ASCVD Risk Estimator*

All fields are required to compute ASCVD risk.

10-Year ASCVD Risk

 
calculated risk
%
risk with optimal risk factors**
%

Lifetime ASCVD Risk

 
calculated risk
%
risk with optimal risk factors
%
Gender
Note: 10-year risk is only calculated for the 40 to 79 year range Note: Lifetime risk is only calculated for the 20 to 59 year range Error: valid Age range is 20 to 79
Race

Note: These estimates may underestimate the 10-year and lifetime risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans).

Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Error: valid Total Cholesterol range is 130 to 320 (mg/dL)
Error: valid HDL - Cholesterol range is 20 to 100 (mg/dL)
Error: valid Systolic Blood Pressure range is 90 to 200
Treatment for Hypertension
Diabetes
Smoker
*Intended for use if there is not ASCVD and the LDL-cholesterol is <190 mg/dL
**Optimal risk factors include: Total cholesterol of 170 mg/dL, HDL-cholesterol of 50 mg/dL, Systolic BP of 110 mm Hg, Not taking medications for hypertension, Not a diabetic, Not a smoker
AHA and ACC Published jointly by ACC and AHA | © 2014
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Recommendation

Based on the data entered (assuming no clinical ASCVD and LDL-C 70-189 mg/dL):
  • Gender:
  • Age:
  • Race:
  • Total Cholesterol:
  • HDL-Cholesterol:
  • Systolic Blood Pressure:
  • Hypertension Treatment:
  • Diabetes:
  • Smoker:

Lifestyle Recommendations

AHA/ACC guidelines stress the importance of lifestyle modifications to lower cardiovascular disease risk. This includes eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products.

Disclaimer

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

AHA and ACC Published jointly by ACC and AHA | © 2014

About the Application

About the Application

This Risk Estimator is intended as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. This Risk Estimator enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and lifetime risk prediction tools. The Risk Estimator is intended for use in those without ASCVD with a LDL-cholesterol <190 mg/dL.

The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

10-Year ASCVD Risk Estimates

Estimates of 10-year risk for ASCVD are based on data from multiple community-based populations and are applicable to African-American and non-Hispanic white men and women 40 through 79 years of age.

For other ethnic groups, we recommend use of the equations for non-Hispanic whites, though these estimates may underestimate the risk for persons from some race/ethnic groups.

Lifetime ASCVD Risk Estimates

Estimates of lifetime risk for ASCVD are provided for adults 20 through 59 years of age and are shown as the lifetime risk for ASCVD for a 50-year old without ASCVD who has the risk factor values entered into the Estimator. The estimates of lifetime risk are most directly applicable to non-Hispanic whites. We recommend the use of these values for other race/ethnic groups, though as mentioned above, these estimates may represent under- and over-estimates for persons of various ethnic groups. Because the primary use of these lifetime risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Disclaimer

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

AHA and ACC Published jointly by ACC and AHA | © 2014

Application Credits

Application Credits

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

David C. Goff, MD, PhD, FACP, FAHA • Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA • Glen Bennett, MPH • Christopher J. O'Donnell, MD, MPH • Sean Coady, MS • Jennifer Robinson, MD, MPH, FAHA • Ralph B. D'Agostino,Sr, PhD, FAHA • J. Sanford Schwartz, MD • Raymond Gibbons, MD, FACC, FAHA • Susan T. Shero, MS, RN • Philip Greenland, MD, FACC, FAHA • Sidney C. Smith, MD, FACC, FAHA • Daniel T. Lackland, DrPH, FAHA • Paul Sorlie, PhD • Daniel Levy, MD • Neil J. Stone, MD, FACC, FAHA • Peter W.F. Wilson, MD, FAHA

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

Neil J. Stone, MD, MACP, FAHA, FACC • Jennifer Robinson, MD, MPH, FAHA • Alice H. Lichtenstein, DSc, FAHA • C. Noel Bairey Merz, MD, FAHA, FACC • Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA • Conrad B. Blum, MD, FAHA • Patrick McBride, MD, MPH, FAHA • Robert H. Eckel, MD, FAHA • J. Sanford Schwartz, MD • Anne C. Goldberg, MD, FACP, FAHA • Susan T. Shero, MS, RN • David Gordon, MD • Sidney C. Smith • Daniel Levy, MD • Karol Watson, MD, PhD, FACC, FAHA • Peter W.F. Wilson, MD, FAHA

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

Michael D. Jensen, MD • Donna H. Ryan, MD • Caroline M. Apovian, MD, FACP • Catherine M. Loria, PhD, FAHA • Jamy D. Ard, MD • Barbara E. Millen, DrPH, RD • Anthony G. Comuzzie, PhD • Cathy A. Nonas, MS, RD • Karen A. Donato, SM • F. Xavier Pi-Sunyer, MD, MPH • Frank B. Hu, MD, PhD, FAHA • June Stevens, PhD • Van S. Hubbard, MD, PhD • Victor J. Stevens, PhD • John M. Jakicic, PhD • Thomas A. Wadden, PhD • Robert F. Kushner, MD • Bruce M. Wolfe, MD • Susan Z. Yanovski, MD

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

Robert H. Eckel, MD, FAHA • John M. Jakicic, PhD • Jamy D. Ard, MD • Nancy Houston • Miller, RN, BSN, FAHA • Van S. Hubbard, MD, PhD • Cathy A. Nonas, MS, RD • Janet M. • de Jesus, MS, RD • Frank M. Sacks, MD, FAHA • I-Min Lee, MD, ScD • Sidney C. Smith • Alice H. Lichtenstein, DSc, FAHA • Laura P. Svetkey, MD, MHS • Catherine M. Loria, PhD, FAHA • Thomas W. Wadden, PhD • Barbara E. Millen, DrPH, RD, FADA • Susan Z. Yanovski, MD

Application Development Credits

Concepts for this application adapted from the Cardiac Risk Assist App developed by Tin T.D. Nguyen, MD.

