Primary prevention of cardiovascular disease

CME credit available from Harvard Medical School through January 2025.

Published Materials

Cardiovascular disease (CVD) is a major cause of death in men and women in the U.S.1 Yet evidence-based strategies can reduce CVD risk, such as lipid-lowering therapy, healthful diet and physical activity, controlling high blood pressure, tobacco cessation and managing diabetes. Aspirin no longer has a role in primary prevention of CVD, especially in older adults.

This module helps primary care clinicians to apply evidence-based practices for the primary prevention of CVD, such as prescribing lipid-lowering therapy, recommending lifestyle interventions, and limiting the role of aspirin. Providing recommendations to prevent a first occurrence of CVD begins by understanding a patient’s CVD risk. A validated tool like the Pooled Cohort Equation (PCE), also called ASCVD Risk Estimator Plus, uses age, sex, race, blood pressure and related treatment, cholesterol, diabetes and smoking status to help determine risk.2

Risk assessment helps decide on recommending a statin for primary prevention³

For primary prevention, in most cases the goal of statin therapy does not require achieving a given LDL level, as long as the patient takes the medication.

Risk factors can help determine if a statin is needed for a patient with intermediate risk. A coronary artery calcium (CAC) score may help patients in which risk is not clear decide on a statin. In older patients a CAC score may be less useful.4 See the Evidence Document above for more detailed information.

Older adults (age 75 and older) may still benefit from a statin. Don’t stop or withhold a statin based on age alone.5-7

Lifestyle modification can be a powerful way to reduce CVD risk.

Plant-predominant diets, such as the Mediterranean diet or DASH diet, can lower CVD risk by 25-30%.8,9 A combination of strength or resistance training and aerobic exercise has a large effect on CVD risk.

Encouraging behavior change may help patients.

Using the 5 A’s can help start the conversation.

1. Assess the patient’s current behaviors and readiness for change.
2. Advise with recommendations tailored to a patient’s risk factors.
3. Agree on SMART goals that have clear links to action.
4. Assist the patient to overcome their own specific barriers.
5. Arrange follow-up with resources and support.

SMART goals provide a structure to create small, actionable goals that help patients change behaviors:

Specific: “What do you want to do?”
Measurable: “How will you know when you’ve reached it?”
Achievable: “Is it in your power to accomplish it?”
Realistic: “Can you realistically achieve it?”
Timely: “When exactly do you want to accomplish it?”

For most patients, especially adults over age 60, the risks of aspirin outweigh the benefit for the primary prevention of CVD.3,10

*Risk factors for bleeding include advanced age, use of non-steroidal anti-inflammatory medications or anti-platelet agents, or a history of gastrointestinal or other major bleeding.

Resources for Providers
Resources for Patients

Information current at time of publication, February 2022.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.

  1. National Center for Health Statistics, Centers for Disease Control and Prevention. Health, United States, 2018 – Data Finder. Published October 30, 2019. Accessed November 29, 2021.
  2. Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Circulation. 2019;139(25):e1162-e1177.
  3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Journal of the American College of Cardiology. 2019;74(10):e177-e232.
  4. Pletcher MJ, Sibley CT, Pignone M, Vittinghoff E, Greenland P. Interpretation of the coronary artery calcium score in combination with conventional cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2013;128(10):1076-1084.
  5. Giral P, Neumann A, Weill A, Coste J. Cardiovascular effect of discontinuing statins for primary prevention at the age of 75 years: a nationwide population-based cohort study in France. Eur Heart J. 2019;40(43):3516-3525.
  6. Orkaby AR, Driver JA, Ho YL, et al. Association of Statin Use With All-Cause and Cardiovascular Mortality in US Veterans 75 Years and Older. Jama. 2020;324(1):68-78.
  7. Yourman LC, Cenzer IS, Boscardin WJ, et al. Evaluation of Time to Benefit of Statins for the Primary Prevention of Cardiovascular Events in Adults Aged 50 to 75 Years: A Meta-analysis. JAMA Intern Med. 2021;181(2):179-185.
  8. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). Bmj. 2007;334(7599):885-888.
  9. Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. N Engl J Med. 2018;378(25):e34.
  10. Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in Older Adults With Cardiovascular Disease. J Am Coll Cardiol. 2019;73(20):2584-2595.