Risk Factors and Prevention Health Habits

2008 AHA Prevention of HF³

2013 ACCF/AHA Guideline for the

Management of Heart Failure²

2019 ACC/AHA Guideline on the Primary

Prevention of Cardiovascular Disease⁴

Guidelines Directed Care According to AHA Simple 7 Recommendations

1. Be active

Physical inactivity has been recognized as an important risk factor for CVD and HF. Prospective epidemiological studies of occupational and leisure-time physical activity have documented a reduced incidence of CAD, HF, and stroke in the more physically active and fit individuals:

• Goal 30 minutes 5 times per week

1. Counseling in healthcare visits to optimize a physically active lifestyle.

2. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity

(or an equivalent combination of moderate

and vigorous activity)

3. For adults unable to meet the minimum physical activity recommendations, engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial

4. Decrease sedentary behavior

1. Keep a healthy weight

Excess body weight is also an independent risk factor for the development of HF and contributes to other HF risk factors, such as hypertension, dyslipidemia, and type 2 diabetes mellitus:

• Goal BMI <25 kg/m2

• Obesity and overweight have been repeatedly linked to an increased risk for HF, explained by the clustering of risk factors for heart disease in those with elevated BMI.

Recommendations:

1. Weight loss In individuals with overweight and obesity;

2. Counseling and comprehensive lifestyle

interventions, including calorie restriction, for achieving and maintaining weight loss in adults with overweight and obesity.

3. Calculate body mass index (BMI) annually or more frequently to identify adults with overweight and obesity for weight loss considerations.

4. Measurement of waist circumference to identify those at higher

cardiometabolic risk.

1. Learn about cholesterol

An increased ratio of total cholesterol to high-density lipoprotein cholesterol is associated with elevated HF risk. Dyslipidemia treatment has been demonstrated to be effective in preventing HF:

• Statin therapy for goal LDL< 130mg/dL

Lipid disorders should be controlled in

accordance with contemporary guidelines to lower the risk

of HF:

• Patients with known ASCVD are likely to develop HF.
• Aggressive treatment of hyperlipidemia with statins reduces the likelihood of HF in at-risk patients.
• In persons with hyperlipidemia, long-term treatment with ACE inhibitors may also decrease the risk of HF.
• In patients with MI, statins should be used to prevent HF

Guideline directed therapy with statins based upon ACSVD risk

1. Do not smoke or use smokeless tobacco

Current smokers have significantly higher risk for the development of HF than prior smokers and nonsmokers.

• Recommend Smoking cessation and any necessary pharmacological therapies

• Tobacco use is strongly associated with risk for incident HF, and patients should be strongly advised about the hazards of smoking, with attendant efforts at quitting.

Advise to quit; a combination

of behavioral interventions plus pharmacotherapy is recommended to

maximize quit rates; tobacco

abstinence is recommended;

dedicate trained staff to tobacco treatment in every healthcare system; avoid

secondhand smoke exposure

1. Eat a heart-healthy diet

Suggest diet limiting sodium and high saturated fat

• Diet modifications: DASH Diet & weight loss
• Avoid excessive alcohol intake

Heavy use of alcohol has repeatedly been associated with

heightened risk for development of HF, recommend avoidance.

1. A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish;

2. Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats;

3. A diet containing reduced amounts of cholesterol and sodium;

4. Minimize the intake of processed meats, refined carbohydrates, and sweetened beverages; and

5. Trans fats should be avoided

1. Keep blood pressure healthy

The prevention and adequate

control of hypertension provides the earliest opportunity to prevent HF:

• Goal BP <140/90 mm Hg treat according to JNC-7
• Use of Diet modifications to lower BP: DASH Diet & weight loss

Hypertension should be controlled in

accordance with contemporary guidelines to lower the risk

of HF

• Elevated blood pressure is a major risk factor for the development of both HFpEF and HFrEF, a risk that extends across all age ranges. Long-term treatment of both systolic and diastolic hypertension has been shown to reduce the risk of incident HF by approximately 50%.
• Antihypertensive therapy recommended: Diuretic-based antihypertensive therapy; ACE inhibitors, ARBs, and beta blockers.
• Blood pressure should be controlled to prevent symptomatic HF in known Stage B

• Nonpharmacologic guideline directed therapies of control including: weight loss, heart-healthy dietary pattern, sodium reduction, dietary potassium supplementation, increased physical activity, and limited alcohol.
• Pharmacological guideline directed therapy to goal BP <130/80 mm Hg.

