Cardiovascular Disease Prevention Management

Last updated: 07 July 2025

Content on this page:

Evaluation

Content on this page:

Evaluation

Evaluation

Risk factor assessment for cardiovascular disease includes identifying modifiable ASCVD risk factors. 

CARDIOVASCULAR DISEASE RISK CATEGORIES
Risk Category ACC/AHA 2019   CCS 2021 ESC 2021
 10-Year ASCVD Risk1  FRS2 Apparently Healthy Individuals3   Patients with Risk Factors  
Very High Risk Not applicable Not applicable • <50 years: ≥7.5%
• 50-69 years: ≥10%
• ≥70 years: ≥15%

SCORE2-Diabetes: ≥20%4		 • Documented clinical ASCVD (eg previous acute myocardial infarction, acute coronary syndrome, coronary revascularization and other arterial revascularization procedures, TIA and stroke, aortic aneurysm and PAD) or unequivocally documented ASCVD finding (eg significant plaque) on imaging that does not include some increase in continuous imaging parameters (eg intima-media thickness of the carotid artery) 
• T2DM with established ASCVD and/or severe TOD5
• Without diabetes or ASCVD but with severe CKD (eGFR <30 mL/min/1.73 m2) or eGFR 30-44 mL/min/1.73 m2 and albumin-to-creatinine ratio (ACR) >30
High Risk ≥20%  ≥20% • <50 years: 2.5-<7.5%
• 50-69 years: 5-<10%
• ≥70 years: 7.5-<15%

SCORE2-Diabetes:
10-<20%4		 • T2DM without ASCVD and/or severe TOD with moderate risk criteria not met5
• Without diabetes or ASCVD but with moderate CKD (eGFR 30-44 mL/min/1.73 m2) and ACR <30 or eGFR 45-59 mL/min/1.73 m2 and ACR 30-300 or eGFR ≥60 mL/min/1.73 m2 and ACR >300
• Familial hypercholesterolemia (FH) associated with markedly increased levels of cholesterol
Moderate Risk Not applicable Not applicable • <50 years: <2.5%
• 50-69 years: <5%
• ≥70 years: <7.5%

SCORE2-Diabetes:
5-<10%4 
 • Patients with <10 years of well-controlled T2DM without TOD or other ASCVD risk factors5
Intermediate Risk 7.5-<20%  10-19.9% Not applicable
Borderline Risk 5-<7.5%  Not applicable Not applicable
Low Risk <5%  <10% • <50 years: <2.5%
• 50-69 years: <5%
• ≥70 years: <7.5%

SCORE2-Diabetes: <5%4		  
ACC/AHA = American College of Cardiology/American Heart Association
CCS = Canadian Cardiovascular Society
ESC = European Society of Cardiology
T2DM = Type 2 Diabetes Mellitus
1ASCVD risk estimator (http://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calculate/estimator/) estimates the 10-year ASCVD risk for asymptomatic individuals 40-75 years old. 
2Based on the Framingham Risk Score (FRS) screening every 5 years for ages 40-75 years.
3Based on SCORE2 and SCORE2-Older Persons (SCORE2-OP); can be accessed in the ESC CVD Risk Calculation app (including SCORE2-Diabetes).  
SCORE2 estimates the 10-year risk of fatal and non-fatal CVD events (eg stroke, MI) in apparently healthy individuals 40-69 years old with risk factors that are not treated or have been stable for several years.   
SCORE2-OP estimates the 5- and 10-year fatal and non-fatal CVD events (eg stroke, MI) adjusted for competing risks in apparently healthy individuals ≥70 years old.  
4Based on the 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes.
5Patients >40 years old with type 1 DM may also be classified according to these criteria.
References:
  • Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019.
  • Pearson GJ, Thanassoulis G, Anderson TJ, et al. 2021 Canadian Cardiovascular Society (CCS) Guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in adults. Can J Cardiol. 2021.
  • Visseren FLJ, Mach F, Smulders YM, et al; ESC National Cardiac Societies, ESC Scientific Document Group. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021.
  • Marx N, Federici M, Schutt K, et al. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023.
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    Principles of Therapy

    CVD development is closely related to lifestyle characteristics and associated risk factors. There is overwhelming scientific evidence that lifestyle modifications and reduction of risk factors can slow the development of CVD both before and after the occurrence of a cardiovascular event.  

