2019 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA CLINICAL PRACTICE GUIDELINE 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Circulation https://www.ahajournals.org/journal/circ WRITING COMMITTEE MEMBERS Donna K. Arnett, PhD, MSPH, FAHA, Co-Chair Roger S. Blumenthal, MD, FACC, FAHA, Co-Chair Michelle A. Albert, MD, MPH, FAHA* Andrew B. Buroker, Esq Zachary D. Goldberger, MD, MS, FACC, FAHA Ellen J. Hahn, PhD, RN* Cheryl Dennison Himmelfarb, PhD, RN, ANP, FAHA* Amit Khera, MD, MSc, FACC, FAHA* Donald Lloyd-Jones, MD, SCM, FACC, FAHA* J. William McEvoy, MBBCh, MEd, MHS* Erin D. Michos, MD, MHS, FACC, FAHA* Michael D. Miedema, MD, MPH* Daniel Mu oz, MD, MPA, FACC* Sidney C. Smith Jr, MD, MACC, FAHA* Salim S. Virani, MD, PhD, FACC, FAHA* Kim A. Williams Sr, MD, MACC, FAHA* Joseph Yeboah, MD, MS, FACC, FAHA* Boback Ziaeian, MD, PhD, FACC, FAHA *ACC/AHA Representative. Lay Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. Task Force Performance Measures Representative. The American Heart Association requests that this document be cited as follows: Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Mu oz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e563 e595. DOI: 10.1161/CIR.0000000000000677. Key Words: AHA Scientific Statements guidelines antihypertensive agents aspirin atherosclerosis atherosclerotic cardiovascular disease atrial fibrillation behavior modification behavior therapy blood cholesterol blood pressure body mass index cardiovascular team-based care cardiovascular cardiovascular disease cholesterol chronic kidney disease coronary artery calcium score coronary disease coronary heart disease cost diet dietary patterns dietary fats dietary sodium dyslipidemia e-cigarettes exercise healthcare disparities health services accessibility heart failure hypertension LDL cholesterol diabetes mellitus lifestyle lipids measurement myocardial infarction nicotine nonpharmacological treatment nutrition physical activity prejudice primary prevention psychosocial deprivation public health quality indicators quality measurement risk assessment risk- enhancing factors risk factors risk reduction risk reduction discussion risk treatment discussion secondhand smoke sleep smoking smoking cessation social determinants of health socioeconomic factors statin therapy systems of care tobacco tobacco smoke pollution treatment adherence treatment outcomes type 2 diabetes mellitus waist circumference weight loss Endorsed by the American Associa- tion of Cardiovascular and Pulmo- nary Rehabilitation, the American Geriatrics Society, the American Society of Preventive Cardiology, and the Preventive Cardiovascular Nurses Association ACC/AHA Task Force Members, see page e577 CLINICAL STATEMENTS AND GUIDELINES TABLE OF CONTENTS Top 10 Take-Home Messages for the Primary Prevention of Cardiovascular Disease e564 Preamble e564 1. Introduction e565 1.1. Methodology and Evidence Review e566 1.2. Organization of the Writing Committee e566 1.3. Document Review and Approval e566 1.4. Scope of the Guideline e567 1.5. Class of Recommendation and Level of Evidence e567 1.6. Abbreviations e568 2. Overarching Recommendations for ASCVD Prevention Efforts e568 2.1. Patient-Centered Approaches to Comprehensive ASCVD Prevention e568 2.2. Assessment of Cardiovascular Risk e569 3. Lifestyle Factors Affecting Cardiovascular Risk e570 3.1. Nutrition and Diet e570 3.2. Exercise and Physical Activity e570 4. Other Factors Affecting Cardiovascular Risk e570 4.1. Adults With Overweight and Obesity e570 4.2. Adults With Type 2 Diabetes Mellitus e570 4.3. Adults With High Blood Cholesterol e571 4.4. Adults With High Blood Pressure or Hypertension e573 4.5. Treatment of Tobacco Use e574 4.6. Aspirin Use e575 5. Cost and Value Considerations e575 6. Conclusion e576 References e578 Appendix 1: Search Criteria e585 Appendix 2: Author Relationships With Industry and Other Entities (Relevant) e589 Appendix 3 Reviewer Relationships With Industry and Other Entities (Comprehensive) e591 TOP 10 TAKE-HOME MESSAGES FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE 1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. 2. A team-based care approach is an effective strat- egy for the prevention of cardiovascular disease. Clinicians should evaluate the social determinants of health that affect individuals to inform treat- ment decisions. 3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovas- cular disease (ASCVD) risk estimation and have a clinician patient risk discussion before starting on pharmacological therapy, such as antihyperten- sive therapy, a statin, or aspirin. The presence or absence of additional risk-enhancing factors can help guide decisions about preventive interven- tions in select individuals, as can coronary artery calcium scanning. 4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, red meat and processed red meats, refined carbohy- drates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. 5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-inten- sity physical activity. 6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations are crucial. If medication is indicated, metformin is first-line therapy, followed by consideration of a sodium- glucose cotransporter 2 inhibitor or a glucagon- like peptide-1 receptor agonist. 7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco should be assisted and strongly advised to quit. 8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. 9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels ( 190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician patient risk discussion. 