Special Thanks to the ACC Best Practice Quality Improvement Subcommittee

Content development and review by the ACC Best Practice Quality Improvement Subcommittee:

Richard Kovacs, MD, FAHA, FACC • Mouaz H. Al-Mallah, MD, FAHA, FACC • Kimberly Birtcher, MS, PharmD, AACC • William T. Cole, CCMA • Andrew M. Freeman, MD, FACC • Ty J. Gluckman, MD, FAHA, FACC (Lead Content Developer) • Eileen Handberg, PhD, ARNP, BC, FAHA, FACC • Eva Kline-Rogers, MS, RN, NP, AACC • Andrea Russo, MD, FACC • John Windle, MD, FACC
AHA and ACC Published jointly by ACC and AHA | © 2014

Reference

Clinician References

AHA and ACC Published jointly by ACC and AHA | © 2014

Reference

Patient References

AHA and ACC Published jointly by ACC and AHA | © 2014
Reference

Statins

Groups that Benefit from Statins

1. Secondary Prevention: Clinical ASCVD

Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD, unless contraindicated. (I A)

In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated. (I A)

In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (IIa B)

2. Primary Prevention: LDL-C ≥190 mg/dL

Individuals with LDL-C ≥190 mg/dL or triglycerides ≥500 mg/dL should be evaluated for secondary causes of hyperlipidemia. (I B)

Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with high-intensity statin therapy unless contraindicated. For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. (I B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, it is reasonable to intensify statin therapy to achieve at least a 50% LDL-C reduction. (IIa B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL-C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. (IIb C)

3. Primary Prevention: Diabetes and aged 40 to 75 years with LDL-C between 70 - 189 mg/dL

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (I A)

High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated. (IIa B)

In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (IIa C)

4. Primary Prevention: No diabetes and estimated 10-year ASCVD risk of ≥7.5% who are between 40 to 75 years of age with LDL-C between 70 - 189 mg/dL

The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL-C 70 to 189 mg/dL without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD. (I B)

Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70 - 189 mg/dL without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. (IIa C)

Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. (I A)

It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%. (IIa B)

In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences. (IIb C)

Additional Factors

These factors may include:

Statin benefit may be less clear in other groups; additional factors may be considered to inform treatment decision making.

  1. 5 to <7.5% 10-year ASCVD risk
  2. Primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias
  3. Family history of premature ASCVD
  4. High sensitivity C-reactive protein ≥2 mg/L
  5. Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
  6. Ankle-brachial index <0.9
  7. Lifetime risk of ASCVD
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Clinician Reference

Recommendations for Initiation of Statin Therapy

Groups that benifit from Statins

This flow diagram is intended to serve as an easy reference guide summarizing recommendations for ASCVD risk assessment and treatment. Assessment of the potential for benefit and risk from statin therapy for ASCVD prevention provides the framework for clinical decision making incorporating patient preferences.

*Percent reduction in LDL-C can be used as an indication of response and adherence to therapy, but is not in itself a treatment goal.

†The Pooled Cohort Equations can be used to estimate 10-year ASCVD risk in individuals with and without diabetes. The estimator within this application should be used to inform decision making in primary prevention patients not on a statin.

‡Consider moderate-intensity statin as more appropriate in low-risk individuals.

§For those in whom a risk assessment is uncertain, consider factors such as primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative, hs-CRP >2 mg/L, CAC score ≥300 Agatston units, or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/CACReference.aspx), ABI <0.9, or lifetime risk of ASCVD. Additional factors that may aid in individual risk assessment may be identified in the future.

||Potential ASCVD risk-reduction benefits. The absolute reduction in ASCVD events from moderate- or high-intensity statin therapy can be approximated by multiplying the estimated 10-year ASCVD risk by the anticipated relative risk reduction from the intensity of statin initiated (~30% for moderate-intensity statin or ~45% for high-intensity statin therapy). The net ASCVD risk reduction benefit is estimated from the number of potential ASCVD events prevented with a statin compared to the number of potential excess adverse events.

¶Potential adverse effects. The excess risk of diabetes is the main consideration in ~0.1 excess cases per 100 individuals treated with a moderate-intensity statin for 1 year and ~0.3 excess cases per 100 individuals treated with a high-intensity statin for 1 year. In RCTs, both statin-treated and placebo-treated participants experienced the same rate of muscle symptoms. The actual rate of statin-related muscle symptoms in the clinical population is unclear. Muscle symptoms attributed to statin therapy should be evaluated (see Statin Safety Recommendations).

ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial.