    Cardiovascular Disease Prevention  

    Primary prevention is aimed at the healthy population and those at risk, such as individuals with one or more CV risk factors, who have not yet experienced a CV event, while secondary prevention is instituted for those with confirmed CVD or who have had a first index CV event (eg MI, stroke, or transient ischemic attack). Prevention and treatment goals are intensified based on the patient’s risk modifiers, 10-year CVD risk, lifetime CVD risk, and the benefit of treatment, as well as comorbidities, frailty, and patient preferences. Lifetime CVD risk can be estimated in apparently healthy individuals, in patients with established ASCVD, and in people with type 2 diabetes mellitus with specific lifetime CVD risk scores, or it can be approximated using factors such as age, level of risk factor, and risk modifiers, etc.  

    Selection of Patients for Clinical Intervention  

    Early intervention is encouraged to address modifiable risk factors. For high- to very high-risk patients, as well as those with established ASCVD and/or DM, intensive lifestyle modification and appropriate drug treatment are required. The risk profile of these patients should be monitored every 3–6 months. High-risk patients who are intolerant of statin therapy should be given non-statin agents (eg Ezetimibe, monoclonal antibodies, bile acid sequestrants, phytosterols). For low- to moderate-risk patients, treatment of risk factors is generally not recommended. However, moderate-risk patients require monitoring of their risk profile every 6–12 months, while low-risk patients may be given conservative management that focuses on lifestyle interventions.

    Pharmacological therapy

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    Antiplatelet Agents      

    Antiplatelet agents have been shown to reduce vascular mortality, non-fatal reinfarction of the myocardium, non-fatal stroke in patients with unstable angina (UA), AMI, stroke, TIAs or other evidence of CVD.  

    Aspirin  

    Primary Prevention  

    Low-dose Aspirin (75–100 mg/day) should not be routinely used for primary prevention of ASCVD in patients >70 years old or in adults of any age who have an increased risk of bleeding. However, it may be considered for primary prevention of ASCVD in select patients aged 40–70 years with high ASCVD risk but without bleeding risk, and in patients with DM at high or very high CVD risk without contraindications. The risk-benefit profile should be assessed before using Aspirin for primary prevention especially in patients with DM. Aspirin is recommended for use in men >45 years, primarily to protect against MI, and in women >55 years, primarily to protect against stroke.  

    Secondary Prevention  

    Good evidence shows that Aspirin therapy (75–100 mg/day) can prevent MI, stroke, and CV death in both men and women with established CVD. A low dose or 75 mg/day is recommended for individuals in the high-risk group or those with >20% risk of MI and stroke, and in diabetic patients. Other groups recommend Aspirin in all patients with established CVD (eg MI or revascularization), and in patients without a history of CVD but with >10% 10-year CVD risk. Low-dose Aspirin given indefinitely is recommended in patients with established CVD and after a TIA or stroke, unless contraindicated. Long-term secondary prevention with Aspirin and a second antithrombotic drug (a P2Y12 inhibitor or low-dose Rivaroxaban) should be considered in patients whose risk for ischemic events is high and risk for bleeding is low.  

    Clopidogrel  

    Clopidogrel is recommended in combination with Aspirin for patients with UA/NSTEMI when Ticagrelor or Prasugrel is unavailable or contraindicated. The recommended dosing begins with an initial dose of 300 mg, followed by 75 mg daily for at least 1 month and ideally up to 12 months. Clopidogrel is also recommended as an alternative to Aspirin in patients who are intolerant to Aspirin and may be considered in preference to Aspirin in those established ASCVD. It is also recommended in patients with TIA or non-cardioembolic ischemic stroke.

