1. Preventative Cardiology
with focus on the role of aspirin and statins in the prevention of cardiovascular events
Paul L. Phillips, M.D.

2. Every medicine is a double edged sword.
An once of prevention is worth a pound of cure.
Every medicine is a double edged sword.

3. The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease was simultaneously published in the
 Journal of the American College of Cardiology and Circulation.

4. Despite the substantial progress in the past few decades atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality throughout the world and in the United States
ASCVD is estimated to cost $2 billion dollars in medical services annually in the United States

5. More than 80% of all cardiovascular events are preventable through lifestyle changes
The most important way to prevent ASCVD is to promote a healthier lifestyle
Healthy diet (Mediterranean)
Weight loss (BMI less than 25)
Exercise - Moderate 150 min per week or High Intensity 75 min per week
Smoking cessation

6. The assessment of ASCVD risk remains the foundation of primary prevention
Adults 40 to 75 being evaluated for prevention should have a 10-year risk assessment before beginning aspirin or statin therapy
Adults 20 to 40 should have a risk assessment about every 5 years

7. Cardiovascular Risk Calculator
Estimating the chance of experiencing an event over a 10-year period
<5% Low Risk
5-7.4% Borderline Risk
% Intermediate Risk
> 20% High Risk

8. Cardiovascular Risk Calculator
Age
Gender
Race
Blood pressure
Total cholesterol
HDL
LDL
History of diabetes
Smoking history
Current treatment (blood pressure, statin, aspirin)

9. Cardiovascular Risk Calculator
White male, age 50
Blood pressure 120/80
Cholesterol 250 (HDL 60/LDL 160)
No diabetes
Never smoked
No current treatment
ASCVD 10-year risk estimated to be 3.5%
Treatment
Lifestyle changes appropriate
No pharmacologic therapy indicated
Calcium Score?
Example 1

10. Cardiovascular Risk Calculator
Example 2
White male, age 60
Blood pressure 150/90
Cholesterol 250 (HDL 45/LDL 160)
No diabetes
Stopped smoking 5 years ago
No current treatment
ASCVD 10-year risk estimated to be 15%
Treatment
Antihypertensive therapy
Statin therapy
Aspirin

11. Cardiovascular Risk Calculator
Underestimation factors
Family history of premature ASCVD
Chronic inflammatory stage
Chronic kidney disease
Preeclampsia/early menopause
Metabolic syndrome
Erectile dysfunction

12. Age is a major driver of risk
Little data to support pharmacologic therapy of cholesterol in patients less than 40 years of age other than those with familial Hypercholesterolemia

13. Calcium Score (Agatson score)
Estimate of plaque burden
Zero is the ideal number
Greater than 100 or greater than the 75th percentile for age/sex can be used to initiate statin therapy in the appropriate patients

14. Calcium Score Strongly associated with ASCVD risk
Independent of traditional risk factors
The presence and severity of coronary artery calcium has been shown to predict benefit from statin therapy
Calcium score particularly useful in patients with borderline or intermediate risk to help guide therapy

15. Radiol bras 2017 May-Jun;
50(3): 182–189.

22. Statin Therapy
LDL greater than 190 is an indication to begin statin therapy
Diabetes mellitus in patients ages 40 to 70
Those of "sufficient" ASCVD risk after clinician-Patient discussion
PCSK9 medications
Familial hypercholesterolemia

23. Statin Therapy Benefit
Each 40 mg decrease in LDL translates to a 25% decrease in cardiovascular risk annually
Statin side effects
Myalgias
Diabetes

24. Aspirin Role in secondary ASCVD prevention is secure
Role in primary prevention is controversial

25. Aspirin Bleeding Risk Limits the Use in Prevention
Avoid: Age less than 40 or greater than 70
History of bleeding
Use in patients with greater than 10% cardiovascular risk
Aspirin should be used infrequently in the primary prevention of ASCVD.

26. Preventative Cardiology
with focus on the role of aspirin and statins in the prevention of cardiovascular events
Paul L. Phillips, M.D.