AHA and ACC Published jointly by ACC and AHA | © 2014
References

Clinician Reference

Recommendations to Monitor Response to Statin Therapy

Groups that benifit from Statins

*Fasting lipid panel preferred. In a nonfasting individual, a non-HDL–C >220 mg/dL may indicate genetic hypercholesterolemia that requires further evaluation or a secondary etiology. If nonfasting triglycerides are >500 mg/dL, a fasting lipid panel is required.

†In those already on a statin, in whom baseline LDL–C is unknown, an LDL–C <100 mg/dL was observed in mostindividuals receiving high-intensity statin therapy in RCT.s

‡Refer to Statin Safety Recommendations

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References

Clinician Reference

Summary of Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults

Recommendations Click here for Definitions of Statin Intensity ACC/AHA COR ACC/AHA LOE
A. Heart-healthy lifestyle habits should be encouraged for all individuals.
B. The appropriate intensity of statin therapy should be initiated or continued:
1. Clinical ASCVD*
a. Age ≤75 y and no safety concerns: High-intensity statin I A
b. Age >75 y or safety concerns: Moderate-intensity statin I A
2. Primary prevention – Primary LDL-C ≥190 mg/dL
a. Rule out secondary causes of hyperlipidemia
b. Age ≥21y: High-intensity statin I B
c. Achieve at least a 50% reduction in LDL-C IIa B
d. LDL-C lowering nonstatin therapy may be considered to further reduce LDL-C IIb C
3. Primary prevention - Diabetes 40-75 years of age and LDL-C 70-189 mg/dL
a. Moderate-intensity statin I A
b. Consider high-intensity statin when ≥7.5% 10-y ASCVD risk using the Pooled Cohort Equations† IIa B
4. Primary prevention – No diabetes 40-75 years of age and LDL-C 70-189 mg/dL
a. Estimate 10-y ASCVD risk using the Risk Calculator based on the Pooled Cohort Equations† in those NOT receiving a statin; estimate risk every 4-6 y I B
b. To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug–drug interactions, and patient preferences. IIa C
c. Re-emphasize heart-healthy lifestyle habits and address other risk factors.
i. ≥7.5% 10-y ASCVD risk: Moderate- or high-intensity statin I A
ii. 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin IIa B
iii. Other factors may be considered‡: LDL-C ≥160 mg/dL, family history of premature cardiovascular disease, hs-CRP ≥2.0 mg/L, CAC score ≥300 Agaston units, ABI <0.9 or lifetime ASCVD risk IIb C
5. Primary prevention when LDL-C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk
a. Statin therapy may be considered in selected individuals‡ IIb C
6. Statin therapy is not routinely recommended for individuals with NYHA class II-IV heart failure or who are receiving maintenance hemodialysis
C. Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments.
Assess adherence, response to therapy, and adverse effects within 4-12 wk following statin initiation or change in therapy. I A
a. Measure a fasting lipid panel I A
b. Do not routinely monitor ALT or CK unless symptomatic IIa C
c. Screen and treat type 2 diabetes according to current practice guidelines. Heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes I B
d. Anticipated therapeutic response approximately ≥50% reduction in LDL-C from baseline for high-intensity statin and 30% to <50% for moderate-intensity statin IIa B
i. Insufficient evidence for LDL-C or non–HDL-C treatment targets from RCTs
ii. For those with unknown baseline LDL-C, an LDL-C <100 mg/dL was observed in RCTs of high-intensity statin therapy
e. Less than anticipated therapeutic response:
i. Reinforce improved adherence to lifestyle and drug therapy I A
ii. Evaluate for secondary causes of hyperlipidemia if indicated I A
iii. Increase statin intensity, or if on maximally-tolerated statin intensity, consider addition of nonstatin therapy in selected high-risk individuals§ IIb C
f. Regularly monitor adherence to lifestyle and drug therapy every 3-12 mo once adherence has been established. Continued assessment of adherence for optimal ASCVD risk reduction and safety. I A
D. In individuals intolerant of the recommended intensity of statin therapy, use the maximally-tolerated intensity of statin. I B
1. If there are muscle or other symptoms, establish that they are related to the statin IIa B
2. For specific recommendations on managing muscle symptoms (see Statin Safety Recommendations)

*Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

†Estimated 10-year or “hard” ASCVD risk includes first occurrence of nonfatal MI, CHD death, and nonfatal and fatal stroke as used by the Risk Assessment Work Group in developing the Pooled Cohort Equations.

‡These factors may include primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative; hs-CRP ≥2 mg/L; CAC score ≥300 Agatston units or ≥75 th percentile for age, sex, and ethnicity; ABI <0.9; or lifetime risk of ASCVD. Additional factors that might aid in individual risk assessment could be identified in the future.

§High-risk individuals include those with clinical ASCVD, an untreated LDL-C ≥190 mg/dL suggesting genetic hypercholesterolemia, or diabetes.