    Prasugrel  

    Prasugrel is recommended in combination with Aspirin only in P2Y12-inhibitor-naïve patients (especially diabetics) in whom coronary anatomy is known and who will undergo PCI. An initial dose of 60 mg is given at the time of PCI, followed by 10 mg daily for 12 months.  

    Ticagrelor  

    Ticagrelor is recommended in combination with Aspirin in UA/NSTEMI/STEMI patients with intermediate to high risk of ischemic events regardless of choice of therapy (invasive or conservative). An initial dose of 180 mg is followed by 90 mg 12 hourly for 12 months.  

    Vorapaxar  

    Vorapaxar is a protease activated receptor-1 (PAR-1) antagonist that inhibits platelet activation. Studies showed that Vorapaxar, when given with other antiplatelet agents, significantly reduced the incidences of MI, stroke, and death caused by CVD.  

    Anticoagulants  

    For COVID-19 patients requiring oral anticoagulant therapy, drug-drug interactions between oral anticoagulants and COVID-19 drugs as well as liver and renal function should be considered in order to decrease the risk of bleeding or thromboembolic complications.  

    Warfarin  

    Warfarin may be used in post- MI patients for stroke prevention when clinically indicated (such as atrial fibrillation or LV thrombus, dilated LV with poor systolic function). It may also be considered for patients with paroxysmal or chronic atrial fibrillation or atrial flutter. However, the combination of Warfarin with either Aspirin or Clopidogrel increases the risk of bleeding and should be monitored closely by checking the PT and international normalized ratio (INR). The INR is monitored when using Warfarin.  

    Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)1  

    Novel oral anticoagulants (NOACs), also called new oral anticoagulants or direct oral anticoagulants, are direct-acting inhibitors of either thrombin (Dabigatran) or factor Xa (Apixaban, Edoxaban, Rivaroxaban). They may be used in the prevention and treatment of VTE, and in the prevention of stroke and systemic embolism in patients with ACS and non-valvular atrial fibrillation.

    Antihypertensive Agents2  

    The initiation of drug therapy3 is recommended for patients with a BP of ≥130/80 mmHg and ≥10% estimated 10-year ASCVD risk, and those with a BP ≥140/90 mmHg and <10% estimated 10-year ASCVD risk. These agents include ACE inhibitors, ARBs with calcium channel blockers, thiazide diuretics or beta blockers, either alone or in combination. If the BP is uncontrolled despite treatment with 3 antihypertensive medications at maximally tolerated doses, an aldosterone antagonist, an alpha blocker, a centrally acting agent or a vasodilator is considered.  

    Lipid-lowering Agents4  

    Lipid-lowering agents include statins, fibrates, bile acid binding resins, Niacin, microsomal transfer protein inhibitor (Lomitapide), PCSK9 monoclonal antibodies, selective cholesterol-absorption inhibitor (Ezetimibe), as well as Evinacumab, Bempedoic acid, Inclisiran, and Icosapent ethyl. These agents may halt the progression or induce regression of coronary atherosclerosis. Statins are the drugs of choice and have been shown not only to reduce hyperlipidemia but also to lower CV events and mortality. A high-intensity statin is recommended to be given at the highest tolerated dose to achieve the LDL-C goals specific to the patient’s risk group. The use of statin therapy may benefit patients undergoing coronary artery bypass grafting (CABG), preoperatively and postoperatively.  

