Dayang Feineliza Bahjin

Section 3F

2019 ACC guidelines

The guidelines focus is about preventing the risk of ASCVD in adults
to reducing it primarily. Some examples of ASCVD are (acute coronary
syndromes, myocardial infarction, stable or unstable angina, arterial
revascularization, stroke/transient ischemic attack, peripheral arterial
disease), as well as heart failure and atrial fibrillation.
The guideline emphasizes to have a shared-decisions between
patient-doctor relationship with a multidisciplinary team-based approach to
the implementation of recommended preventive strategies with sensitivities
to the social determinants of health.
Also, the guidelines help the doctor to have multidisciplinary approach
on preventing the ASCVD. Some should consider the patients
cardiovascular risk because some cardiovascular disease is hereditary and
should look upon on family history. Some works raises cardiovascular risk
due to psychosocial stressors.
Diet should be look upon because some diet will increase the risk the
ASCVD. High cholesterol diet will increase plaque formation in the blood
vessels. Low salt diet also should be advocated due to decreasing the risk
of hypertension.
Assessment of ASCVD risk is the foundation of primary prevention. For
the patients aged 20-39 years, it is reasonable check the risk factors every
4-6 years to identify major factors such as tobacco, dyslipidemia, family
history of premature ASCVD, chronic inflammatory diseases, hypertension,
or type 2 diabetes mellitus [T2DM]. This will provide rationale for optimizing
lifestyle and tracking risk factor progression and need for treatment.
For adults aged 20-39 years and those aged 40-59 years who are not
already at elevated (≥7.5%) 10-year risk, estimating a lifetime or 30-year risk
for ASCVD may be considered (ASCVD Risk Estimator Plus).
 For those aged 20-59 years not at high short-term risk, the 30-year
and lifetime risk would be reasons for a communication strategy for
reinforcing adherence to lifestyle recommendations and for some drug
therapy for familial hypercholesterolemia, hypertension, prediabetes, and
family history of premature ASCVD with dyslipidemia or elevated lipoprotein.
The guideline suggests the race and sex has effect on the risk of the
patients. Primarily on the black American which has strong race factor.
Moreover, the general Framingham CVD risk score, Reynolds risk score,
SCORE, and QRISK/JBS3 tools helps in diagnosing. Among borderline and
intermediate-risk adults, one may consider additional individual "risk-
enhancing" clinical factors that can be used to revise the 10-year ASCVD
risk estimate. For initiating or intensifying statin therapy, include: family
history of premature ASCVD; low-density lipoprotein cholesterol or non-high-
density lipoprotein cholesterol (non-HDL-C) ≥190 mg/dl; chronic kidney
disease (estimated glomerular filtration rate [eGFR] <60 ml/min/1.73 m2);
metabolic syndrome; pre-eclampsia and premature menopause (<40 years);
inflammatory diseases including rheumatoid arthritis, lupus, psoriasis, HIV;
South Asian ancestry; biomarkers including fasting triglycerides ≥175 mg/dl,
Lp(a) ≥50 mg/dl, high-sensitivity C-reactive protein ≥2 mg/L, apolipoprotein
B >130 mg/dl, and ankle-brachial index (ABI) <0.9.
The patient’s dietary patterns should be associated with ASCVD such
as sugar, low-calorie sweeteners, high-carbohydrate diets, low-carbohydrate
diets, refined grains, trans fat, saturated fat, sodium, red meat, and
processed red meat (such as bacon, salami, ham, hot dogs, and sausage.
The patient should be on dash diet if there’s a risk of cardiovascular disease
for the patient,
Obesity should also one of the risk factors for cardiovascular disease.
We classify obese on body mass index score of greater than 30 or
overweight of greater than 25. The above classifications are for Caucasian
but for Asia pacific classification have different numbers. Overweight is 23-
24.9 and obese 1 is 25-29.9. Obesity increases the risk of ASCVD, heart
failure, and atrial fibrillation compared with those of a normal weight. People
with obesity should have calorie intake control (800-1500) and should have
high level of activity.
 Diabetes mellitus and hypercholesterolemia have high impact on the
increase of risk on ASCVD. People with DM should be enrolled to dash diet
and proper exercise for non-pharmaceutical intervention. For pharmaceutical
intervention then we should check for the blood sugar like of HBA1C, FBS
and 2hr ogtt. the patient should be in line for 1st line medications such as
metformin then it may be combined drugs. Also, insulin will help also the
patient.
Smoking cessation will also decrease ASCVD events because the
smoking is the strongest environmental factor.