk,” said Goff, dean of the Colorado School of Public Health in Aurora.
The new equations are recommended for 40- to 79-year-olds and measure a person’s risk for a heart attack or stroke within the next 10 years. A separate equation is available to estimate a person’s lifetime risk, which is recommended starting at age 20.
To calculate 10-year risk, the equation uses race, gender, age, total cholesterol, HDL (good) cholesterol, blood pressure, use of blood pressure medication, diabetes status and smoking status. “That’s it,” Goff said. “Nothing that requires anything more than a visit to your healthcare provider and a fasting blood draw.”
About 610,000 Americans have a first stroke every year. Another 525,000 have a first heart attack. The good news is that the risks can be lowered through lifestyle changes and, in some cases, medications such as statins.
“You can’t do much about your risk if you don’t know what it is,” Goff said.
New guideline outlines the best dietary pattern and exercise for heart health
Americans shouldn’t sweat satisfying a sweet tooth with a slice of cake or ice cream every now and then. More critical to wellness is maintaining an overall heart-healthy dietary pattern than avoiding occasional indulgences, according to a new lifestyle management guideline from the American Heart Association and American College of Cardiology.
Just 40 minutes of moderate to vigorous aerobic exercise three to four times a week was also found to be sufficient for most people. Even brisk walking will do.
The new recommendations are designed for people who need to lower cholesterol and blood pressure. Many Americans fit that category: About one-third of U.S. adults have elevated levels of bad cholesterol, and nearly two-thirds have high blood pressure or prehypertension.
Recommended are dietary patterns that emphasize fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. Red meat and sugary foods and beverages should be limited. Many diets would work, including the DASH eating plan and plans suggested by the U.S. Department of Agriculture and the American Heart Association.
“Eating a healthy diet is not about good foods and bad foods in isolation from the rest of your diet – it’s about the overall diet,” said Robert Eckel, M.D., co-chair of a 19-member expert committee that wrote the guideline. Eckel is also a past American Heart Association president.
The overall dietary pattern should include less sodium, the guideline says. For people who need to lower their blood pressure, the guideline recommends an initial step-down approach to no more than 2,400 milligrams of sodium a day. Currently, the average American adult consumes about 3,600 milligrams daily.
Americans can lower blood pressure even further by getting sodium down to 1,500 mg a day. Cutting out processed foods high in sodium may be necessary to stay below that threshold. “We all eat too much sodium, and this guideline provides further evidence that we’d all do well to eat less of it,” Eckel said.