    Statin therapy recommendations per target LDL-C reductions as follows:

    • High-intensity statin therapy (eg Atorvastatin [40-80 mg], Rosuvastatin [20-40 mg]) for approximately ≥50% LDL-C reduction
      • May be given to patients with ≥20% 10-year ASCVD risk
    • Moderate-intensity statin therapy (eg Atorvastatin [10-20 mg], Rosuvastatin [5-10 mg], Simvastatin [20-40 mg], Pravastatin [40-80 mg], Lovastatin [40 mg], Fluvastatin [40 mg 12 hourly], Pitavastatin [2-4 mg]) for goals of <50% lower LDL-C levels
      • May be given to patients with 7.5-19.9% 10-year ASCVD risk
    • Low-intensity statin therapy (eg Atorvastatin [5 mg], Rosuvastatin [2.5 mg], Simvastatin [5-10 mg], Pravastatin [10-20 mg], Lovastatin [20 mg], Fluvastatin [20-40 mg], Pitavastatin [1 mg]) for <30% reduced LDL-C levels

    If the LDL-C goals are not reached, it is recommended to combine a maximally tolerated statin dose with Ezetimibe.

    1Please see Ischemic Stroke, Venous Thromboembolism – Management and Venous Thromboembolism – Prevention disease management charts for specific dosing recommendations.
    2Many antihypertensive agents are available. Specific formulations and prescribing information may be found in the latest MIMS. Please see Hypertension disease management chart for specific dosing recommendations.
    3Recommendations for treatment initiation may vary between countries. Please refer to available guidelines from local health authorities.
    4Many lipid-lowering agents are available. Specific formulations and prescribing information may be found in the latest MIMS. Please see Dyslipidemia disease management chart for specific recommendations.

    PCSK9 Monoclonal Antibodies  

    Example drugs: Alirocumab, Evolocumab

    PCSK9 monoclonal antibodies are indicated for the prevention of CV events. Alirocumab reduces the risk of MI, stroke, and UA requiring hospitalization in patients with established CVD, while Evolocumab reduces the risk of MI, stroke, peripheral arterial disease, and coronary revascularization in patients with established ASCVD. These agents are recommended in patients with FH who are intolerant of statins, or for very high-risk FH patients whose treatment with a maximally tolerated statin dose plus Ezetimibe did not achieve the target LDL-C goal. As human monoclonal antibodies, PCSK9 inhibitors work by inhibiting the binding of PCSK9 to low-density lipoprotein receptors (LDLRs), thus increasing the number of available LDLRs to clear LDL thereby decreasing LDL-C concentration. Alirocumab may be given as an adjunct to diet, alone or in combination with other lipid-lowering therapies. Evolocumab may also be given as an adjunct to diet and correction of other risk factors: In combination with the maximum tolerated dose of a statin, with or without other lipid-lowering therapies, or alone or in combination with other lipid-lowering therapies in patients who are statin-intolerant or for whom statins are contraindicated.  

    Other Agents  

    Colchicine at a low dose (0.5 mg/day) may be considered for the secondary prevention of CVD, particularly if other risk factors are insufficiently controlled or if recurrent CVD events occur despite optimal therapy. It has been shown to reduce the risk of MI, stroke, coronary revascularization, and CV death in adult patients with established atherosclerotic disease or with multiple risk factors for CVD.  

    Vaccination  

    Patients with CVD or other atherosclerotic vascular diseases (such as PAD, CAD), should have an annual influenza vaccination. Some studies support the association between pneumococcal pneumonia and the development of concurrent acute cardiac events (eg MI, arrhythmia, new or worsening congestive heart failure), hence, pneumococcal vaccination is recommended in high-risk populations. Influenza and pneumococcal vaccinations are important for reducing the risk of respiratory infections and subsequent complications in patients with CVD during the COVID-19 pandemic. Furthermore, all CVD patients are encouraged to receive the COVID-19 vaccination as the risk of severe COVID-19 infection is high.