ABI indicates ankle-brachial index; ACC, American College of Cardiology; AHA, American Heart Association; ALT, alanine aminotransferase, a test of hepatic function; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CHD, coronary heart disease; CK, creatine kinase, a test of muscle injury; COR, Class of Recommendation; HDL-C, high-density lipoprotein cholesterol; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LOE, Level of Evidence; NHLBI, National Heart, Lung, and Blood Institute; NYHA, New York Heart Association; RCTs, randomized controlled trials; and TIA, transient ischemic attack.
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Clinician Reference

Statin Safety Recommendations

Statin Selection

To maximize the safety of statins, selection of the appropriate statin and dose in men and nonpregnant/nonnursing women should be based on patient characteristics, level of ASCVD risk, and potential for adverse effects.

Moderate-intensity statin therapy should be used in individuals in whom high-intensity statin therapy would otherwise be recommended when characteristics predisposing them to statin associated adverse effects are present.

Characteristics predisposing individuals to statin adverse effects include, but are not limited to: (I B)

  • Multiple or serious comorbidities, including impaired renal or hepatic function.
  • History of previous statin intolerance or muscle disorders.
  • Unexplained ALT elevations >3 times ULN.
  • Patient characteristics or concomitant use of drugs affecting statin metabolism.
  • >75 years of age.

Additional characteristics that may modify the decision to use higher statin intensities may include, but are not limited to:

  • History of hemorrhagic stroke.
  • Asian ancestry.

Statin Dosage

  • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL. (IIb C)
  • It may be harmful to initiate simvastatin at 80 mg daily or increase the dose of simvastatin to 80 mg daily. (III A)

Creatine Kinase (CK)

  • CK should not be routinely measured in individuals receiving statin therapy. (III A)
  • Baseline measurement of CK is reasonable for individuals believed to be at increased risk for adverse muscle events based on a personal or family history of statin intolerance or muscle disease, clinical presentation, or concomitant drug therapy that might increase the risk for myopathy. (IIa C)
  • During statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue. (II C)

Muscle Symptoms

It is reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin-treated patients according to the following management algorithm: (IIa B)

  • To avoid unnecessary discontinuation of statins, obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy.
  • If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine, and a urinalysis for myoglobinuria.
  • If mild to moderate muscle symptoms develop during statin therapy:
    • Discontinue the statin until the symptoms can be evaluated.
    • Evaluate the patient for other conditions that might increase the risk for muscle symptoms (e.g., hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases).
    • If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy.
    • If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin.
    • Once a low dose of a statin is tolerated, gradually increase the dose as tolerated.
    • If, after 2 months without statin treatment, muscle symptoms or elevated CK levels do not resolve completely, consider other causes of muscle symptoms listed above.
    • If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose.

Hepatic Function

  • Baseline measurement of hepatic transaminase levels (ALT) should be performed before initiating statin therapy. (I B)
  • During statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise (e.g., unusual fatigue or weakness, loss of appetite, abdominal pain, dark colored urine or yellowing of the skin or sclera). (IIa C)

Diabetes

Individuals receiving statin therapy should be evaluated for new-onset diabetes mellitus according to the current diabetes screening guidelines. Those who develop diabetes mellitus during statin therapy should be encouraged to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events. (I B)

Age and Drug Regimen Consideration

For individuals taking any dose of statins, it is reasonable to use caution in individuals >75 years of age, as well as in individuals that are taking concomitant medications that alter drug metabolism, taking multiple drugs, or taking drugs for conditions that require complex medication regimens (e.g., those who have undergone solid organ transplantation or are receiving treatment for HIV). A review of the manufacturer's prescribing information may be useful before initiating any cholesterol-lowering drug. (IIa C)

Cognitive Impairment

For individuals presenting with a confusional state or memory impairment while on statin therapy, it may be reasonable to evaluate the patient for nonstatin causes, such as exposure to other drugs, as well as for systemic and neuropsychiatric causes, in addition to the possibility of adverse effects associated with statin drug therapy. (IIb C)

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References

Clinician Reference

Intensities of Statin Therapy

High-Intensity Statin

Daily dose lowers LDL-C, on average by approximately ≥50%

  • Atorvastatin 40*-80 mg
  • Rosuvastatin 20-(40) mg

Moderate-Intensity Statin

Daily dose lowers LDL-C, on average by approximately 30% to <50%

  • Atorvastatin 10-(20) mg
  • Fluvastatin 40 mg bid
  • Fluvastatin XL 80 mg
  • Lovastatin 40 mg
  • Pitavastatin 2-4 mg
  • Pravastatin 40-(80) mg
  • Rosuvastatin (5)-10 mg
  • Simvastatin 20-40 mg**

Low-Intensity Statin

Daily dose lowers LDL-C, on average by approximately <30%

  • Fluvastatin 20-40 mg
  • Lovastatin 20 mg
  • Simvastatin 10 mg
  • Pitavastatin 1 mg
  • Pravastatin 10-20 mg

Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in parentheses

*Evidence from 1 RCT (down-titration if unable to tolerate atorvastatin 80 mg)

**Initiation of or titration to simvastatin 80 mg is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis
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References

Clinician Reference

Links to Guidelines and More Information


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References

Clinician Reference

Understanding Cardiovascular Risk

10-Year ASCVD Risk

  • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples.
  • The 10-year risk estimate for "optimal risk factors" is represented by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of 170 mg/dL, HDL-cholesterol of 50 mg/dL, untreated systolic blood pressure of 110 mm Hg, no diabetes history, and not a current smoker.
  • While the risk estimate is applied to individuals, it is based on group averages.
  • Just because two individuals have the same estimated risk does not mean that they will or will not have the same event of interest.
  • Example: If the 10-year ASCVD risk estimate is 10%, this indicates that among 100 patients with the entered risk factor profile, 10 would be expected to have a heart attack or stroke in the next 10 years.

