 Welcome everyone, and I want you to thank Dr. Joe Rogers as well as Dr. Juan Carlos Plana for this opportunity to talk to you about prevention of cardiovascular disease. What do the guidelines say? Now, as you all know, that this is a very vast space for ACC AHA. We've had three major guidelines that have come out in the last five years, and those include the 2017 hypertension guideline, the 2018 ACC AHA cholesterol management guideline, and the 2019 prevention of cardiovascular disease guideline. So I would talk about those three guidelines in terms of what we can do to prevent cardiovascular disease in our patients. And one other thing I will mention here is that this is preventing first event from happening in our patients. We are not talking about secondary prevention that is preventing a recurrent event in a patient who already had a cardiovascular disease event. Now when we talk about cardiovascular disease prevention, please understand that the kind of patients that I'm talking about are patients who have not had their cardiovascular disease event yet. So what we're trying to do is to prevent the first event from happening in those patients. And the other thing I would like to emphasize here is that when we use the term cardiovascular disease, it's a very broad term. It's not just patients with ordinary artery disease or history of MI that we usually see, but it also includes patients with history of stroke or it includes patients with PLE. So when we're trying to prevent those cardiovascular events, it's not just the prevention of myocardial infarction. It's also prevention of stroke. It's also prevention of peripheral arterial disease. Interestingly, in the last decade or so, there has been a lot of work in even expanding that definition to prevention of heart failure, which has become a very, very important clinical and research topic, as well as prevention of atrial fibrillation. So when I talk about prevention of cardiovascular disease in the next 15 to 18 minutes that we have, what you will notice is that implementing those strategies does not only reduce the risk of MI, it includes the risk of other atrial sclerotic cardiovascular disease, as well as heart failure and prevention. So please keep that in mind when we are trying to talk about cardiovascular disease as to what that entails. So as I said, I'm going to give you an easy A-B-C-D-E approach to cardiovascular disease prevention. So A includes assessing risk of cardiovascular events in a patient. A also includes for antiplatelet therapy. For example, aspirin. What's the role of aspirin now in primary prevention? B is for blood pressure. C is for cholesterol. C is also for cigarette or tobacco cessation or tobacco products. C is also for context of care, what we now call the social determinants of health. D is for diet and weight management. D is also for diabetes prevention and treatment. And E is for exercise, which is really talking about physical activity. So I'll try to very quickly give you some take-home messages related to each of these A-B-C-D-Es of cardiovascular disease prevention. In terms of assessing risk, if you look at the ACC-AHA guidelines, they recommend performing a 10-year risk calculation for assessing the risk of first cardiovascular event in patients 40 to 75 years of age. And that is recommended doing what we call pool cohort risk equations, which are sex and race specific. And you might ask the question, why do I need to do a 10-year risk calculation? So here I have data related to both cholesterol lowering as well as blood pressure lowering. These are the most, I would say, strong evidence we have for blood pressure and cholesterol lowering because these are patient level meta-analysis. What you will notice here is that for the same amount of LDL cholesterol lowering, whether it's 1.5 millimoles or 2 millimoles, each millimole is about 3940 milligrams per deciliter, what you will notice here is that the number of vascular events that are prevented for the same amount of cholesterol lowering are much higher as the baseline risk of the patient goes up. The same holds true for systolic blood pressure lowering or diastolic blood pressure lowering. So if we do not know our patient's baseline risk, we will not be able to tailor therapy to identify those patients who are going to derive the most benefit from cholesterol lowering, blood pressure lowering, and the same holds true for any other lifestyle or medication related strategy that we may use to reduce cardiovascular disease related risk in our patients and that's why we should perform 10-year risk in all patients that we see. And if you look at this approach and doing it in patients who are 40 to 75 years of age, what you will notice is that if the risk is less than 10% or less than 5% rather, that is low risk. In both patients, all we need to do is emphasize lifestyle, which is extremely important. If the patients have a 10-year risk that's more than or equal to 20%, we don't need to do anything else. We need to go ahead and do lifestyle and start stacking therapy preferably high intensity stacking therapy because these are very high risk patients. If the patient otherwise falls into what we call the borderline or intermediate risk category, then in those patients, one foot starts stacking therapy because stacking therapy works when you have a 10-year risk of 5 to 20%, but then if there is any ASCVD risk enhancers, for example, family history of premature cardiovascular disease, which is not picked up in the 10-year risk calculation. If the patient has borderline elevated LDL cholesterol, if they have chronic kidney disease, metabolic syndrome, women's specific risk enhancers, for example, preeclampsia, premature menopause, inflammatory bowel disease, saudation, ethnicity, persistently elevated triglycerides, high lp-litylae, high HHCRP, in those patients, again, clinicians could start therapy early on because these patients likely have a high lifetime risk of cardiovascular events. And if after these two steps of doing the risk calculation, personalizing the risk