    Nonpharmacological

    Patient Education  

    Counseling should be part of the patient encounter as patients tend to respond more favorably when engaged in the process. It is important to inform the patient that multiple risk factors contribute to atherosclerosis which causes CVD; therefore, the aim is to decrease the total risk from all these factors through the maintenance of multiple healthy behaviors. If a goal related to a particular risk factor cannot be reached, this can be addressed by achieving greater reductions in other risk factors. Counseling regarding a healthy and physically active lifestyle forms the foundation of primary prevention and has the potential to either reduce or prevent the development of risk factors. It would help to include family members in the educational process so they can assist the patient in achieving lifestyle modifications. A plan is developed to make the patient part of the management through shared decision making and holding discussions over time so the patient is not overwhelmed by changing several behaviors all at one time (eg smoking, diet, exercise). The approach to care should be team-based, and social determinants of health should be evaluated for ASCVD prevention. Patients should be re-educated about proper food selection, stress management, self-monitoring, the importance of an active lifestyle, and the maintenance of ideal body weight. Progress should be monitored through follow-up contact, with regular re-evaluation and behavioral interventions to maintain treatment adherence. As continuous medical management is required for patients with CVD and its risk factors, patients are informed about telehealth services, which may be used to ensure access to healthcare providers during the coronavirus disease 2019 (COVID-19) pandemic.



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    Lifestyle Modification  

    Medical nutrition therapy, physical activity, and comprehensive lifestyle approaches have been shown to improve the control of modifiable risk factors and intermediate markers of CVD risk. Therapeutic lifestyle changes of proven benefit include diet modification, increased physical activity, weight loss, reduction or avoidance of alcohol, and smoking cessation.



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    Diet Modification1  

    The patient is counseled on a balanced diet consisting of fruits, vegetables, low-fat dairy products, fiber, whole grains, and protein sources that are low in trans-fat, saturated fat, and cholesterol. The total dietary intake of fats should be ≤30% of the total calories consumed, while the intake of saturated fats should be ≤7% of the total calories. Intake of polyunsaturated fats should be <10% of total calories, while monounsaturated fatty acids should account for <20% of caloric intake. Trans fats should be limited to <1% of total calories, and intake of dietary cholesterol should be <200 mg per day. Dietary options such as plant stanols or sterols at 2 g per day and soluble fiber at 30–45 g per day may be added. However, plant stanols or sterols are not advised in individuals being treated for primary or secondary prevention and those with CKD or type 1 or 2 DM. Saturated fats should be replaced with monounsaturated and polyunsaturated fats from vegetable or marine sources, as polyunsaturated fat has shown slightly greater LDL-C reductions compared to monounsaturated fat. A Mediterranean-style or plant-based diet rich in unsaturated fats lowers CV risk. Intake of beverages and foods with added sugar, red meat, and processed meat should be minimized.  

    The Prospective Urban Rural Epidemiology (PURE) study demonstrated that a high carbohydrate intake (>60% of total energy) was associated with adverse effects on total and non-CVD mortality, while a high fat intake, including both saturated and unsaturated fatty acids, was associated with a lower risk of total mortality, non-CVD mortality, and stroke. Therefore, overall carbohydrate intake should be limited, especially from refined sources; choose foods with low glycemic index or load. The recommended sodium intake for the general population is <5 g per day. Patients should be advised about the hidden salt content in processed foods. Consuming 30 g of unsalted nuts daily may help reduce CVD risk. Increasing the consumption (≥2 servings per week) of fish high in omega-3 fatty acids is also recommended. Daily intake of 2–4 g of fish oil can reduce triglycerides by ≥25%. AHA finds it reasonable to provide omega-3 polyunsaturated fatty acid supplementation for secondary prevention of CHD and sudden cardiac death in patients with prevalent CHD or heart failure. Food portions can be controlled by using a 9-inch plate, with half the plate composed of vegetables and fruits, and the other half divided between carbohydrates and proteins. Patients with CVD or identified risk factors such as diabetes, dyslipidemia, hypertension, or obesity may benefit from personalized dietary advice or referral to a dietitian.  

    1Dietary recommendations may vary between countries. Please refer to available nutritional guidelines from local health authorities.

