Dr. Erin Michos discusses the primary prevention of cardiovascular disease



so as you know primary prevention we're focused on individuals who don't have clinical signs of heart disease or stroke and we're trying to prevent that first event and we understand that there's been a lot of guidelines from blood pressure and cholesterol and lifestyle and our goal was really to have a one-stop shop to bring in all the pieces from different guidelines as well as new updates to have a comprehensive resource for clinicians and for public health communities to address the primary prevention of cardiovascular disease and so that it all be in one document for an easy resource to put it all together for them so although we talk about each individual risk factors there's sort of three what we call overarching theme that was really the front and center like front page of the guidelines and the first was the emphasis that the most important way to prevent cardiovascular disease is a healthy lifestyle throughout one's life span the second sort of emphasis is that it really takes a team this is a team-based approach that we've seen the clinicians and their patients but there may be lots of other and nutritionist smoking cessation counselors exercise physiologists nurses we need a whole community to work together to move this prevention forward and the third real key is a focus on social determinants of health that we understand it's very important that social economic inequalities are actually a key determinant of cardiovascular risk and therefore it's really important to address questions of patients about their safety in their neighborhood their access to heart-healthy foods their transportation whether they have adequate insurance or any insurance at all because really if you want to deliver the most effective implementation of these Prevention's we have to understand the social determinants of their health it's very easy to sorta tell patients well you need to eat healthy and you need to exercise and you need to take these medications but we don't ask you know do you have access to healthy foods are you living in a safe place or have an ability to get that physical activity in can you afford these medications can you take these medications and so unless we address these questions we're not going to be able to implement and so that's why this is a really a key focus that and I think no other guidelines has really highlighted the importance of these social determinants of one's health yes first of all I want to emphasize these are primary prevention guidelines so the recommendation to take aspirin for secondary prevention for people who have established cardiovascular disease that hasn't changed that doesn't apply to them but the overall weight of the evidence of 30 recent trials indicate that most healthy individuals don't need to take an aspirin for primary prevention than it might do more harm from bleeding than benefit and particularly based on the Esprit trial that actually showed not only increased risk of bleeding but actually increased risk of mortality for healthy adults over the age of 70 based on that we actually gave a class-3 recommendation that healthy older adults who don't have established cardiovascular disease should not generally be taking aspirin for primer prevention and in my own personal practice even before these guidelines I've been actually D prescribing I've been taking patients off off aspirin we give aspirin over all A to B recommendation and what that means is that it means it's a no for most people but there may be a select group of individuals who are particularly at high risk for cardiovascular disease who are between the ages of 40 and 70 who are at low risk for bleeding so they're at high risk for cardiovascular disease low risk for bleeding and it sometimes it's hard to sort that out but there may be a select few that might still benefit from aspirin but the vast majority of people know so not the people that are low risk certainly no one that's at risk for bleeding should be taking aspirin and not the older adults over 70 where there's a good suggestion of harm actually so we emphasize the importance of heart healthy lifestyle throughout one's life span and we talk about even measuring risk factors and younger adults to track those risk factors an optimized lifestyle so that is things that primary care doctors have already been doing and we've pulled in themes since from prior documents about estimating absolute risk in individuals that are aged 40 to 75 using various equations we endorse the full court equation to estimate 10-year risk of heart attacks and strokes as a way to help guidance for preventive medications the idea about this is we want to maximize anticipated benefits but minimize harm from over treatment and I think primary care doctors get anonymous this emphasis about identifying risk but what's been brought forward and the cholesterol guidelines and continued here is that once you estimate risk we really have to personalize it for the individual sitting in front of us and that is where the shared decision-making becomes so very important that these guidelines are based on scientific evidence but we have to consider the individual at hand we give targets and recommendations heart healthy numbers based on the overwhelm Simon tipic evidence but we realize that patients are individuals and that certain therapies and certain blood pressure targets may not be appropriate for individual patients and that's where there's this merging between the scientific evidence ones clinical judgment as a clinician with the patient sitting in front of us and then the patient's personal preferences people patients have different interest in the how much they want to utilize taking preventive medications they have different views and beliefs on that so we really put all those fears together to kind of come up with the best decision for individual patients and so that's why I think that the larger medical community will embrace this because we give guidance but we also allow for some flexibility for modifications based on individual circumstances you

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