based on patient's risk enhancers, if there's still doubt, then a coronary calcium score could be done by clinicians and if the score is zero, then one could withhold stacking therapy for five years. So if I have to summarize these three steps, I call it the CPR approach. Calculate risk, personalize risk based on patient's risk enhancers, and then some patients reclassify risk using coronary artery calcium score, the so-called CPR approach. The way I talk to our residents and fellows about this is do CPR now so you don't have to do CPR later on. And remember at each of these steps, communication with patients is extremely, extremely important. So the other A we have here is aspirin. We've had multiple trials now in the last, I would say, seven to eight years where aspirin does not seem to work in primary prevention. The three most recent ones I have there, Ascent, which was done in patients with diabetes, Arrived, which was done in patients with moderate CBD risk, as well as Esprit, which was done in older adults. And each of these trials, we either did not have benefit from aspirin or the benefit from aspirin was outweighed by an increased risk of bleeding. And that is why when you look at the guidelines now, aspirin is really recommended as a 2B recommendation, something that might be considered in primary prevention of cardiovascular disease only for a specific age segment of 40 to 75 in those patients who are higher risk of ACVD, but at the same time, they are not at increased risk of bleeding. So whenever aspirin is prescribed in primary prevention, not secondary prevention, in primary prevention, it's not just the ACVD risk we need to look at. We also need to look at the bleeding risk of the patient. If the patient has high bleeding risk, doesn't matter what their ACVD risk is, aspirin is contraindicated. Similarly, for patients 70 years, above 70 years of age, aspirin should not be used because it's associated with increased risk of bleeding. So the aspirin used, the window has actually shrunk a little bit in the last 10 years or so. So it has to be used sparingly in some very high risk patients. Again, B is for blood pressure control and here I'll give you some very big messages from the 2017 hypertension guideline. First concept, that stage one hypertension now is systolic blood pressure above 130 up to 139 and diastolic is 80 to 89. So rather than 140 as the beginning of stage one, now it's 130. In fact, at stage two, hypertension is when your systolic is already hitting 140 millimeters of mercury systolic or 90 of diastolic. The second concept is that in most patients with hypertension, the goal for treatment is now a systolic of less than 130 millimeters of mercury for cardiovascular disease prevention. So we have become more stringent when it comes to blood pressure control in our patients. So we talked about the A's of cardiovascular disease prevention. We talked about the B, let's move on to C, which is cholesterol management. We briefly talked about cholesterol management when we talked about the risk assessment piece. Now there are groups where we don't do risk assessment and directly treat them because they're baseline high risk. And those include patients with LDL cholesterol of 190 or higher. In these patients, the recommendation is not to perform 10-year risk calculation, but rather treat them so they don't get their first M.I. at the age of 40, 45, even before they are eligible for 10-year risk assessment. The second group of patients with diabetes age 40 to 75 years. In these patients, again, we treat them early on. And then the third group we talked about is the high risk based on actual 10-year risk calculation. So when you have these three high-risk patients, patients with LDL cholesterol 190 or higher, doesn't matter what their 10-year risk is, patients with diabetes between the ages of 40 to 75 years, as well as patients in whom risk assessment is performed and their 10-year risk is 20% or higher. These are high-risk patients in whom cholesterol should be lowered by using either a moderate but preferably a high-intensity statin therapy because these are the patients who will derive the most benefit from aggressive cholesterol lowering as we discussed because their absolute risk of having a cardiovascular event is so high. C is also for cigarette smoking and other tobacco products. And I've used the term other tobacco products because we know that other products like hookah and e-cigarettes are actually also increasing. The concepts here are that every minute that we as healthcare professionals spend with our patient talking about smoking cessation or cessation of other tobacco products, it works. Every minute leads to a higher quit rate for smoking as well as other tobacco products. And then we have two products on the market that really help patients quit their tobacco or cigarette and that includes bupropion as well as verinocline. So these medications can be used if we need to use them on our patients who are either smoking cigarettes or other tobacco products. So again, remember counseling is extremely important. Medications can also be used to serve as aid in addition to counseling, not as a replacement to smoking cessation counseling. C is also for context, understanding the social determinants of health, seeing where our patients are coming from. If we prescribe our patients the best diet and then the best recommendations related to physical activity, but if the patients really live in a neighborhood where they don't have access to healthy food or if they cannot walk safely, then all of those recommendations do not matter. If we work on giving healthcare access to our patients in terms of giving them insurance, but the patient doesn't have transportation to be at the visit with their healthcare clinician with their primary care or their specialist, it's not going to work. If they have food insecurity, giving any kind of dietary advice is not going to work. So C in terms of understanding the context where our patients are coming from and tailoring our recommendation that