    Increased Physical Activity  

    Physical activity contributes to weight loss, glycemic control, improved BP, lipid profile, and insulin sensitivity. All individuals should be encouraged to engage in moderate-intensity aerobic activity, such as brisk walking, for at least 30 to 60 minutes per day, 5 to 7 days a week, or alternatively, 15 minutes per day for 5 days a week of high-intensity aerobic activity, such as jogging or swimming, or a combination of the two. This is done in addition to increasing daily lifestyle activities like household work, gardening, and walking breaks during work. Resistance training may also be advised at least 2 days a week. Patients with CVD or CVD equivalents should be assessed prior to beginning a vigorous physical activity for conditions that might contraindicate certain types of exercise or increase the risk of injury. Patients should be encouraged to exercise at their maximum safe capacity.  

    Moderate Alcohol Consumption  

    Alcohol consumption above 3 units per day increases BP, as well as the risk of cardiac arrhythmias, cardiomyopathy, and sudden death. Patients should be advised to abstain from alcohol or reduce their alcohol consumption. The goal is to limit alcohol intake to 100 grams per week, which corresponds to <2 glasses per day or 20 grams per day of alcohol for men, and one glass per day or 10 grams per day for women.  

    Smoking Cessation  

    Studies have shown that smoking accelerates coronary plaque development and may lead to plaque rupture, which is dangerous in patients with advanced coronary atherosclerosis. Smoking cessation has been shown to significantly increase HDL-C. Evidence supports its beneficial effect on CHD mortality. All smokers should be strongly encouraged by a health professional to quit smoking and be supported in their efforts to do so. This includes assessing the tobacco user’s willingness to quit, assisting through counseling and developing a quitting plan, and offering pharmacologic interventions (eg Nicotine replacement therapy, Bupropion or Varenicline) for motivated smokers who have failed to quit by counseling. However, the use of electronic cigarettes as a tool for smoking cessation is not recommended due to insufficient evidence and potential harm. Follow-up should be arranged, and referral to special programs is considered. It must be noted that successful smoking cessation program often requires a multidisciplinary approach. In addition, all non-smokers should be encouraged not to start smoking. The goal is complete smoking cessation and no exposure to environmental tobacco smoke.  

    Please see Smoking Cessation disease management chart for further information.

    Weight Management  

    The risk of coronary disease and mortality is increased in obese patients, as obesity also contributes to other CHD risk factors (eg hypertension, dyslipidemia, type 2 DM). The presence of abdominal obesity particularly raises and independently predicts CV risk. Therefore, waist circumference along with the waist-to-hip ratio should be evaluated. The waist-to-hip ratio is indicative of central obesity. Gender-specific waist circumference cutoff points for increased CVD risk have been established in Asians, with values of ≥80 cm in women and ≥90 cm in men. Weight reduction results in lower BP, lower LDL-C and TG, higher HDL-C, and improvements in hyperinsulinemia and hyperglycemia, and is therefore recommended in overweight and obese patients. The initial target for weight loss is 5–10% for patients with a BMI of 20–25 kg/m². The goal BMI for Asian adults is 18.5–22.9 kg/m². Weight control can be achieved through a healthy diet maintained over time, increased physical activity, structured exercises, and behavioral counseling programs. Successful weight reduction requires sustained personal and family motivation, along with long-term professional support. Pharmacological intervention is also an option for patients who are determined to lose weight and will able to incorporate the therapy with comprehensive lifestyle intervention strategies.