Lifetime ASCVD Risk

  • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile.
  • This estimation of risk is based on the grouping of risk factor levels into 5 strata.
    • All risk factors are optimal*
    • ≥1 risk factors are not optimal†
    • ≥1 risk factors are elevated‡
    • 1 major risk factor§
    • ≥2 major risk factors§
  • The division of lifetime risk by these 5 strata leads to thresholds in the data with large apparent changes in lifetime risk estimates.
  • Example: An individual that has all optimal risk factors except for a systolic blood pressure of 119 mm Hg has a lifetime ASCVD risk of 5%. In contrast, a similar individual that has all optimal risk factors except for a systolic blood pressure of 120 mm Hg has a lifetime ASCVD risk of 36%. This substantial difference in lifetime risk is due to the fact that they are in different stratum.
*Optimal risk levels for lifetime risk are represented by the simultaneous presence of all of the following: Untreated total cholesterol <180 mg/dL, untreated blood pressure <120/<80 mm Hg, no diabetes history, and not a current smoker

†Nonoptimal risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 180 to 199 mg/dL, untreated systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg, and no diabetes history and not a current smoker

‡Elevated risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 200 to 239 mg/dL, untreated systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg, and no diabetes history and not a current smoker

§Major risk levels for lifetime risk are represented by any of the following: Total cholesterol ≥240 mg/dL or treated, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg or treated, or diabetes, or current smoker
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Clinician Reference

Lifestyle Recommendations

Diet recommendations

Diet recommendations for LDL-C lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. (I A)
  3. Reduce percent of calories from saturated fat. (I A)
  4. Reduce percent of calories from trans fat. (I A)

Diet recommendations for blood pressure lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Lower sodium intake. (I A)
  3. Consume no more than 2400 mg of sodium per day. (I B)

Weight management recommendations

Diets for weight loss

  1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention with 1 of the following (I A):
    • 1200-1500 kcal/day for women and 1500-1800 kcal/day for men.
    • 500-750 kcal/day energy deficit.
    • Use one of the evidence-based diets that restricts certain food types (e.g., high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
  2. Prescribe a calorie-restricted diet for obese or overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional for counseling. (I A)

Lifestyle interventions and counseling for weight loss

  1. Advise participation in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and increasing physical activity through the use of behavioral strategies. (I A)
  2. Prescribe on site, high-intensity (i.e., >14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. (I A)
  3. Consider prescription of electronically delivered weight loss programs (including by telephone) that includes personalized feedback from a trained interventionist, recognizing that it may result in smaller weight loss than face-to-face interventions. (IIa A)
  4. Consider some commercial-based programs that provide comprehensive lifestyle interventions, provided there is peer-reviewed published evidence of their safety and efficacy. (IIa A)
  5. Consider a very low calorie diet (<800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. (IIa A)
  6. Advise individuals who have lost weight to participate long term (>1 year) in a comprehensive weight loss maintenance program. (I A)
  7. Prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (> monthly) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (> weekly), and consume a reduced-calorie diet (need to lower body weight). (I A)

Selection criteria for bariatric surgical treatment of obesity

  1. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related co-morbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. (IIa A)

Physical activity recommendations

Physical activity recommendations for modifying lipids and blood pressure lowering

  1. Advise adults to engage in aerobic physical activity to reduce LDL-cholesterol, non-HDL-cholesterol, and blood pressure. (IIa A)
    • Frequency: 3-4 sessions a week
    • Intensity: Moderate to vigorous
    • Duration: 40 minutes on average

Physical activity recommendations for secondary prevention*

  1. Aerobic exercise
    • Frequency: 3-5 days/week
    • Intensity: 50-80% of exercise capacity
    • Duration: 20-60 minutes
    • Modalities: Examples include walking, treadmill, cycling, rowing, stair climbing, and arm/leg ergometry
  2. Resistance exercise
    • Frequency: 2-3 days/week
    • Intensity: 10-15 repetitions/set to moderate fatigue
    • Duration: 1-3 sets of 8-10 upper and lower body exercises
    • Modalities: Examples include calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, and weight machines
*Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a Scientific Statement of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682

Tobacco cessation recommendations

5 R's for patients not ready to quit

  1. Relevance—Encourage the patient to indicate why quitting is personally relevant.
  2. Risks—Ask the patient to identify potential negative consequences of tobacco use.
  3. Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
  4. Roadblocks—Ask the patient to identify barriers or impediments to quitting.
  5. Repetition—The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

5 A's for patients that are ready to quit

  1. Ask—Systematically identify all tobacco users at every visit.
  2. Advise—Strongly urge all smokers to quit.
  3. Assess—Identify smokers willing to make a quit attempt.
  4. Assist—Aid the patient in quitting.
  5. Arrange—Schedule follow-up contact.
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Understanding My Cardiovascular Risk

The "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" provides clear recommendations for estimating cardiovascular disease risk. Risk assessments are extremely useful when it comes to reducing risk for cardiovascular disease because they help determine whether a patient is at high risk for cardiovascular disease, and if so, what can be done to address any cardiovascular risk factors a patient may have. Here are the highlights of the guideline:

  • Risk assessments are used to determine the likelihood of a patient developing cardiovascular disease, heart attack or stroke in the future. In general, patients at higher risk for cardiovascular disease require more intensive treatment to help prevent the development of cardiovascular disease.

  • Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. Typically, these factors are used to estimate a patient's risk of developing cardiovascular disease in the next 10 years. For example, someone who is young with no risk factors for cardiovascular disease would have a very low 10-year risk for developing cardiovascular disease. However, someone who is older with risk factors like diabetes and high blood pressure will have a much higher risk of developing cardiovascular disease in the next 10 years.

  • If a preventive treatment plan is unclear based on the calculation of risk outlined above, care providers should take into account other factors such as family history and level of C-reactive protein. Taking this additional information into account should help inform a treatment plan to reduce a patient's 10-year risk of developing cardiovascular disease.

  • Calculating the 10-year risk for cardiovascular disease using traditional risk factors is recommended every 4-6 years in patients 20-79 years old who are free from cardiovascular disease. However, conducting a more detailed 10-year risk assessment every 4-6 years is reasonable in adults ages 40-79 who are free of cardiovascular disease. Assessing a patient's 30-year risk of developing cardiovascular disease can also be useful for patients 20-59 years of age who are free of cardiovascular disease and are not at high short-term risk for cardiovascular disease.

  • Risk estimations vary drastically by gender and race. Patients with the same traditional risk factors for cardiovascular disease such as high blood pressure can have a different 10-year risk for cardiovascular disease as a result of their sex and race.

  • After care providers and patients work together to conduct a risk assessment, it's important that they discuss the implications of their findings. Together, patients and their care providers should weigh the risks and benefits of various treatments and lifestyle changes to help reduce the risk of developing cardiovascular disease.

Source: www.cardiosmart.org
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Blood Cholesterol Management Recommendations

The American College of Cardiology (ACC) and the American Heart Association (AHA) recently developed new standards for treating blood cholesterol. These recommendations are based on a thorough and careful review of the very latest, highest quality clinical trial research. They help care providers deliver the best care possible. This page provides some of the highlights from the new practice guidelines. The ultimate goal of the new cholesterol practice guidelines is to reduce a person's risk of heart attack, stroke and death. For this reason, the focus is not just on measuring and treating cholesterol, but identifying whether someone already has or is at risk for atherosclerotic cardiovascular disease (ASCVD) and could benefit from treatment.

What is ASCVD?

Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

These practice guidelines outline the most effective treatments that lower blood cholesterol in those individuals most likely to benefit. Most importantly, they were selected as the best strategies to lower cholesterol to help reduce future heart attack or stroke risk. Share this information with your health care provider so that you can ask questions and work together to decide what is right for you.

Key Points

Based on the most up-to-date and complete look at available clinical trial results:

  • Health care providers should focus on identifying those people who are most likely to have a heart attack or stroke and make sure they are given effective treatment to reduce their risk.

  • Cholesterol should be considered along with other factors known to make a heart attack or stroke more likely.

  • Knowing your risk of heart attack and stroke can help you and your health care provider decide whether you may need to take a medication—most likely a statin—to lower that risk.

  • If a medication is needed, statins are recommended as the first choice to lower heart attack and stroke risk among certain higher-risk patients based on an overwhelming amount of evidence. For those unable to take a statin, there are other cholesterol-lowering drugs; however, there is less research to support their use.

Evaluating Your Risk

Your health care provider will first want to assess your risk of ASCVD (assuming you don't already have it). This information will help determine if you are at high enough risk of a heart attack or stroke to need treatment.

To do this, your care provider will 1) review your medical history and 2) gauge your overall risk for heart attack or stroke. He/she will likely want to know:

  • whether you have had a heart attack, stroke or blockages in the arteries of your heart, neck, or legs.

  • your risk factors. In addition to your total cholesterol, LDL cholesterol, and HDL (so-called "good") cholesterol, your health care provider will consider your age, if you have diabetes, and whether you smoke and/or have high blood pressure.

  • about your lifestyle habits, other medical conditions, any previous drug treatments, and if anyone in your family has high cholesterol or suffered a heart attack or stroke at an early age.

A lipid or blood cholesterol panel will be needed as part of this evaluation. This blood test measures the amount of fatty substances (called lipids) in your blood. You may have to fast (not eat for a period of time) before having your blood drawn.

If there is any question about your risk of ASCVD, or whether you might benefit from drug therapy, your care provider may make additional assessments or order additional tests. The results of these tests can help you and your health care team decide what might be the best treatment for you. These tests may include:

  • Lifetime risk estimates—how likely you are to have a heart attack and stroke during your lifetime

  • Coronary artery calcium (CAC) score—a test that shows the presence of plaque or fatty build-up in the heart artery walls

  • High-sensitivity C-Reactive Protein (CRP)—a blood test that measures the amount of CRP, a marker of inflammation or irritation in the body; higher levels have been associated with heart attack and stroke

  • Ankle-brachial index (ABI)—the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD)

If you have very high levels of low-density lipoprotein (LDL or "bad") cholesterol, your care provider may want to find out if you have a genetic or familial form of hypercholesterolemia. This condition can be passed on in families.