they hold true in the context of that particular patient is extremely, extremely important. This is important not just for cardiovascular disease prevention, but for anything that we do with our patients. Now D is for diet and the four main principles here are that we're not going to talk about a particular diet. A dietary pattern is what's more important. So again, a diet emphasizing high intake of vegetables, fruits, legumes, nuts, whole grains and fish is what's recommended as a class one recommendation, something that should be done. Replacing saturated fat with mono and polyunsaturated fat and be beneficial. The third is reducing sodium and cholesterol in the diet. And the fourth principle is to minimize intake of processed meats, refined carbohydrates and sweetened beverages. Really these are the four main messages that we need to provide to our patients and keep talking about them, give them practical advice as to what food choices they have, what can they switch around that will go a long way rather than a particular diet. A dietary pattern is more important. D is also for diabetes and I remember when we came out with 2019 prevention guidelines, we actually had this diagram and the way this field has evolved so quickly, even this has become irrelevant at this point. What we said was yes, do diet, diet and physical activity in patients with diabetes, but then start metformin on everyone and then if hemoglobin A1C remains high, then use SGLT2 inhibitors and GLP1 receptor admins. Well, we have so much data now, even in the last two years with this class of medication that they reduce risk of ACVD, atherosclerotic cardiovascular disease, they are very powerful tool against prevention of heart failure in patients without history of heart failure as well as those with history of heart failure, as well as prevention of chronic kidney disease that they have become front and center of diabetes treatment. And you'll hear more about it in the heart failure section when Dr. Baskar and Dr. Rogers talk about it. But this is what the ADA is recommending now, that if you have patients who have high risk of cardiovascular events, then go ahead and use an SGLT2 inhibitor or a GLP1 receptor agonist, even before you use metformin, you have that option. On the other hand, if you have patients with established cardiovascular disease, which is not what I'm talking about, you definitely should use GLP1 receptor agonist or an SGLT2 inhibitor. If you have heart failure, then SGLT2 inhibitors are recommended. And when you have CKD, again, you could use SGLT2 inhibitors or GLP1 receptor agonist who've shown to be of benefit in CKD patients. So the whole field has been transformed from just controlling A1C levels to now actually having, in our toolbox, medications that actually lower cardiovascular disease event rates and prevent development of first heart failure or atherosclerotic cardiovascular disease event. So extremely important group of medications. The earlier trials included quite a few of secondary prevention patients. But as these clinical trials have been performed using these medications, we have more and more patients who are purely in the primary prevention space who also seem to derive similar benefit from prevention of cardiovascular disease as far as the use of these medications is concerned. So we really need to look into how we can improve more and more evidence-based use of these medications in our patients with diabetes. Now E is for exercise and the term here is physical activity. The concepts are, you will notice that in the guidelines, we have removed the word exercise. We just talk about physical activity and the reason for that is that if you use the word exercise, it can be deflating for some of our patients and we know that physical activity is what matters. The second concept is it's 150 minutes per week of market or 75 minutes per week of vigorous accumulated physical activity. The word that is missing there is bouts because any physical activity that we do, which is accumulated matter. So even five minute walk is good as long as we are getting 150 minutes per week of moderate or 75 minutes per week of vigorous. The other thing I want you to notice here is that it's a curvilinear association. You get the most bang for your buck in this steep early portion of the curve. So at a population level, getting our most sedentary patients to increase the physical activity will provide us the most dividend. Even if they don't get to the goal, getting them out and having them increase their physical activity will give us the most bang for our buck as a society. So making sure that any amount of physical activity is better than no physical activity should also be emphasized to our patients. So those were the ABCDEs, but I wanted to end with one other concept and that is that prevention is a team sport, making sure that we are leveraging all the members of the CV team. That includes our nurses, that includes our nurse practitioners, that includes our physician assistants, that includes our pharmacists. We have a lot of data showing that control of cardiovascular risk factors is the best when we all, including physicians, nurses, physician assistants, pharmacists, when everybody works together, we have better outcomes in terms of control of cardiovascular risk factor than just one member of the team. So again, this was our ABCD approach, A is for assessing risk, A is for antiplatelet therapy, B is for blood pressure control, C is for cholesterol, cigarette and tobacco cessation, C is also for context understanding where the patient is coming from in terms of their built environment and their social determinants, diet and weight management, diabetes prevention and treatment, and E is for exercise which, as I said, we should use the word physical activity. I hope you found this useful. I'll end with this proverb, which really summarizes these concepts in three lines. The secret to living well and longer is eat half, walk double, laugh triple and love without measure. With that, I'll stop and thank you for your time.