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Experts Announce Major Updates to Guidelines for Heart Disease Risk Assessment and Prevention

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December 19, 2013

Extensive new guidelines for cardiovascular disease (CVD) risk assessment are slated to better guide health practitioners in assessing, managing, and treating patients who are at risk of developing the disease. Released in November by the American College of Cardiology (ACC) and the American Heart Association (AHA), the series of four guidelines are long-awaited after the organizations took five years to perform a comprehensive review of new research and the latest cardiovascular medical evidence. The primary purposes of the recommendations are to better define what important factors are involved in determining CVD risk and to provide ways to reduce risk through treatment and lifestyle modifications.

The ACC and AHA reviewed large studies, including controlled clinical trials conducted up through 2011, to develop their recommendations, which are an update to the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel (Adult Treatment Panel III) that was last revised in 2004. Each of the four guidelines offers key advice for specific patient populations at risk for CVD, including assessing risk, treating high blood cholesterol, and guiding patients on how to lead a healthy lifestyle and manage their weight.

Examples of a few key points
For determining CVD risk, the newly-released guidelines highlight several important factors for health care providers to take into account when assessing a patient's risk level. For example, a new CV Risk Calculator is a downloadable companion tool to the first guideline that helps to predict 10-year and lifetime CVD risk levels. It is intended for people without heart disease between the ages of 40 and 79. Many factors are considered in the calculation, including age, gender, race, total cholesterol, high-density lipoprotein cholesterol (HDL-C), blood pressure, presence of diabetes, and smoking habit.

Some experts have criticized the calculator's accuracy, however, saying that it overestimates patients' CVD risk and could lead to many more people being treated with preventive statins than is necessary. Proponents of the calculator's new formula say that it is still a valuable resource because it is better than previous risk calculators. The guidelines underscore the importance of discussing options and using judgment for both doctors and patients when making treatment decisions.

The second of the four guidelines addresses high blood cholesterol as a significant factor that can be treated to reduce cardiovascular risk. While previous guidelines recommended aiming for low-density lipoprotein cholesterol (LDL-C) levels within certain targets through the use of prescription medication, the new recommendations have dropped the targets altogether. This is because some drugs will improve cholesterol levels but not prevent CVD events, such as heart attacks and strokes. For those at high risk of having cardiac problems, the preferred treatment is with statins, as evidence shows they have the greatest benefit for patients. In fact, the guideline discourages health practitioners from treating high-risk individuals with any drug other than statins.

In the third guideline that outlines lifestyle changes, the AHA and ACC provide diet and exercise recommendations that are most effective for reducing CVD risk. While the overall message is for people to lead a healthy lifestyle, specific diet recommendations encourage a Mediterranean-like diet with vegetables, fruits, and whole grains, in addition to low-fat dairy products, poultry, fish, legumes, and non-tropical vegetable oils and nuts. Foods that should be avoided or consumed minimally include sweets, sugar, red meats, and foods containing saturated or trans fats. Exercising for 40 minutes 3-4 times per week is recommended in conjunction with diet modifications to lower LDL cholesterol and blood pressure.

The fourth ACC/AHA guideline makes recommendations for reducing CVD risk related to being overweight or obese. People who have a body mass index (BMI) of 25-29 are defined as overweight, and those with a BMI of 30 or higher are defined as obese. It is recommended that health care providers calculate BMI for their patients annually as well as track waist circumference using a tape measure, as increased waist size can be a risk indicator for type 2 diabetes, CVD, and other life-threatening conditions.

Treatment is recommended for men with waist sizes above 40 inches and for women above 35 inches. Weight loss strategies implemented with help from a dietician or weight-loss counselor are highly recommended for those who need to lose weight. Behavioral counseling programs that offer advice on diet and exercise were found to be very beneficial for weight loss when followed for 6 months or longer. The guideline names bariatric surgery as an option for individuals who are morbidly obese (BMI greater than 40) and who have not been successful losing weight with diet and exercise.

There are many additional recommendations within the guidelines for health practitioners and patients to manage CVD risk, and those detailed above are merely some highlights of the guidelines. It is not yet known how the ACC/AHA recommendations will impact clinical practice. Any changes that may take place will be implemented over time.

As some in the medical community have questioned the new guidelines, it is important that people discuss CVD risk assessment and treatment with their health care providers when having a checkup or screening for high cholesterol, high blood pressure, or other CVD risk factors.

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NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used.

CV Risk Calculator. MyAmericanHeart.org. Available online at http://my.americanheart.org/professional/StatementsGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp through http://my.americanheart.org. Accessed December 2013.

Clinical Practice Guidelines For Prevention. MyAmericanHeart.org Science News. Available online at http://my.americanheart.org/professional/ScienceNews/Clinical-Practice-Guidelines-for-Prevention_UCM_457211_Article.jsp through http://my.americanheart.org. Accessed December 2013.

Elia, Joe. (Nov. 19, 2013.) Fuzzy Math: New Calculator Seen as Overestimating Cardiovascular Risk. New England Journal of Medicine Journal Watch. Available online at http://www.jwatch.org/fw108169/2013/11/19/fuzzy-math-new-calculator-seen-overestimating?query=pfw through http://www.jwatch.org. Accessed December 2013.

Brett, A. S. (Nov. 12, 2013.) Lipid-Modifying Therapy: A New Paradigm. New England Journal of Medicine Journal Watch. Available online at http://www.jwatch.org/na32828/2013/11/12/lipid-modifying-therapy-new-paradigm through http://www.jwatch.org. Accessed December 2013.

Nainggolan, L. (Nov. 12, 2013.) New Obesity Guidelines: Authoritative "Roadmap" to Treatment. Medscape. Available online at http://www.medscape.com/viewarticle/814202 through http://www.medscape.com. Accessed December 2013.

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