    Prevention

    Management of Other Risk Factors  

    Blood Pressure (BP) Control  

    The goal is BP <140/90 mmHg in all patients, though BP targets should be individualized. Recommendations for BP treatment goals may vary between countries. Please refer to available guidelines from local health authorities. The target SBP range is 130-139 mmHg in individuals ≥65 years old. A DBP of <80 mmHg is recommended in all treated patients. BP goal and management may be determined through risk stratification. BP should be recorded at each visit. Lifestyle modification should be started in all patients, including weight reduction, consumption of fruits, vegetables, and low-fat dairy products, reducing salt intake, supplementing with dietary potassium (3.5–5 g/day), limiting alcohol intake, and increasing physical activity. If BP goals are not achieved with lifestyle changes alone, drug therapy is started and individualized for each patient, considering age, race, or the need for drugs with specific benefits, CVD risk, or the presence of hypertension-mediated organ damage. Antihypertensive treatment is initiated in patients with BP ≥130/80 mmHg who have established CVD or a 10-year ASCVD risk >10%, and patients with BP ≥140/90 mmHg regardless of their CVD status or calculated CV risk. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) as well as calcium channel blockers, thiazide or thiazide-like diuretics and, for certain indications, beta-blockers are commonly used in the treatment of CV disorders (eg hypertension, CAD, and congestive heart failure. The risk of COVID-19 infection or of developing severe complications from COVID-19 is not increased with prior or current treatment with ACE inhibitors or ARBs; therefore, such treatment should be continued as prescribed.  

    Please see Hypertension disease management chart for further information.  

    Lipid Management  

    A reduction of plasma TC by 10% has been shown to decrease the incidence of CAD by 25% after 5 years, while a reduction of LDL-C by 40 mg/dL (1 mmol/L) is associated with a 20% reduction in CHD events.  

    Goal for LDL-C based on risk groups:

    • Low risk: <116 mg/dL (<3 mmol/L)
    • Moderate risk: <100 mg/dL (<2.6 mmol/L)
    • High risk: <70 mg/dL (<1.8 mmol/L)
    • Very high risk: <55 mg/dL (<1.4 mmol/L)

    The general lipid goals are:

    • TC: <200 mg/dL (<5.18 mmol/L)
    • HDL-C: As high as possible but at least >40 mg/dL (>1.0 mmol/L) in men and >45 mg/dL (>1.2 mmol/L) in women
    • TG: <150 mg/dL (<1.69 mmol/L)
      • If TG is ≥200 mg/dL (≥2.26 mmol/L), non-HDL-C should be <130 mg/dL (<3.27 mmol/L) or <100 mg/dL (<2.59 mmol/L) for very high-risk individuals
    • Apo B: <90 mg/dL in high-risk patients, <80 mg/dL in very high-risk patients with established ASCVD or DM with ≥1 additional risk factor, and <70 mg/dL in extreme-risk patients

    Therapeutic lifestyle changes should be advised to all patients whose lipid levels are above the goal range, and if levels are persistently above treatment goals, a specialist referral should be considered. It is important to stress the role of smoking cessation, weight reduction, and physical activity in lipid management. Lipid-lowering therapy may be initiated. However, secondary causes of dyslipidemia (such as hypothyroidism, alcohol abuse, Cushing’s syndrome, diseases of the liver and kidneys) should be ruled out before initiating treatment. Statins are commonly used for both primary and secondary CVD events in high-risk patients. They are also the first drugs of choice in high-patients with hypertriglyceridemia. Initiation of statin therapy is recommended for patients aged 40–75 years with LDL-C levels between 70–189 mg/dL without clinical ASCVD or DM, patients ≥21 years of age with primary LDL-C levels ≥190 mg/dL, and patients aged 40–75 years with DM. Statins may also be considered for primary prevention in patients ≥70 years old if they are at high risk or above. They are the first-line therapy for patients ≥75 years old with clinical ASCVD unless contraindicated. It is important to discuss the risks and benefits of statin therapy with the patient including possible interactions with other drugs or substances. Although fibrates have not been shown to reduce cardiovascular events, they may be used in the treatment of severe hypertriglyceridemia. Individuals with TG >500 mg/dL should be started with a fibrate in addition to statin to prevent acute pancreatitis. Current evidence shows that lipid-lowering therapy is safe in patients with COVID-19 infection, and such therapy should generally be continued in patients with confirmed COVID-19 diagnosis and abnormal LFTs, unless alanine transaminase (ALT) or aspartate transaminase (AST) levels progressively increase, a significant drug-drug interaction between the lipid-lowering agents and COVID-19 drugs has been identified, or the patient is critically ill and/or unable to take oral medications. Bile acid sequestrants and Niacin may be temporarily discontinued in patients with COVID-19 infection due to the lack of evidence of CV outcome date.  