10. Nonpharmacological interventions are recom- mended for all adults with elevated blood pressure or hypertension. For those requiring pharmaco- logical therapy, the target blood pressure should generally be <130/80 mm Hg. PREAMBLE Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic meth- ods to evaluate and classify evidence, provide a founda- tion for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publica- tion of clinical practice guidelines without commercial support, and members volunteer their time to the writ- ing and review efforts. CLINICAL STATEMENTS AND GUIDELINES Clinical practice guidelines provide recommenda- tions applicable to patients with or at risk of developing cardiovascular disease (CVD). The focus is on medical practice in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the goals are to improve quality of care and align with patients interests. Guidelines are intended to define practices meeting the needs of patients in most but not all circumstances and should not replace clinical judgment. Recommendations for guideline-directed manage- ment and therapy, which encompasses clinical evalua- tion, diagnostic testing, and both pharmacological and procedural treatments, are effective only when adopted by both practitioners and patients. Adherence to rec- ommendations can be enhanced by shared decision- making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated condi- tions and comorbidities. The ACC/AHA Task Force on Clinical Practice Guide- lines strives to ensure that the guideline writing com- mittee includes requisite expertise and is representative of the broader medical community by selecting experts from a broad array of backgrounds, representing dif- ferent geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and scopes of clinical practice. The ACC and AHA have rigorous policies and methods to ensure that documents are developed with- out bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found online. Beginning in 2017, numerous modifications to the guidelines have been and continue to be implemented to make guidelines shorter and enhance user friendli- ness. Guidelines are written and presented in a modu- lar knowledge chunk format, in which each chunk in- cludes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when appropriate, flow diagrams or additional tables. Hyper- linked references are provided for each modular knowl- edge chunk to facilitate quick access and review. More structured guidelines including word limits ( tar- gets ) and a web guideline supplement for useful but noncritical tables and figures are 2 such changes. This Preamble is an abbreviated version, with the detailed version available online. Patrick T. O Gara, MD, MACC, FAHA Chair, ACC/AHA Task Force on Clinical Practice Guidelines Although there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of morbidity and mortality globally.S1-1 S1-3 In the Unit- ed States, it is also the leading cause of death for peo- ple of most racial/ethnic groups, with an estimated cost of >$200 billion annually in healthcare services, medications, and lost productivity. Much of this is at- tributable to suboptimal implementation of preven- tion strategies and uncontrolled ASCVD risk factors in Most Americans who have had a myocardial infarc- tion (MI) had unfavorable levels of at least 1 cardiovas- cular risk factor before their ASCVD event.S1-4 the AHA defined a new model of ideal cardiovascular health, referred to as Life s Simple 7.S1-5 Clinicians will find the 2018 Journal of American College of Cardiol- ogy (JACC) Cardiovascular Health Promotion Series very helpful in approaching the various aspects of preven- tion with patients.S1-6 An increasing number of ideal cardiovascular health factors have been associated with a lower prevalence and incidence of ASCVD events, heart failure, atrial fibrillation, cancer, depression, and Therefore, moving individuals toward ideal cardiovascular health is critically important for prevention of many important health conditions. The ACC/AHA Task Force on Clinical Practice Guide- lines has commissioned this guideline to consolidate existing recommendations and various recent scientific statements, expert consensus documents, and clinical practice guidelines into a single guidance document fo- cused on the primary prevention of ASCVD. However, this guideline also includes newly generated recom- mendations for aspirin use, exercise and physical activ- ity, and tobacco use, in addition to recommendations related to team-based care, shared decision-making, and assessment of social determinants of health, to cre- ate a comprehensive yet targeted ACC/AHA guideline on the prevention of ASCVD. This guideline has been formatted in the modular chunk format to facilitate readability and future updating. Prevention strategies occur at the population level but must also engage individual adults to slow the de- velopment of ASCVD. The most important way to pre- vent ASCVD is to promote a healthy lifestyle through- out life. Prevention strategies must include a strong focus on lifestyle optimization (improvements in diet, physical activity, and avoidance of tobacco use and ex- posure to secondhand smoke) to minimize the risk of future ASCVD events. A comprehensive patient-centered approach that addresses all aspects of a patient s lifestyle habits and estimated risk of a future ASCVD event is the first step in deciding on where there may be a need for pharmacotherapy. Even if a blood pressure (BP) reduc- ing medication, lipid-lowering medication, or diabe- tes medication is ultimately prescribed, lifestyle goals should be emphasized on a regular basis. Only when a CLINICAL STATEMENTS AND GUIDELINES person s risk is sufficiently high should medications to reduce ASCVD risk be considered as part of a shared decision-making process for optimal treatment. In summary, clinicians and individuals should focus at- tention on living a healthy lifestyle by referring to these evidence-based recommendations to help pre- vent ASCVD. 1.1. Methodology and Evidence Review This guideline continues the ACC and AHA effort to de- sign a comprehensive yet succinct compilation of practi- cal guidance for the primary prevention of ASCVD and to promote optimal dissemination of information by us- ing concise language and formatting. The recommen- dations listed in this guideline are evidence based and supported by an extensive evidence review. A search for literature derived from research involving human sub- jects, published in English, and indexed in Ovid MED- LINE, PubMed, Cochrane Library, National Institute for Health and Care Excellence (NICE), and other selected databases relevant to this guideline, was conducted be- tween May and July 2018. For specific search terms used and years searched per section, please see Appendix 1. Randomized controlled trials (RCTs), systematic re- views of RCTs, meta-analyses, and large, United States based, high-quality cohort studies, as well as observa- tional studies and systematic reviews of observational studies, were evaluated for their content on the pre- vention of ASCVD outcomes related to the following 9 topic areas: risk assessment, diet, exercise/physical ac- tivity, obesity and weight loss, type 2 diabetes mellitus (T2DM), blood cholesterol, hypertension, smoking ces- sation, and aspirin use. Previous ACC/AHA guidelines, as well as US Preventive Services Task Force (USPSTF) reviews and other guidance