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The American Heart Association’s Focus on Primordial Prevention

2021; Lippincott Williams & Wilkins; Volume: 144; Issue: 15 Linguagem: Inglês

10.1161/circulationaha.121.057125

1524-4539

Donald M. Lloyd‐Jones, Michelle A. Albert, Mitchell S.V. Elkind,

Heart Rate Variability and Autonomic Control

HomeCirculationVol. 144, No. 15The American Heart Association's Focus on Primordial Prevention Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBThe American Heart Association's Focus on Primordial Prevention Donald M. Lloyd-Jones, MD, ScM, Michelle A. Albert, MD, MPH and Mitchell Elkind, MD, MS, MPhil Donald M. Lloyd-JonesDonald M. Lloyd-Jones Correspondence to: Donald M. Lloyd-Jones, MD, ScM, FAHA, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0847-6110 Department of Preventive Medicine, Medicine, and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (D.M.L.-J.). , Michelle A. AlbertMichelle A. Albert Department of Medicine, Division of Cardiology, Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), University of California at San Francisco, School of Medicine (M.A.A.). and Mitchell ElkindMitchell Elkind https://orcid.org/0000-0003-2562-1156 Department of Neurology, Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York (M.E.). Originally published11 Oct 2021https://doi.org/10.1161/CIRCULATIONAHA.121.057125Circulation. 2021;144:e233–e235Medicine has enjoyed remarkable successes in the past 50 years in reducing the incidence, morbidity, and mortality of cardiovascular disease (CVD). Driven by observational studies and basic science elucidating risk factors and mechanisms of disease, interventional trials have revealed numerous effective therapies that prevent mortality and morbidity from acute CVD events (tertiary prevention); prevent recurrence of cardiovascular events in those with clinical CVD (secondary prevention); and prevent the initial incidence of CVD among those with adverse risk factor levels (primary prevention). Each of these areas has contributed to decades-long declines in CVD and stroke mortality rates across much of the world, with greater achievable impact the further upstream prevention strategies are implemented.Despite the successes of prevention in reducing the risk for CVD, there are limits. Implementation of evidence-based prevention is hampered by therapeutic inertia, economic and social factors, access to quality health care, and adherence, among many other issues. The American Heart Association's (AHA's) guidelines provide evidence-based strategies to improve levels of blood glucose, blood pressure, and blood lipids in those who have developed adverse levels, leading to a significantly lower risk for CVD and stroke events. But even perfect implementation of primary prevention among all those at risk would not abolish CVD.Lower risk achieved through the restoration of adverse risk factors to optimal levels is not the same as the lowest risk state enjoyed by those who maintain optimal levels of all risk factors into midlife. Individuals who reach midlife with optimal levels of all physiological risk factors and who do not smoke have very low (≤8%) remaining lifetime risk of developing major atherosclerotic cardiovascular events. Conversely, lifetime risks are ≈30% for those who have even just 1 risk factor at nonoptimal levels, and up to 70% for those with ≥2 clinically elevated risk factors.1In addition, patients who have elevated risk factors that are treated to restore optimal levels enjoy significant benefit, but do not fully achieve the lowest risk levels of those who always had optimal levels. For example, individuals with hypertension and a treated blood pressure of <120/<80 mm Hg were at lower risk than individuals with uncontrolled hypertension, but still at twice the risk of those who had (always) untreated blood pressure <120/ 120/80 mm Hg before treatment was associated with greater target organ damage. Indeed, an increasing left ventricular mass index was noted for those above a cumulative systolic blood pressure exposure of 3000 mm Hg-years (similar to pack-years of exposure to cigarette smoking), which would be achieved at a level of systolic blood pressure of ≥120 mm Hg for 25 years.2 Thus, there appeared to be a point of no return in cumulative blood pressure exposure beyond which restoration of optimal blood pressure with efficacious medication could not prevent all excess CVD events; in other words, despite effective therapy that lowers risk, the horse could not be put back fully in the barn. Similar recent findings suggest that statin treatment that achieves low levels of low-density lipoprotein cholesterol may not fully restore lowest risk among those who have already developed coronary artery calcification.3 These data in no way refute the remarkable benefits of primary preventive strategies demonstrated in numerous randomized, controlled trials in recent decades; they merely indicate that the remediation of risk, although successful, is less successful than the preservation of lowest risk status.The implications of these 2 lines of evidence appear clear. To maintain the lowest risk for CVD and prevent the maximum numbers of events, we must not only treat those with risk factors using evidence-based approaches, but we must also prevent the development of adverse risk factors in the first place, a concept known as primordial prevention.Worsening risk factors are not a genetically determined or a universal feature of aging. Primordial prevention with optimization of modifiable health behaviors and health policies can be very effective at preventing the development of risk factors. Young adults who follow 5 healthy lifestyle indicators (DASH [Dietary Approaches to Stop Hypertension] style eating pattern, participation in physical activity at recommended levels, normal body mass index, no cigarette smoking, and low or no alcohol use) have ≈60% probability of maintaining optimal levels of all risk factors to midlife, compared with only ≈2% of young adults who follow 0 or 1 healthy lifestyle.4 Likewise, formal lifestyle intervention strategies, such as the Diabetes Prevention Program, effectively prevent the onset of diabetes and hypertension. Specific primordial prevention strategies from infancy can also preserve ideal levels of risk factors. For example, the STRIP study (Special Turku Coronary Risk Factor