Your Treatment Plan

Before coming up with a specific treatment plan, your care provider will talk with you about options for lowering your blood cholesterol and reducing your personal risk of atherosclerotic disease. This will likely include a discussion about heart-healthy living and whether you might benefit from a cholesterol-lowering medication.

Heart-Healthy Lifestyle

Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest:

  • Eating a diet rich in vegetables, fruits, and whole grains; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats.

  • Getting regular exercise; check with your health care provider about how often and how much is right for you.

  • Maintaining a healthy weight.

  • Not smoking or getting help quitting.

  • Staying on top of your health, risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

Medications

There are two types of cholesterol-lowering medications: statins and non-statins.

Statin Therapy

There is a large body of evidence that shows the use of a statin provides the greatest benefit and fewest safety issues. In particular, specific groups of patients appear to benefit most from taking moderate or high-intensity statin therapy. Based on this information, your care provider will likely recommend a statin if you have:

  • ASCVD

  • Very high LDL cholesterol (190 mg/dL or higher)

  • Type 2 diabetes and are between 40 and 75 years of age

  • Above a certain likelihood of having a heart attack or stroke in the next 10 years (7.5% or higher) and are between 40 and 75 years of age

In certain cases, your care provider may still recommend a statin even if you don't fit into one of the groups above. He/she will consider your overall health and other factors to help decide if you are at enough risk to benefit from a statin. Based on the guidelines, these may include:

  • Family history of premature heart attack or stroke

  • Your lifetime risk of ASCVD

  • LDL-cholesterol ≥160 mg/dL

  • hs-CRP ≥2 mg/L

  • Results from other special testing (CAC scoring, ABI)

If you are on a statin, your care provider will need to find the dose that is right for you.

  • People who have had a heart attack, stroke or other types of ASCVD tend to benefit the most from taking the highest amount (dose) of statin therapy if they tolerate it. This may be more appropriate than taking multiple drugs to lower cholesterol.

  • A more moderate dose of statin may be appropriate for some people with ASCVD, such as those over 75 years or those that might have problems taking the highest dose of a statin (i.e., those with prior organ transplantation).

Sometimes more than one statin needs to be tried before finding the one that works best.

If you are 75 years or older and have not already had a heart attack, stroke or other types of ASCVD, your care provider will discuss whether a statin is right for you.

Other cholesterol-lowering medications

Not all patients will be able to take the optimum dose of statin. After attention to lifestyle changes and statin therapy, non-statin drugs may be considered if you have high-risk with known ASCVD, diabetes, or very high LDL cholesterol values (≥190 mg/dL) and:

  • Have side effects from statins that prevent you from getting to the optimal dose or are not able to take a statin at all.

  • Are limited from taking an optimal dose due to other drugs that you are taking, including:

    • Transplant drug regimens to prevent rejection

    • Multiple drugs to treat HIV

    • Some antibiotics like erythromycin and clarithromycin or certain oral anti-fungal drugs

As always, it's important to talk with your health care provider about which medication is right for you.

What About Having Goals of Treatment?

Although keeping LDL-cholesterol lower with an optimal dose of statin is supported strongly by clinical trials, getting to a specific goal level is not.

Staying on Top of Your Risk

  • Take steps to lower your risk factors for heart attack, stroke and other problems—Make healthy choices (eating a healthy diet, getting exercise, maintaining a healthy weight and not smoking). Drug therapy, if needed, can help control risk factors.

  • Report side effects—Muscle aches are commonly reported and may or may not be due to the statin. If you are having problems, your care provider needs to know to help manage any side effects and possibly switch you to a different statin.

  • Take your medications as directed.

  • Get blood cholesterol and other tests that are recommended by your health care team. These can help assess whether statin therapy—and the dose—is working for you.

Questions to Ask

  • What are my risk factors for heart attack and stroke? Am I on the best prevention program to minimize this risk?

  • Is my cholesterol high enough that it might be due to a genetic condition?

  • What lifestyle changes can I make to stay healthy and prevent problems?

  • Do I need to be on a statin?

  • How do I monitor how I am doing?

  • What should I do if I develop muscle aches or weakness after starting the statin?

  • What do I do if I have other symptoms after starting the statin?

Source: www.cardiosmart.org
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Weight Management Recommendations

The "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults" was created to reflect the latest research to outline best practices when it comes to treating obesity--a condition that affects more than one-third of American adults. These guidelines help address questions like "What's the best way to lose weight?" and "When is bariatric surgery appropriate?". Here is what every patient should know about the treatment of overweight and obesity:

  • Definition of obesity: Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one's health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

  • Benefits of weight loss: Obesity increases the risk for serious conditions such as cardiovascular disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3-5% of body weight can improve blood pressure and cholesterol levels and reduce the risk for cardiovascular disease and diabetes. Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits.

  • Weight loss strategies: There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

  • Bariatric Surgery: Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI ≥40) or in patients that have a BMI ≥35 in addition to a chronic health condition.

Source: www.cardiosmart.org
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Diet and Physical Activity Recommendations

The "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk" provides recommendations for heart-healthy lifestyle choices based on the latest research and evidence. The guidelines focus on two important lifestyle choices--diet and physical activity--which can have a drastic impact on cardiovascular health. Here's what every patient should know about the latest recommendations for reducing cardiovascular disease risk through diet and exercise.