relevant to this guideline, were also assessed. The final evidence tables included in the Online Data Supplement summarize the evidence used to formulate recommendations. References se- lected and published in this document are representa- tive and not all-inclusive. Avalere Health, a healthcare advisory services firm contracted by ACC/AHA, served as the document manager for this guideline to facilitate its development process. As document manager, Avalere facilitated the deliberations of the writing committee and led the modified Delphi process for establishing the Class of Recommendation and the Level of Evidence. In parallel, an independent health data and epidemiology expert, Lee Ann Prebil, conducted a systematic evidence review for the key topic of exercise and physical activity and conducted targeted literature searches to support this document s discussion of patient-centered approaches, including team-based care, shared decision-making, and assessment of social determinants of health. A targeted literature search was also conducted for this guideline s cost and value considerations. These search- es are available as downloadable Excel files. Recommendations and supportive text relevant to cardiovascular risk, blood cholesterol, and high BP were taken directly from 2 recently released ACC/AHA guide- lines, the 2017 Hypertension Clinical Practice Guideli- and the 2018 Cholesterol Clinical Practice and were adapted for the present guide- line, which aims to provide an overview of the primary prevention of ASCVD among adults. Recommendations that were adapted from previous publications are noted in the recommendation tables, and both the original published recommendation and the adapted version are provided in the guideline Web Supplement. The results of these evidence reviews were evalu- ated by the writing committee for incorporation into the present guideline. (See Table S1 in the Web Supple- ment for a list of relevant publications and statements used in support of the guideline s recommendations.) Each topic area was assigned a primary writer, as well as a primary, and sometimes secondary, reviewer. These assignments were based on areas of particular expertise of writing committee members. All recommendations were fully reviewed and discussed among the full com- mittee to allow for diverse perspectives and consider- ations for this guideline. Recommendations were then voted upon, with a modified Delphi process used to reach consensus. 1.2. Organization of the Writing Committee The writing committee consisted of clinicians, cardi- ologists, health services researchers, epidemiologists, internists, nurses, and a lay representative. The writing committee included representatives from the ACC and AHA. Appendix 2 of the present document lists writing committee members relevant RWI. For the purposes of full transparency, the writing committee members com- prehensive disclosure information is available online. 1.3. Document Review and Approval This document was reviewed by 5 official reviewers nominated by the ACC and AHA (1 reviewer from the ACC/AHA Task Force for Practice Guidelines, 2 review- ers from the AHA, and 2 reviewers from the ACC); 3 reviewers on behalf of the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Society for Nutrition, and the American So- ciety of Preventive Medicine; and 23 individual con- tent reviewers. Reviewers RWI information was dis- tributed to the writing committee and is published in this document (Appendix 3). This document was ap- proved for publication by the governing bodies of the ACC and AHA. CLINICAL STATEMENTS AND GUIDELINES 1.4. Scope of the Guideline This guideline is intended to be a resource for the clinical and public health practice communities. It addresses the primary prevention of CVD in adults ( 18 years of age), focused on outcomes of ASCVD (ie, acute coronary syndromes, MI, stable or unstable angina, arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of ath- erosclerotic origin), as well as heart failure and atrial fibrillation. The guideline presents recommendations to prevent CVD that are related to lifestyle factors (eg, diet and exercise or physical activity), other factors af- fecting CVD risk (eg, obesity, diabetes, blood choles- terol, high BP, smoking, aspirin use), patient-centered approaches (eg, team-based care, shared decision- making, assessment of social determinants of health), and considerations of the cost and value of primary prevention. 1.5. Class of Recommendation and Level of Evidence Recommendations are designated with both a Class of Recommendation (COR) and a Level of Evidence (LOE). Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated August 2015) CLINICAL STATEMENTS AND GUIDELINES The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the qual- ity of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1).S1.5-1 Abbreviation Meaning/Phrase ASCVD atherosclerotic cardiovascular disease AU Agatston units BMI body mass index BP blood pressure CHD coronary heart disease CKD chronic kidney disease CVD cardiovascular disease DASH Dietary Approaches to Stop Hypertension DBP diastolic blood pressure DM diabetes mellitus ENDS electronic nicotine delivery systems FDA US Food and Drug Administration HDL-C high-density lipoprotein cholesterol LDL-C low-density lipoprotein cholesterol MI myocardial infarction PCE pooled cohort equations RCT randomized controlled trial SBP systolic blood pressure T2DM type 2 diabetes mellitus USPSTF US Preventive Services Task Force RECOMMENDATIONS FOR ASCVD PREVENTION EFFORTS 2.1. Patient-Centered Approaches to Comprehensive ASCVD Prevention Recommendations for Patient-Centered Approaches to Comprehensive ASCVD Prevention Referenced studies that support recommendations are summarized in Online Data Supplements 1 and 2. COR LOE Recommendations I A A team-based care approach is recommended for the control of risk factors associated with ASCVD.S2.1-1 S2.1-14 I B-R Shared decision-making should guide discussions about the best strategies to reduce ASCVD risk.S2.1-15 S2.1-18 I B-NR Social determinants of health should inform optimal implementation of treatment recommendations for the prevention of Table 2 outlines key considerations related to social determinants of health and ASCVD prevention. Table 2. Example Considerations for Addressing Social Determinants of Health to Help Prevent ASCVD Events Topic/Domain Example Considerations Cardiovascular risk Adults should be routinely assessed for psychosocial stressors and provided