    Please see Dyslipidemia disease management chart for further information.

    Diabetes Management  

    Diabetic patients (type 1 or type 2) are at increased risk for CVD and have worse outcomes after surviving a CVD event. Good glycemic control substantially reduces the risk of CV events and microvascular diseases. Therefore, treatment of DM is always recommended regardless of the overall risk of vascular disease. Appropriate therapy is started to achieve near-normal fasting plasma glucose levels (<7 mmol/L) or as indicated by near-normal HbA1c levels, beginning with a healthy diet and regular exercise. The general goal is an HbA1c <7% (<53 mmol/mol) for both type 1 and type 2 DM, but since HbA1c may vary with the patient’s ethnicity or race, values must be individualized. An HbA1c goal of ≤6.5% (≤48 mmol/mol) should be considered in type 2 DM patients with good health status and without ASCVD.  

    To reduce the risk of hypoglycemia, glycemic targets should be individualized based on the patient’s profile. Lifestyle modification, along with BP and lipid management, is recommended in all diabetic patients. If lifestyle modification fails, oral antidiabetic medications should be added to the treatment regimen. Sodium-glucose linked transporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists with proven CV benefit are recommended for patients with type 2 diabetes mellitus (T2DM) and ASCVD to reduce CV risk. Metformin should be considered if additional glucose control is needed. Metformin should also be considered to reduce CV risk in T2DM patients without ASCVD or severe TOD who are at low or moderate risk. Lipid-lowering drugs are recommended for all patients with T2DM patients and for those with type 1 DM >40 years old. These may also be considered in patients <40 years old who are at high risk with multiple risk factors and microvascular complications, or who have had diabetes for ≤10 years. Patients with diabetes require strict blood glucose monitoring and prevention of diabetes complications during the COVID-19 pandemic in order to keep their susceptibility low and to prevent severe COVID-19 disease courses.  

    Please see Diabetes Mellitus disease management chart for further information.  

    Obesity/Overweight Management  

    Weight loss is indicated for patients with a WHO BMI >30 kg/m² or 25–29.9 kg/m² who have risk factors (DM, prediabetes, hypertension, dyslipidemia, waistline >88 cm in women or >102 cm in men), or who have obesity-associated comorbidities. The goal is to achieve a 5–10% weight loss in 6 months and to maintain this weight reduction within 2 years. Lifestyle modifications (diet modification, increased physical activity, and weight management) are recommended in all obese or overweight patients. Comprehensive lifestyle intervention is recommended if no weight loss is seen with lifestyle modifications. Preventive measures, including lifestyle modifications, decrease the risk of cardiometabolic diseases, which in turn lowers the risk of severe COVID-19 infection. The addition of pharmacological therapy is recommended if the patient continues to gain weight or is unable to lose weight despite comprehensive lifestyle interventions. Referral for bariatric surgery may be considered if all other interventions fail and the patient has a BMI of ≥35 kg/m², or a BMI of 30–34.9 kg/m² with comorbidities.  

    Please see Obesity disease management chart for further information.  



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    Cardiac Rehabilitation  

    A comprehensive outpatient CV rehabilitation program is recommended for patients with ACS, chronic angina, post-coronary artery bypass surgery (CABG), or post-percutaneous coronary intervention. It is recommended for patients after ASCVD events and/or revascularization, and those with heart failure (particularly heart failure with reduced ejection fraction) to have an exercise-based cardiac rehabilitation and prevention program to improve patient outcomes.  

    Depression Management  

    Screening for depression is advisable in patients with recent CABG or MI. Management of depression has not been shown to improve CVD prognosis but may be advisable for its other clinical effects.