Diet

  • Diet is a vital tool for lowering cholesterol and blood pressure levels, which are two major risk factors for cardiovascular disease.
  • Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats.
  • There are many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate.
  • Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat.
  • Patients with high blood pressure should consume no more than 2,400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. However, even reducing sodium intake in one's current diet by 1,000 mg each day can help lower blood pressure.
  • It's important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Doing so helps create healthy eating patterns that are realistic and sustainable.

Physical Activity

  • Regular physical activity helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease.
  • In general, adults should engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes.
  • Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.
Source: www.cardiosmart.org
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Groups that Benefit from Statin Therapy Infographic

Groups that benifit from Statins
AHA and ACC Published jointly by ACC and AHA | © 2014
References

Patient Reference

Common Cardiovascular Terms

Alphabetical Glossary

  • Ankle-Brachial Index (ABI)

    The ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD).

  • ASCVD

    Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

  • C-reactive Protein

    C-reactive protein (CRP) measures general levels of inflammation in your body. High levels of CRP are caused by infections and many long-term diseases. A CRP test, however, cannot show where the inflammation is located or what is causing it.

  • Cholesterol

    Cholesterol is a waxy, fat-like substance that travels through the blood. In and of itself, cholesterol isn't bad. It actually helps create the outer coating of our cells and aids the body in making vitamin D and certain hormones.

  • Coronary Artery Calcium (CAC) Score

    A test that shows the presence of plaque or fatty build-up in the heart artery walls.

  • Coronary Artery Disease

    It happens when your coronary arteries--which act like fuel lines to supply blood to the heart--become damaged or diseased. There is a build-up of fat and cholesterol in the blood that sticks to the inner walls of the arteries (this is also called atherosclerosis). As this happens, the arteries can narrow or become blocked. Keep in mind, coronary artery disease typically develops over decades; so many people don't even know they have it until it starts causing problems.

  • Diabetes

    When you have type 2 diabetes, your body does not use or make insulin the way it should. As a result, the amount of sugar (glucose) in your blood becomes too high. Over time, high blood glucose levels can start to damage the blood vessels in the heart, eyes, kidneys, brain, and other parts of your body.

  • HDL

    HDL (high-density lipoprotein) cholesterol is sometimes referred to as "good" cholesterol, because it helps move cholesterol out of the body. HDL does this by binding with cholesterol in the bloodstream and carrying it back to the liver for disposal. Higher HDL levels help to lower the risk of cardiovascular disease.

  • Heart Attack

    Your heart muscle needs oxygen and nutrients to work as it should. A heart attack (your care provider may call it a myocardial infarction) usually occurs when blood flow to the heart is suddenly cut off. When this happens, the heart muscle is starved of oxygen-rich blood. In just a short period of time, part of the heart can be damaged or die. That's why immediate care is critical--it can spare your heart and save your life. If you think you are having a heart attack, dial 9-1-1 immediately.

  • High Blood Pressure

    Blood pressure is the force of blood moving against the walls of your arteries. Over time, elevated blood pressure can weaken your heart, blood vessels, kidneys and other parts of your body.

  • LDL

    LDL (low-density lipoprotein) cholesterol is sometimes referred to as "bad" cholesterol. LDL carries mostly fat and only a small amount of protein from the liver to other parts of the body. A higher LDL level is considered a risk factor for coronary artery disease (CAD) because, under certain conditions, it can cause hardening of the arteries (atherosclerosis).

  • Metabolic Syndrome

    Metabolic syndrome is the combination of high blood pressure, high blood sugar, excess fat around the waist, low HDL ("good") cholesterol, and high triglycerides. Metabolic syndrome is closely linked to insulin resistance, in which the body cannot use insulin properly. Metabolic syndrome increases your risk for cardiovascular disease, diabetes, and stroke. Weight loss and increased physical activity can help to reduce the risk for metabolic syndrome.

  • Peripheral Artery Disease (PAD)

    Peripheral artery disease (PAD) is a narrowing or blockage of arteries that causes poor blood flow to your legs or arms. When you walk or exercise, your leg muscles don't get enough blood and you can get painful cramps.

  • Statin

    Statins are a type of medicine commonly used to treat high cholesterol. Statins block an enzyme the body needs to produce cholesterol, thereby lowering the total amount of it in the blood.

  • Stroke

    Your brain is the master control center for your body. It directs most of what you do--speedily orchestrating your movements, emotions and ability to think, talk and learn. To do this, your brain needs a steady supply of oxygen and nutrient-rich blood. That's why if you suffer a stroke--when blood flow to the brain is cut off--brain cells can die very quickly. Stroke is a leading cause of death and disability in adults. According to the American Stroke Association, a stroke occurs every 40 seconds in the United States.

  • Triglycerides

    Triglycerides are a type of fat found in your blood. Your body uses them for energy. Some triglycerides are needed for good health. However, high triglycerides may raise your risk of cardiovascular disease and may be a sign of metabolic syndrome.

For additional cardiovascular terms visit www.cardiosmart.org
AHA and ACC Published jointly by ACC and AHA | © 2014