with appropriate counseling.S2.1-26 Health literacy should be assessed every 4 to 6 y to maximize recommendation effectiveness.S2.1-27 Diet In addition to the prescription of diet modifications, body size perception, as well as social and cultural influences, should be assessed.S2.1-28,S2.1-29 Potential barriers to adhering to a heart-healthy diet should be assessed, including food access and economic factors; these factors may be particularly relevant to persons from vulnerable populations, such as individuals residing in either inner-city or rural environments, those at socioeconomic disadvantage, and those of advanced age*.S2.1-30 Exercise and physical activity In addition to the prescription of exercise, neighborhood environment and access to facilities for physical activity should be Obesity and weight loss Lifestyle counseling for weight loss should include assessment of and interventional recommendations for psychosocial stressors, sleep hygiene, and other individualized barriers.S2.1-34 S2.1-36 Weight maintenance should be promoted in patients with overweight/obesity who are unable to achieve recommended weight loss. Diabetes mellitus In addition to the prescription of type 2 diabetes mellitus interventions, environmental and psychosocial factors, including depression, stress, self-efficacy, and social support, should be assessed to improve achievement of glycemic control and adherence to High blood pressure Short sleep duration (<6 h) and poor-quality sleep are associated with high blood pressure and should be considered.S2.1-41 Because other lifestyle habits can impact blood pressure, access to a healthy, low-sodium diet and viable exercise options should also be considered. Tobacco treatment Social support is another potential determinant of tobacco use. Therefore, in adults who use tobacco, assistance and arrangement for individualized and group social support counseling are recommended.S2.1-42,S2.1-43 *Advanced age generally refers to age 75 years. ASCVD indicates atherosclerotic cardiovascular disease. Abbreviation Meaning/Phrase CLINICAL STATEMENTS AND GUIDELINES 2.2. Assessment of Cardiovascular Risk Recommendations for Assessment of Cardiovascular Risk Referenced studies that support recommendations are summarized in Online Data Supplement 3. COR LOE Recommendations I B-NR 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).S2.2-1,S2.2-2 IIa B-NR For adults 20 to 39 years of age, it is reasonable to assess traditional ASCVD risk factors at least every 4 to IIa B-NR In adults at borderline risk (5% to <7.5% 10-year ASCVD risk) or intermediate risk), it is reasonable to use additional risk-enhancing factors to guide decisions about preventive interventions (eg, statin IIa B-NR 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 IIb B-NR For adults 20 to 39 years of age and for those 40 to 59 years of age who have <7.5% 10-year ASCVD risk, estimating lifetime or 30-year ASCVD risk may be Among adults at borderline (5% to <7.5%) and inter- mediate ( 7.5% to <20%) risk, one may consider ad- ditional individual risk-enhancing clinical factors (Table 3) that can be used to revise the 10-year ASCVD risk These factors may include having a fam- ily history of premature ASCVD,S2.2-5 chronic inflam- matory disease [rheumatoid arthritis,S2.2-6 or ], South Asian ancestry,S2.2-13 a his- tory of preeclampsiaS2.2-8 or preterm delivery,S2.2-9 early chronic kidney disease (CKD), metabolic syndrome, persis- tently elevated inflammatory markers,S2.2-14 or elevat- ed lipid biomarkers.S2.2-4 After these clinically available risk-enhancing factors have been considered, if there is still uncertainty about the reliability of the risk es- timate for individuals in the borderline- or interme- diate-risk categories, further testing to document subclinical coronary atherosclerosis is reasonable to more accurately reclassify the risk estimate upward or Table 3. Risk-Enhancing Factors for Clinician Patient Risk Discussion Risk-Enhancing Factors Family history of premature ASCVD (males, age <55 y; females, age <65 y) Primary hypercholesterolemia (LDL-C 160 189 mg/dL [4.1 4.8 mmol/L]; non HDL-C 190 219 mg/dL [4.9 5.6 mmol/L])* Metabolic syndrome (increased waist circumference [by ethnically appropriate cutpoints], elevated triglycerides [>150 mg/dL, nonfasting], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 mg/dL in women] are factors; a tally of 3 makes the diagnosis) with or without albuminuria; not treated with dialysis or kidney transplantation) Chronic inflammatory conditions, such as psoriasis, RA, lupus, or HIV/AIDS History of premature menopause (before age 40 y) and history of pregnancy-associated conditions that increase later ASCVD risk, such as preeclampsia High-risk race/ethnicity (eg, South Asian ancestry) Lipids/biomarkers: associated with increased ASCVD risk Persistently elevated* primary hypertriglyceridemia ( 175 mg/dL, nonfasting); If measured: Elevated high-sensitivity C-reactive protein ( 2.0 mg/L) Elevated Lp(a): A relative indication for its measurement is family history of premature ASCVD. An Lp(a) 50 mg/dL or 125 nmol/L constitutes a risk- enhancing factor, especially at higher levels of Lp(a). Elevated apoB ( 130 mg/dL): A relative indication for its measurement would be triglyceride 200 mg/dL. A level 130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor *Optimally, 3 determinations. ABI indicates ankle-brachial index; AIDS, acquired immunodeficiency syndrome; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; HIV, human immunodeficiency virus; LDL-C, low-density lipoprotein cholesterol; Lp(a), lipoprotein (a); and RA, rheumatoid arthritis. Reproduced with permission from Grundy et al.S2.2-4 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Assessment of Cardiovascular Risk (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES 3. LIFESTYLE FACTORS AFFECTING CARDIOVASCULAR RISK 3.1. Nutrition and Diet Recommendations for Nutrition and Diet Referenced studies that support recommendations are summarized in Online Data Supplements 4 and 5. COR LOE Recommendations I B-R A diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk IIa B-NR Replacement of saturated fat with dietary monounsaturated and polyunsaturated fats can be beneficial to reduce ASCVD IIa B-NR A diet containing reduced amounts of cholesterol and sodium can be beneficial to decrease ASCVD risk.S3.1-9,S3.1-14 S3.1-16 IIa B-NR As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk.S3.1-17 S3.1-23 III-Harm B-NR As a part of a healthy diet, the