What is primary Cardiovascular (CV) prevention?

What is Primary Cardiovascular Prevention?

Primary cardiovascular (CV) prevention refers to interventions designed to modify adverse levels of risk factors once present with the goal of preventing an initial cardiovascular disease event in individuals who do not yet have established CVD. 1

Distinction from Other Prevention Levels

Primary prevention targets individuals who already have developed cardiovascular risk factors (such as hypertension, dyslipidemia, diabetes, or smoking) but have not yet experienced a cardiovascular event like myocardial infarction or stroke. 1 This distinguishes it from:

• Primordial prevention: Prevention of the development of risk factors in the first place, starting early in life before risk factors emerge 1, 2
• Secondary prevention: Treatment of patients with established cardiovascular disease to prevent recurrent events 1

Target Population

Primary prevention applies to adults aged 40-75 years who have one or more cardiovascular risk factors including dyslipidemia, diabetes mellitus, hypertension, or smoking, but no history of clinical cardiovascular disease. 1, 3

Core Components of Primary Prevention

Risk Assessment

• Calculate 10-year atherosclerotic cardiovascular disease (ASCVD) risk using validated tools like the pooled cohort equations for adults aged 40-75 years before initiating pharmacologic therapy 1, 4
• Reassess risk every 4-6 years in those not receiving statin therapy 4
• Patients with LDL-C ≥190 mg/dL or clinical ASCVD automatically qualify for treatment without requiring risk calculation 4

Lifestyle Interventions

Primary prevention emphasizes non-pharmacological approaches as the foundation: 1

• Dietary modification: Emphasize vegetables, fruits, nuts, whole grains, lean protein, and fish while minimizing trans fats, processed meats, refined carbohydrates, and sweetened beverages; the DASH diet shows the most effectiveness on multiple CVD risk factors 1, 4
• Physical activity: Engage in at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity physical activity 4
• Weight management: Counsel adults with overweight and obesity to achieve weight loss through caloric restriction 4
• Smoking cessation: Complete tobacco avoidance is essential 1

Pharmacologic Interventions

Blood Pressure Control:

• Target blood pressure <130/80 mm Hg for most patients requiring pharmacologic therapy 4
• Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension 4

Lipid Management:

• Moderate-intensity statin therapy is recommended for primary prevention in patients with diabetes aged 40-75 years 4
• For adults aged 40-75 years with one or more CVD risk factors and 10-year ASCVD risk ≥10%, clinicians should prescribe a statin 1, 3
• For those with 7.5% to <10% 10-year risk, selectively offer statin therapy based on shared decision-making 1, 3

Diabetes Management:

• Lifestyle changes including diet and exercise are crucial 4
• Metformin is first-line pharmacologic therapy 4
• Consider SGLT-2 inhibitor or GLP-1 receptor agonist for patients with additional ASCVD risk factors requiring glucose-lowering therapy despite metformin 4

Aspirin:

• Use aspirin infrequently in routine primary prevention due to lack of net benefit, as bleeding risk generally outweighs ASCVD risk reduction 4

Implementation Approach

Team-Based Care

A multidisciplinary team approach is recommended for controlling risk factors, including primary care physicians, cardiologists, specialist nurses, pharmacists, dieticians, physiotherapists, and social workers. 1, 5 Team-based care produces greater blood pressure reduction and risk factor control than usual care. 1, 5

Shared Decision-Making

Engage patients in collaborative discussions addressing potential for ASCVD risk reduction, adverse effects of therapy, patient preferences and values, and presence of risk-enhancing factors before initiating pharmacologic therapy. 1, 4

Social Determinants

Social determinants of health should inform optimal implementation of treatment recommendations for ASCVD prevention. 1

Evidence for Effectiveness

Combining dietary interventions with other measures such as exercise and smoking cessation increases efficacy beyond single interventions. 1 Clinical trial evidence demonstrates that pharmacological treatment of risk factors can prevent cardiovascular events, with cost-effectiveness analyses suggesting that public policy, community efforts, and pharmacological interventions are likely cost-effective compared with common benchmarks. 1

The distinction between primary and secondary prevention is somewhat arbitrary given the underlying, gradually developing atherosclerotic process that begins early in life and continues for decades. 1 However, the absolute benefit of interventions is greater in higher-risk individuals, making risk stratification essential for resource allocation. 1