Intervention Project for Children) randomly assigned 6-month-old infants and their families to individualized dietary and antismoking counseling at least every 2 years to 20 years of age. In late adolescence, those in the intervention group since infancy were more likely to have higher cardiovascular health scores and ideal cholesterol and blood pressure levels, and to follow a more heart healthy diet.5 A number of favorable cardiometabolic outcomes were maintained into young adulthood even after the intervention stopped at 20 years of age.Driven by this science, in recent years the AHA has increased focus on primordial prevention to promote health and reduce the population burden of CVD risk factors. AHA's Healthy for Good program6 and its Wellness Toolkit provide patients and clinicians with easy steps for healthier living and risk factor control. Voices for Healthy Kids7 provides information and resources for community-based and advocacy efforts to improve children's' health in schools and in their daily lives. AHA's Advocacy Program recently celebrated its 40-year anniversary and has a remarkable legacy of successful lobbying at the federal, state, and local levels for healthier schools, a healthier food supply, greater opportunities for physical activity, healthier air quality, greater access to health care, tobacco cessation, and much more. All of us can support these efforts by joining You're the Cure8 and becoming advocates. And, of course, AHA is leading the way in the science of primordial prevention. In June 2021, AHA awarded $20 million to a multicenter group, led by Dr Gbenga Ogedegbe at New York University, that will test strategies for preventing hypertension in 5 Black communities across the country, and identify sustainable and scalable ways to address the striking inequities in hypertension incidence and outcomes that affect Black Americans. These are but a few examples of AHA's commitment to primordial prevention as a key strategy for improving the health of the population, improving health equity, and being a relentless force for a world of longer, healthier lives. There is much more information for clinicians, patients, advocates, and communities at the American Heart Association website.9We must continue maximal efforts in tertiary, secondary, and primary prevention for all who need them. And there will remain individuals who develop risk factors and CVD because of important genetic influences, even with optimal primordial prevention strategies. Although inflection points arise during the lifespan after which time the likelihood of return to ideal cardiovascular health is reduced, optimism about the ability to reduce cardiovascular risk should still continue throughout the life course. It must also be acknowledged that, whereas primordial prevention is the ideal, economic and social circumstances may prevent disadvantaged populations from embracing these strategies. Large social and policy changes will be needed to realize the potential of primordial prevention. But only a strong focus on primordial prevention will help us make CVD a rare disease in the future. Additional benefits of protecting the population against other chronic diseases of aging, and against infectious diseases like coronavirus disease 2019 (COVID-19), are certain to accrue as well. Leveraging our science, advocacy, and community-based programs, the AHA will continue to champion primordial prevention.Disclosures Drs Lloyd-Jones, Albert, and Elkind serve as unpaid Officers of the American Heart Association.Footnoteshttps://www.ahajournals.org/journal/circCorrespondence to: Donald M. Lloyd-Jones, MD, ScM, FAHA, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611. Email [email protected]eduReferences1. Lloyd-Jones DM, Leip EP, Larson MG, D'Agostino RB, Beiser A, Wilson PW, Wolf PA, Levy D. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age.Circulation. 2006; 113:791–798. doi: 10.1161/CIRCULATIONAHA.105.548206LinkGoogle Scholar2. Liu K, Colangelo LA, Daviglus ML, Goff DC, Pletcher M, Schreiner PJ, Sibley CT, Burke GL, Post WS, Michos ED, et al.. Can antihypertensive treatment restore the risk of cardiovascular disease to ideal levels?: The Coronary Artery Risk Development in Young Adults (CARDIA) Study and the Multi-Ethnic Study of Atherosclerosis (MESA).J Am Heart Assoc. 2015; 4:e002275. doi: 10.1161/JAHA.115.002275LinkGoogle Scholar3. Liu K, Wilkins JT, Colangelo LA, Lloyd-Jones DM. Does lowering low-density lipoprotein cholesterol with statin restore low risk in middle-aged adults? analysis of the observational MESA Study.J Am Heart Assoc. 2021; 10:e019695. doi: 10.1161/JAHA.120.019695LinkGoogle Scholar4. Liu K, Daviglus ML, Loria CM, Colangelo LA, Spring B, Moller AC, Lloyd-Jones DM. Healthy lifestyle through young adulthood and the presence of low cardiovascular disease risk profile in middle age: the Coronary Artery Risk Development in (Young) Adults (CARDIA) study.Circulation. 2012; 125:996–1004. doi: 10.1161/CIRCULATIONAHA.111.060681LinkGoogle Scholar5. Pahkala K, Hietalampi H, Laitinen TT, Viikari JS, Rönnemaa T, Niinikoski H, Lagström H, Talvia S, Jula A, Heinonen OJ, et al.. Ideal cardiovascular health in adolescence: effect of lifestyle intervention and association with vascular intima-media thickness and elasticity (the Special Turku Coronary Risk Factor Intervention Project for Children [STRIP] study).Circulation. 2013; 127:2088–2096. doi: 10.1161/CIRCULATIONAHA.112.000761LinkGoogle Scholar6. Healthy Living.Accessed September 15, 2021. https://www.heart.org/en/healthy-livingGoogle Scholar7. American Heart Association. Voices for Healthy Kids.Accessed September 15, 2021. https://voicesforhealthykids.org/Google Scholar8. American Heart Association. You're the Cure.Accessed September 15, 2021. https://www.yourethecure.org/Google Scholar9. American Heart Association.Accessed September 15, 2021. https://www.heart.orgGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByLloyd-Jones D (2022) The Power of Patient Stories to Inspire Us to Prevent Cardiovascular Disease and Death: Personal Reflections on the AHA's Scientific Sessions 2021, Circulation, 145:5, (e143-e145), Online publication date: 1-Feb-2022. October 12, 2021Vol 144, Issue 15Article InformationMetrics Download: 494 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.121.057125PMID: 34633862 Originally publishedOctober 11, 2021 PDF download