intake of trans fats should be avoided to reduce 3.2. Exercise and Physical Activity Recommendations for Exercise and Physical Activity Referenced studies that support recommendations are summarized in Online Data Supplements 6 and 7. COR LOE Recommendations I B-R Adults should be routinely counseled in healthcare visits to optimize a physically I B-NR 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) to reduce ASCVD IIa B-NR For adults unable to meet the minimum physical activity recommendations (at least 150 minutes per week of accumulated moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity), engaging in some moderate- or vigorous-intensity physical activity, even if less than this recommended amount, can be beneficial to reduce ASCVD risk.S3.2-5,S3.2-6 IIb C-LD Decreasing sedentary behavior in adults may be reasonable to reduce ASCVD Other activity states that comprise a 24-hour period for an average individual include sleep, light-intensity physical activity, and sedentary behavior (Figure 1). Sedentary behavior refers to waking behavior with an energy expenditure of 1.5 metabolic equivalents while in a sitting or reclining posture (Table 4).S3.2-12 4. OTHER FACTORS AFFECTING CARDIOVASCULAR RISK 4.1. Adults With Overweight and Obesity Recommendations for Adults With Overweight and Obesity Referenced studies that support recommendations are summarized in Online Data Supplements 8 and 9. COR LOE Recommendations I B-R In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.S4.1-1 I B-R Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.S4.1-1,S4.1-2 I C-EO Calculating body mass index (BMI) is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations. IIa B-NR It is reasonable to measure waist circumference to identify those at higher 4.2. Adults With Type 2 Diabetes Mellitus See Figure 2 for an algorithm for treatment of T2DM for primary prevention of cardiovascular disease. Figure 1. Hours per day spent in various states of activity. US adults spend >7 h/d on average in sedentary activities. Replacing sedentary time with other physical activity involves increasing either moderate- to vigorous-intensity physical activity or light-intensity physical activity. Data modified from Young et al.S3.2-12 CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With Type 2 Diabetes Mellitus Referenced studies that support recommendations are summarized in Online Data Supplement 10. COR LOE Recommendations I A For all adults with T2DM, a tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-1,S4.2-2 I A Adults with T2DM should perform at least 150 minutes per week of moderate-intensity physical activity or 75 minutes of vigorous- intensity physical activity to improve glycemic control, achieve weight loss if needed, and improve other ASCVD risk factors.S4.2-3,S4.2-4 IIa B-R For adults with T2DM, it is reasonable to initiate metformin as first-line therapy along with lifestyle therapies at the time of diagnosis to improve glycemic control and reduce ASCVD risk.S4.2-5 S4.2-8 IIb B-R 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 to improve glycemic control and reduce CVD risk.S4.2-9 S4.2-14 4.3. Adults With High Blood Cholesterol Recommendations from the 2018 Cholesterol Clini- cal Practice GuidelinesS4.3-1 are included and adapted below. Table 4. Definitions and Examples of Different Intensities of Physical Activity Intensity METs Examples Sedentary behavior* 1 1.5 Sitting, reclining, or lying; watching television Light 1.6 2.9 Walking slowly, cooking, light housework Moderate 3.0 5.9 Brisk walking (2.4 4 mph), biking (5 9 mph), ballroom dancing, active yoga, recreational swimming Vigorous 6 Jogging/running, biking ( 10 mph), singles tennis, swimming laps *Sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 METs while in a sitting, reclining, or lying posture. Standing is a sedentary activity in that it involves 1.5 METs, but it is not considered a component of sedentary behavior. MET indicates metabolic equivalent; mph, miles per hour. Figure 2. Treatment of T2DM for primary prevention of cardiovascular disease. type 2 diabetes mellitus. CLINICAL STATEMENTS AND GUIDELINES Recommendations for Adults With High Blood Cholesterol Referenced studies that support recommendations are summarized in Online Data Supplements 11 and 12. COR LOE Recommendations I A In adults at intermediate risk ( 7.5% to <20% 10-year ASCVD risk), statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended.S4.3-2 S4.3-9 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I A year ASCVD risk) patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk ( 20% 10-year ASCVD risk), levels should be reduced by 50% or Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I A In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated.S4.3-11 S4.3-19 Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 I B-R In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL ( 4.9 mmol/L) or higher, maximally tolerated statin therapy is Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIa B-R In adults with diabetes mellitus who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C levels by 50% Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Figure 3. Primary prevention. Colors correspond to Class of Recommendation in Table 1. ABI indicates ankle-brachial index; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coro- nary artery calcium; CHD, coronary heart disease; HIV, human immunodeficiency virus; hs-CRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; and Lp(a), lipoprotein (a). Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Adults With High Blood Cholesterol (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES IIa B-R year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIa B-NR ASCVD risk) adults or selected borderline-risk in whom a coronary artery calcium score is measured for the purpose of making a treatment decision, AND If the coronary artery calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (eg, diabetes, family history of premature CHD, cigarette smoking); If coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients 55 years of age; If coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.S4.3-28,S4.3-34 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 IIb B-R In patients at borderline risk (5% to <7.5% 10- year ASCVD risk), in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy.S4.3-28,S4.3-35 Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines.S4.3-1 Primary ASCVD prevention requires attention to AS- CVD risk factors beginning early in life (Figure 3). The benefit from statin therapy is related to both global risk and intensity of treatment,S4.3-2 and no RCTs of high- intensity statin therapy have been carried out in cohorts of patients exclusively with diabetes. On the basis of these considerations and the fact that patients with dia- betes have a higher trajectory of lifetime risk than do those without diabetes, high-intensity statin therapy is preferred in patients with diabetes as they develop risk modifiers (Table 5). Selected examples of candidates who might benefit from knowing their coronary artery calcium score is zero are listed in Table 6. 