1. Learn about blood sugar and diabetes

Diabetes is an independent risk factor for development of HF. The Framingham Study revealed a 2.4-fold increase in symptomatic HF in diabetic men and a 5.0-fold increase in diabetic women, independent of coexisting hypertension or ischemic heart disease. Diabetes also may act synergistically to increase the risk of HF by accelerating the development of atherosclerosis, MI, and ischemic HF.

• Goal Hgb A1c <7%
• Recommend pharmacologic treatment of Pre-diabetes with metformin or acarbose

Other conditions that may lead to or contribute to HF, such as diabetes mellitus & should be controlled or avoided:

• In women, diabetes mellitus may triple the risk for developing HF.
• Persons with HbA1c >10.5% had a nearly 4-fold increase in the risk for HF compared with those with a value of <6.5%.
• Consider addition of ACE inhibitors or ARBs in persons with DM, to prevent development of other risk factors for HF, such as renal dysfunction, to directly lower the likelihood of HF.

1. For all adults with T2DM, a tailored nutrition

plan focusing on a heart-healthy dietary

pattern is recommended

2. Adults with T2DM should perform at least

150 minutes per week of moderate-intensity

physical activity or 75 minutes of vigorous intensity

physical activity

3. For adults with T2DM, it is reasonable

to initiate metformin as first-line therapy

along with lifestyle therapies at the time of

diagnosis

4. For adults with T2DM and additional ASCVD

risk factors who require glucose-lowering

therapy despite initial lifestyle modifications

and metformin, it may be reasonable to

initiate a sodium-glucose cotransporter

2 (SGLT-2) inhibitor or a glucagon-like

peptide-1 receptor (GLP-1R) agonist

5. Guideline directed statin therapy

Clinician Specific Actions

Assessing Risk for Heart Failure

The future creation of an objective scoring system for risk of developing HF, perhaps along the lines of the Framingham risk assessment for HF, will help identify those individuals in stage A with especially high risk for early events and development of stage B, C, or D disease.

• Assess for LV dysfunction in persons with known cardiotoxic chemotherapies

• Be aware of and screen for other conditions that may lead to or contribute to HF, such as cardiotoxic regimens (particularly anthracycline based) and trastuzumab which require evaluation with advanced echocardiographic techniques or biomarkers for LV dysfunction.

Screening Guidelines:

1. For adults 40 to 75 years of age, clinicians should routinely assess traditional cardiovascular risk factors and calculate 10-year risk of ASCVD by using the pooled cohort equations (PCE).

2. For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to 6 years.

3. In adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk

(≥7.5% to <20% 10-year ASCVD risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive

interventions (eg, statin therapy).

4. In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk) or selected

adults at borderline risk (5% to <7.5% 10-year ASCVD risk), if risk-based decisions for

preventive interventions (eg, statin therapy) remain uncertain, it is reasonable to measure a coronary artery calcium score to guide clinician–patient risk discussion.

Clinician Specific Treatment of Known Stage B HF

• If known CAD, prescribe Cardioprotective meds: ACEi, Betablockers, antiplatelet agents, statins, aldosterone antagonists
• Surgical Management if possible for known valvular heart disease
• Prescribed CPAP to improve LV structure and function in persons with Sleep Disordered Breathing
• Consider ACEi for persons with Chronic Kidney Disease

• ACE inhibitors recommended in all patients with a reduced EF to prevent HF.
• Beta-blockers recommended in all patients with a reduced EF to prevent HF.
• An ICD recommended in patients with asymptomatic ischemic cardiomyopathy who are at least 40 d post-MI, have an LVEF <30%, and on GDMT
• Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF