TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL. 132, 2022
THE ABCDE’S OF PRIMARY PREVENTION OF
CARDIOVASCULAR DISEASE
ROGER S. BLUMENTHAL, MD, and (by invitation) ABDULHAMIED
ALFADDAGH, MD, MHS
BALTIMORE, MARYLAND
ABSTRACT
The growing burden of obesity, smoking, elevated cholesterol, diabe-
tes, hypertension, sedentary lifestyle, and unhealthy dietary habits fuels
cardiovascular disease. In 2015, the rates of cardiovascular disease in
the United States rose for the first time after decades of steady decline.
To combat this rising trend, there is a great need to emphasize primary
cardiovascular prevention. In this review, we provide a summary of the
current primary prevention recommendations using a simplified ABCDE
approach. The aim is to help clinicians utilize an easy-to-use, structured
approach to primary atherosclerotic cardiovascular disease prevention.
INTRODUCTION
Cardiovascular disease remains the leading cause of morbidity and
mortality in the United States and worldwide (1). In 2015, the death
rate from atherosclerotic cardiovascular disease (ASCVD) rose for the
first time since 1999 (2). The increased burden of ASCVD is primar-
ily driven by the rise in cardiovascular risk factors such as obesity,
smoking, elevated cholesterol, diabetes, hypertension, sedentary life-
style, and unhealthful dietary habits (2). In the INTERHEART study,
approximately 90% of the population’s attributable risk of a first myo-
cardial infarction could be explained by potentially modifiable ASCVD
risk factors (3). Thus, serious efforts to control risk factors through
primary prevention are crucial to combat the rising trends in ASCVD.
To help promote cardiovascular health, the American Heart Associa-
tion (AHA) developed the “Life’s Simple 7” health criteria, which include
seven metrics that constitute ideal cardiovascular health (4); these
Correspondence and reprint requests: Roger S. Blumenthal, MD, FACC, FAHA, Ciccarone
Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins
University School of Medicine, MD, USA, Halsted 560, 600 North Wolfe Street, Baltimore, MD
21287, Tel: 410-955-7376, Fax: 410-614-9190, E-mail: .
Potential Conflicts of Interest: None disclosed.
135
,136 ROGER S. BLUMENTHAL ET AL
metrics include attaining healthy weight, adequate physical activity,
a balanced healthful diet, and not smoking, in addition to achieving
target values for blood pressure, cholesterol, and blood glucose. In U.S.
adults, only 17% have ≥5 of these metrics at ideal levels, highlighting
an important gap in the primary prevention of ASCVD (2).
We provide a summary of the current primary prevention recom-
mendations using a simplified ABCDE approach. The aim is to help cli-
nicians utilize an easy-to-use, structured approach to primary ASCVD
prevention.
A – Assessing ASCVD Risk
In asymptomatic patients, assessing ASCVD risk begins the clinician–
patient discussion around primary prevention. Stratifying patients
according to ASCVD risk helps guide appropriate pharmacological
therapies and the need for intensifying lifestyle interventions. To esti-
mate the 10-year ASCVD risk in adults between 40 and 70 years of
age without ASCVD, the 2019 American College of Cardiology (ACC)/
AHA Primary Prevention of Cardiovascular Disease Guideline recom-
mends the use of the race- and sex-specific pooled cohort equations
(PCE) calculator (5). In addition, clinicians should routinely assess for
traditional ASCVD risk factors.
Using readily available patient characteristics, the PCE risk calcu-
lator provides a reasonable assessment of ASCVD risk (including the
risk of coronary death, nonfatal myocardial infarction, and fatal or
nonfatal stroke) in the majority of patients (6).Patient characteristics
included in the most recent version of the PCE (ASCVD Risk Estima-
tor Plus found on ACC.org) are age, sex, race (White, African American,
and other), systolic and diastolic blood pressure, history of diabetes,
smoking, use of antihypertensive agents, current statin and aspirin
therapy, and cholesterol measurements [total, high-density lipopro-
tein cholesterol, and low-density lipoprotein cholesterol (LDL-C)] (6).
Accordingly, patients could be risk stratified into low (<5%), borderline
(5% to <7.5%), intermediate (≥7.5 to <20%), and high (≥20%) 10-year
ASCVD risk groups (5).
Because the PCE risk calculator does not include all ASCVD risk
factors, the calculated risk estimate often significantly overestimates
or underestimates actual ASCVD risk in some subgroups (5). Notably,
the PCE frequently underestimates risk in those with low socioeco-
nomic status or family history of premature coronary artery disease
(CAD), or those with multiple risk-enhancing factors not included in
, PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE 137
the PCE risk calculator (7). Therefore, the PCE risk estimate should be
interpreted within the context of the patient’s medical history, and risk
estimates should be refined when uncertainty around risk estimates
exists.
In those with borderline and intermediate estimated 10-year ASCVD
risk in whom there is “uncertainty” about the accuracy of risk estima-
tion by PCE, the use of additional risk-enhancing factors, when avail-
able, helps guide interventions such as statin therapy (Table 1 ) (5).
The presence of a risk-enhancing factor would reclassify patients into
a higher risk category.
Uncertainty about risk estimates may persist in patients with inter-
mediate or high 10-year ASCVD risk, considering risk-based preven-
tive therapies such as statin therapy (7). Measuring a coronary artery
calcium (CAC) score is reasonable and may be the best way to refine
risk and guide preventive interventions (7). CAC scores reflect the
overall burden of subclinical atherosclerosis in the coronary tree and
have superior ability to reclassify risk compared to other blood or imag-
ing biomarkers (8).
TABLE 1
Atherosclerotic Cardiovascular Disease Risk-Enhancing Risk Factors
Risk-Enhancing Factors
advanced psoriasis, HIV)
triglycerides (>150 mg/dL)
○ In selected individuals, if measured:
¤ hsCRP ≥2 mg/L
¤ Lp(a) levels ≥50 mg/dL or ≥125 nmol/L
¤ ApoB levels ≥130 mg/dL
¤ Ankle-brachial index <0.9
THE ABCDE’S OF PRIMARY PREVENTION OF
CARDIOVASCULAR DISEASE
ROGER S. BLUMENTHAL, MD, and (by invitation) ABDULHAMIED
ALFADDAGH, MD, MHS
BALTIMORE, MARYLAND
ABSTRACT
The growing burden of obesity, smoking, elevated cholesterol, diabe-
tes, hypertension, sedentary lifestyle, and unhealthy dietary habits fuels
cardiovascular disease. In 2015, the rates of cardiovascular disease in
the United States rose for the first time after decades of steady decline.
To combat this rising trend, there is a great need to emphasize primary
cardiovascular prevention. In this review, we provide a summary of the
current primary prevention recommendations using a simplified ABCDE
approach. The aim is to help clinicians utilize an easy-to-use, structured
approach to primary atherosclerotic cardiovascular disease prevention.
INTRODUCTION
Cardiovascular disease remains the leading cause of morbidity and
mortality in the United States and worldwide (1). In 2015, the death
rate from atherosclerotic cardiovascular disease (ASCVD) rose for the
first time since 1999 (2). The increased burden of ASCVD is primar-
ily driven by the rise in cardiovascular risk factors such as obesity,
smoking, elevated cholesterol, diabetes, hypertension, sedentary life-
style, and unhealthful dietary habits (2). In the INTERHEART study,
approximately 90% of the population’s attributable risk of a first myo-
cardial infarction could be explained by potentially modifiable ASCVD
risk factors (3). Thus, serious efforts to control risk factors through
primary prevention are crucial to combat the rising trends in ASCVD.
To help promote cardiovascular health, the American Heart Associa-
tion (AHA) developed the “Life’s Simple 7” health criteria, which include
seven metrics that constitute ideal cardiovascular health (4); these
Correspondence and reprint requests: Roger S. Blumenthal, MD, FACC, FAHA, Ciccarone
Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins
University School of Medicine, MD, USA, Halsted 560, 600 North Wolfe Street, Baltimore, MD
21287, Tel: 410-955-7376, Fax: 410-614-9190, E-mail: .