4.4. Adults With High Blood Pressure or Hypertension Recommendations from the 2017 Hypertension Clinical are adapted below. Recommendations for Adults With High Blood Pressure or Hypertension Referenced studies that support recommendations are summarized in Online Data Supplements 13 and 14. COR LOE Recommendations I A In adults with elevated blood pressure (BP) or hypertension, including those requiring antihypertensive medications nonpharmacological interventions are recommended to reduce BP. These include: ; a heart-healthy dietary patternS4.4-6 S4.4-8 ; ; dietary potassium supplementationS4.4-14 S4.4-18 ; increased physical activity with a structured ; and Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 I SBP:A In adults with an estimated 10-year ASCVD risk* of 10% or higher and an average systolic BP (SBP) of 130 mm Hg or higher or an average diastolic BP (DBP) of 80 mm Hg or higher, use of BP-lowering medications is recommended for primary prevention of Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO Table 5. Diabetes-Specific Risk Enhancers That Are Independent of Other Risk Factors in Diabetes Mellitus Risk Enhancers in Diabetic Patients Long duration ( 10 years for T2DMS4.3-36 or 20 years for type 1 diabetes ) Albuminuria 30 mcg albumin/mg creatinineS4.3-37 ABI indicates ankle-brachial index; eGFR, estimated glomerular filtration rate; and T2DM, type 2 diabetes mellitus. Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Table 6. Selected Examples of Candidates for Coronary Artery Calcium Measurement Who Might Benefit From Knowing Their Coronary Artery Calcium Score Is Zero Coronary Artery Calcium Measurement Candidates Who Might Benefit from Knowing Their Coronary Artery Calcium Score Is Zero Patients reluctant to initiate statin who wish to understand their risk and potential for benefit more precisely Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms Older patients (men 55 80 y of age; women 60 80 y of age) with low burden of risk factorsS4.4-42 who question whether they would benefit from statin therapy Middle-aged adults (40 55 y of age) with PCE-calculated 10-year risk for ASCVD 5% to <7.5% with factors that increase their ASCVD risk, although they are in a borderline risk group. Caveats: If patient is at intermediate risk and if a risk decision is uncertain and a coronary artery calcium score is obtained, it is reasonable to withhold statin therapy unless higher-risk conditions, such as cigarette smoking, family history of premature ASCVD, or diabetes mellitus, are present and to reassess the coronary artery calcium score in 5 to 10 years. Moreover, if coronary artery calcium is recommended, it should be performed in facilities that have current technology and expertise to deliver the lowest radiation possible. ASCVD indicates atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol; and PCE, pooled cohort equations. Reproduced with permission from Grundy et al.S4.3-1 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. Recommendations for Adults With High Blood Cholesterol (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES I SBP:B-RSR In adults with confirmed hypertension and a 10-year ASCVD event risk of 10% or higher, a BP target of less than 130/80 mm Hg is Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR In adults with hypertension and chronic kidney disease, treatment to a BP goal of less than 130/80 mm Hg is Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I SBP:B-RSR In adults with T2DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher, with a treatment goal of less than 130/80 Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 DBP:C-EO I C-LD In adults with an estimated 10-year ASCVD risk <10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher, initiation and use of BP-lowering medication Adapted from recommendations in the 2017 Hypertension Clinical Practice Guidelines.S4.4-1 IIb SBP:B-NR In adults with confirmed hypertension without additional markers of increased ASCVD risk, a BP target of less than 130/80 mm Hg may be reasonable.S4.4-59 S4.4-62 Adapted from recommendations in the 2017 Hypertension Clinical Practice DBP:C-EO *ACC/AHA pooled cohort equations to estimate 10-year risk of ASCVD. See Figure 4 for the BP thresholds and treatment rec- ommendations algorithm and refer to the 2017 Hyper- tension Clinical Practice Guidelines for comprehensive See Table 7 for recommended dose and approximate impact on SBP. 4.5. Treatment of Tobacco Use Recommendations for Treatment of Tobacco Use Referenced studies that support recommendations are summarized in Online Data Supplements 15 and 16. COR LOE Recommendations I A All adults should be assessed at every healthcare visit for tobacco use and their tobacco use status recorded as a vital sign to facilitate tobacco cessation.S4.5-1 I A To achieve tobacco abstinence, all adults who use tobacco should be firmly advised I A In adults who use tobacco, a combination of behavioral interventions plus pharmacotherapy is recommended to maximize quit rates.S4.5-2,S4.5-3 I B-NR In adults who use tobacco, tobacco abstinence is recommended to reduce IIa B-R To facilitate tobacco cessation, it is reasonable to dedicate trained staff to tobacco treatment in every healthcare III: Harm B-NR All adults and adolescents should avoid secondhand smoke exposure to reduce In alignment with previous expert consensus regard- ing strategies for tobacco cessation,S4.5-7 Table 8 sum- marizes recommended behavioral interventions and pharmacotherapy for tobacco treatment. There are 7 FDA-approved cessation medications, including 5 forms of nicotine replacement. Note that the black box warn- ings about neuropsychiatric events have been removed by the FDA.S4.5-8,4.5-9 Figure 4. BP thresholds and recommendations for treatment. Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; and CVD, cardiovascular disease. Adapted with permission from Whelton Copyright 2017, American College of Cardiology Foundation and the American Heart Association, Inc. Recommendations for Adults With High Blood Pressure or Hypertension (Continued) COR LOE Recommendations CLINICAL STATEMENTS AND GUIDELINES 4.6. Aspirin Use Recommendations for Aspirin Use Referenced studies that support recommendations are summarized in Online Data Supplements 17 and 18. COR LOE Recommendations IIb A Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding III: Harm B-R Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.S4.6-9 III: Harm C-LD Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of 5. COST AND VALUE CONSIDERATIONS The growing need to consider value stems directly from the goal of achieving the best possible health outcomes with finite healthcare resources in the pri- mary prevention of CVD.S5-1 Value in healthcare can be defined as the incremental health benefits of a therapy or procedure relative to its incremental net long-term costs. The consideration of cost and value in the guideline development process supports key goals, including: 1) enhancing overall value in the de- livery of cardiovascular care and 2) involving health- care professionals in the challenging care decisions that must be made to increase value in the US health- The integration of value assessments into our na- tional guidelines involves inherent methodological chal- lenges, including: 1) variability in costs across different healthcare settings; 2) variability in costs and benefits across different patient subgroups; 3) variability over time; 4) variability in who bears the burden of the health outcome (ie, typically the individual patient) ver- sus who bears the burden of the healthcare cost (eg, often spread beyond the individual to third-party pay- ers, taxpayers); and 5) an inadequate literature base on which to render a sound, evidence-based assessment of certain specific therapies.S5-1,S5-2 There are additional challenges specific to the pre- vention realm. As described in the 2011 AHA policy statement, Value of Primordial and Primary Prevention Table 7. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* Nonpharmacological Intervention Goal Approximate Impact on SBP Hypertension Normotension Reference Weight loss Weight/body fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. Healthy diet DASH dietary pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Reduced intake of dietary sodium Dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. Enhanced intake of dietary potassium Dietary potassium Aim for 3500 5000 mg/d, preferably by consumption of a diet rich in potassium. Physical activity Aerobic 90 150 min/wk 65% 75% heart rate reserve Dynamic resistance 90 150 min/wk Isometric resistance 4 2 min (hand grip), 1 min rest between exercises, 30% 40% maximum voluntary contraction, 3 sessions/wk Moderation in alcohol intake Alcohol consumption In individuals who drink alcohol, reduce alcohol to: Men: 2 drinks daily Women: 1 drink daily *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. Detailed information about the DASH diet is available via the NHLBIS4.4-65 In the United States, 1 standard drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).S4.4-64 BP indicates blood pressure; DASH, Dietary Approaches to Stop Hypertension; NHLBI, National Heart, Lung, and Blood Institute; and SBP, systolic blood pressure. Reproduced with permission from Whelton et al.S4.4-1 Copyright 2017, American College of Cardiology Foundation and the American Heart Association, Inc. CLINICAL STATEMENTS AND GUIDELINES Assessing the value of prevention in appar- ently healthy patients is generally more difficult than evaluating therapy for established disease because the time horizon to the clinical mani- festation of disease is generally long many decades in the young. Thus, it is difficult, per- haps impossible, to assess long-term effective- ness in terms of survival or quality-adjusted life-years (QALYs) or associated costs because of increasing uncertainty about outcome the fur- ther one tries to look into the future. Furthermore, the principle of discounting, which places relative emphasis on current costs and benefits while deemphasizing downstream costs and benefits, creates disadvantages for prevention because costs of- ten accrue in the present while the benefit may only be fully realized long into the future. These methodologi- cal challenges notwithstanding, prior AHA statements have highlighted the public policies, community efforts, and pharmacological interventions that are likely to be cost-effective and, at times, cost-saving prevention tac- tics compared with common benchmarks. For example, robust evidence suggests that both antihypertensive and statin therapy,S5-7 S5-9 particularly with low-cost generic drug formulations, are high-value inter- ventions across a wide spectrum of risk and age strata. The incorporation of the value category into clinical practice guidelines is one of several considerations in medical decision-making and resource allocation. Clini- cians, researchers, and policymakers alike must contin- ue to place cost-effective analyses in the proper context, extracting key value determinations while acknowledg- ing the challenges in fully characterizing and incorpo- rating the downstream benefits of a given therapeutic prevention tactic. Further research and methodological advances are needed to comprehensively characterize the full spectrum of benefits produced by the preven- tion approach, thereby rendering cost-effectiveness as- sessments more consequential to clinical practice. Most ASCVD events are avoidable through primordial prevention (ie, the prevention of risk factor develop- ment) and control of traditional cardiovascular risk factors. Tobacco avoidance is critically important for ASCVD prevention, and all adults should strive to en- gage in regular brisk physical activity most days of the Table 8. Highlights of Recommended Behavioral and Pharmacotherapy Tobacco Treatment Modalities for Prescribers* Timing of Behavioral Interventions <3 min of tobacco status assessment with cessation counseling at each clinic encounter >3-10 min of tobacco status assessment with cessation counseling at each clinic encounter >10 min of tobacco status assessment with cessation counseling at each clinic encounter Treatment Dosing Precautions NRT* Patch 21 mg, 14 mg, or Starting dose: 21 mg for 10 CPD; 14 mg for <10 CPD Local irritation possible; avoid with skin disorders; may remove for sleep