Potential Conflicts of Interest: None disclosed.
135
,136 ROGER S. BLUMENTHAL ET AL
metrics include attaining healthy weight, adequate physical activity,
a balanced healthful diet, and not smoking, in addition to achieving
target values for blood pressure, cholesterol, and blood glucose. In U.S.
adults, only 17% have ≥5 of these metrics at ideal levels, highlighting
an important gap in the primary prevention of ASCVD (2).
We provide a summary of the current primary prevention recom-
mendations using a simplified ABCDE approach. The aim is to help cli-
nicians utilize an easy-to-use, structured approach to primary ASCVD
prevention.
A – Assessing ASCVD Risk
In asymptomatic patients, assessing ASCVD risk begins the clinician–
patient discussion around primary prevention. Stratifying patients
according to ASCVD risk helps guide appropriate pharmacological
therapies and the need for intensifying lifestyle interventions. To esti-
mate the 10-year ASCVD risk in adults between 40 and 70 years of
age without ASCVD, the 2019 American College of Cardiology (ACC)/
AHA Primary Prevention of Cardiovascular Disease Guideline recom-
mends the use of the race- and sex-specific pooled cohort equations
(PCE) calculator (5). In addition, clinicians should routinely assess for
traditional ASCVD risk factors.
Using readily available patient characteristics, the PCE risk calcu-
lator provides a reasonable assessment of ASCVD risk (including the
risk of coronary death, nonfatal myocardial infarction, and fatal or
nonfatal stroke) in the majority of patients (6).Patient characteristics
included in the most recent version of the PCE (ASCVD Risk Estima-
tor Plus found on ACC.org) are age, sex, race (White, African American,
and other), systolic and diastolic blood pressure, history of diabetes,
smoking, use of antihypertensive agents, current statin and aspirin
therapy, and cholesterol measurements [total, high-density lipopro-
tein cholesterol, and low-density lipoprotein cholesterol (LDL-C)] (6).
Accordingly, patients could be risk stratified into low (<5%), borderline
(5% to <7.5%), intermediate (≥7.5 to <20%), and high (≥20%) 10-year
ASCVD risk groups (5).
Because the PCE risk calculator does not include all ASCVD risk
factors, the calculated risk estimate often significantly overestimates
or underestimates actual ASCVD risk in some subgroups (5). Notably,
the PCE frequently underestimates risk in those with low socioeco-
nomic status or family history of premature coronary artery disease
(CAD), or those with multiple risk-enhancing factors not included in
, PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE 137
the PCE risk calculator (7). Therefore, the PCE risk estimate should be
interpreted within the context of the patient’s medical history, and risk
estimates should be refined when uncertainty around risk estimates
exists.
In those with borderline and intermediate estimated 10-year ASCVD
risk in whom there is “uncertainty” about the accuracy of risk estima-
tion by PCE, the use of additional risk-enhancing factors, when avail-
able, helps guide interventions such as statin therapy (Table 1 ) (5).
The presence of a risk-enhancing factor would reclassify patients into
a higher risk category.
Uncertainty about risk estimates may persist in patients with inter-
mediate or high 10-year ASCVD risk, considering risk-based preven-
tive therapies such as statin therapy (7). Measuring a coronary artery
calcium (CAC) score is reasonable and may be the best way to refine
risk and guide preventive interventions (7). CAC scores reflect the
overall burden of subclinical atherosclerosis in the coronary tree and
have superior ability to reclassify risk compared to other blood or imag-
ing biomarkers (8).
TABLE 1
Atherosclerotic Cardiovascular Disease Risk-Enhancing Risk Factors
Risk-Enhancing Factors
advanced psoriasis, HIV)
triglycerides (>150 mg/dL)
○ In selected individuals, if measured:
¤ hsCRP ≥2 mg/L
¤ Lp(a) levels ≥50 mg/dL or ≥125 nmol/L
¤ ApoB levels ≥130 mg/dL
¤ Ankle-brachial index <0.9