if needed Gum 2 mg or 4 mg Starting dose: 4 mg if first tobacco use is 30 min after waking; 2 mg if first tobacco use is >30 min after waking; maximum of 20 lozenges or 24 pieces of gum/d. Chew and park gum* Hiccups/dyspepsia possible; avoid food or beverages 15 min before and after use Lozenge 2 mg or 4 mg Nasal spray 10 mg/mL Starting dose: maximum of 40 doses/d Local irritation possible; avoid with nasal or reactive airway disorders Oral inhaler 10-mg cartridge Starting dose: Puff for 20 min/cartridge every 1-2 h; maximum 16 cartridges/d Cough possible; avoid with reactive airway disorders Other Bupropion (Zyban [GlaxoSmithKline], Wellbutrin SR [GlaxoSmithKline]) 150 mg SR 150 mg once daily (am) for 3 d; then 150 mg twice daily; may use in combination with NRTS4.5-9 Avoid with history/risk of seizures, eating disorders, MAO inhibitors, or CYP 2D6 inhibitor Varenicline (Chantix [Pfizer]) 0.5 mg or 1 mg 0.5 mg once daily (am) for 3 d; then 0.5 mg twice daily for 4 d; then 1 mg twice daily (use start pack followed by continuation pack) for 3-6 mo Nausea common; take with food. Renal dosing required. Very limited drug interactions; near-exclusive renal clearance. *CPD can guide dosing. 1 CPD is 1-2 mg of nicotine. Note: Use caution with all NRT products for patients with recent ( 2 wk) MI, serious arrhythmia, or angina; patients who are pregnant or breastfeeding; and adolescents. Timing of assessment relates to ICD-10 coding. Dose and duration can be titrated on the basis of response.S4.5-9 The FDA has issued a removal of black box warnings about neuropsychiatric events.S4.5-8,S4.5-9 am indicates morning; CPD, cigarettes smoked per day; FDA, US Food and Drug Administration; ICD-10, International Classification of Diseases, Tenth Revision; MAO, monoamine oxidase; NRT, nicotine replacement; and SR, sustained release. CLINICAL STATEMENTS AND GUIDELINES week and adhere to a healthy dietary pattern to help lower future ASCVD risk. A diet high in fruits, veg- etables, and whole grains is best. Fish, legumes, and poultry are the preferred sources of protein. Minimizing the consumption of trans fats, added sugars (includ- ing sugar-sweetened beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in partnership with patients to assess their readi- ness for sustained lifestyle improvements, identify po- tential barriers to change, and encourage them to try to achieve measurable goals and continue to monitor Finally, social determinants of ASCVD risk and their impact on the patient s ability to prevent or treat risk factors must be taken into account. Clini- cians need to consider patients health literacy and edu- cation levels and assess patients motivation to improve their lifestyle habits. The goal of the clinician is to match the intensity of preventive efforts with an individual s absolute risk of a future ASCVD event and with the individual s willing- ness and capacity to implement preventive strategies. Risk estimation is imperfect and based on group aver- ages that are then applied to individual patients. The clinician must balance an understanding of a patient s estimated ASCVD risk with potential benefits and ad- verse risk from pharmacological therapy in the context of a risk discussion. To determine the appropriateness of pharmacological therapy after quantitative risk estima- tion in cases that are unclear, risk-enhancing factors or selective use of a coronary artery calcium measurement can inform decision-making for cholesterol-lowering or antihypertensive medication use in intermediate-risk in- dividuals. This primary-prevention guideline strives to provide clinicians with the information they need to help their patients reduce their risk of ASCVD and encourage them to make healthier lifestyle changes when needed. ACC/AHA TASK FORCE MEMBERS Patrick T. O Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA; Kim K. Birtcher, PharmD, MS, AACC; Joaquin E. Cigarroa, MD, FACC; Anita Deswal, MD, MPH, FACC, FAHA; Lee A. Fleisher, MD, FACC, FAHA; Federico Gentile, MD, FACC; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Mark A. Hlatky, MD, FACC, FAHA; John Iko- nomidis, MD, PhD, FAHA*; Jos A. Joglar, MD, FACC, FAHA; Laura Mauri, MD, MSc, FAHA*; Mariann R. Piano, RN, PhD, FAHA; Barbara Riegel, PhD, RN, FAHA*; Duminda N. Wijeysundera, MD, PhD PRESIDENTS AND STAFF American College of Cardiology C. Michael Valentine, MD, FACC, President Timothy W. Attebery, MBA, FACHE, Chief Executive Officer William J. Oetgen, MD, MBA, FACC, Executive Vice Presi- dent, Science, Education, Quality, and Publishing MaryAnne Elma, MPH, Senior Director, Science, Educa- tion, Quality, and Publishing Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing American College of Cardiology/ American Heart Association Katherine A. Sheehan, PhD, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Senior Manager, Guideline Science Thomas S.D. Getchius, Manager, Guideline Operations American Heart Association Ivor Benjamin, MD, FAHA, President Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations Cammie Marti, PhD, MPH, RN, Science and Medicine Advisor, Office of Science Operations Jody Hundley, Production and Operations Manager, Scientific Publications, Office of Science Operations ARTICLE INFORMATION This document was approved by the American College of Cardiology Clinical Policy Approval Committee, the American Heart Association Science Advisory and Coordinating Committee, and the American Heart Association Executive Committee in February 2019. Supplemental materials are available with this article at https://www. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the websites of the American College of Cardiology (www.acc.org) and the American Heart Association (professional.heart.org/). A copy of the document is also available at https:// professional.heart.org/statements by selecting the Guidelines & Statements button. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@ wolterskluwer.com. The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guide- lines development, visit https://professional.heart.org/statements. Select the Guidelines & Statements drop-down menu near the top of the web page, then click Publication Development. Permissions: Multiple copies, modification, alteration, enhancement, and/ or distribution of this document are not permitted without the express permis- sion of the American Heart Association. Instructions for obtaining permission are are located at https://www.heart.org/permissions. 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