Summary

Comprehensive ACC/AHA guideline consolidating primary prevention of ASCVD, heart failure, and atrial fibrillation in adults. Emphasizes healthy lifestyle as foundation, 10-year ASCVD risk estimation via Pooled Cohort Equations to guide pharmacotherapy decisions, and shared decision-making augmented by risk-enhancing factors and coronary artery calcium scoring. New recommendations downgrade routine aspirin for primary prevention, endorse SGLT-2 inhibitors/GLP-1 agonists for T2DM with high ASCVD risk, and address team-based care and social determinants of health.

Key Recommendations

Estimate 10-year ASCVD risk using the race/sex-specific Pooled Cohort Equations in adults 40–75 years before initiating statin, antihypertensive, or aspirin therapy.
In borderline (5–<7.5%) or intermediate (≥7.5–<20%) risk adults, use risk-enhancing factors and consider coronary artery calcium (CAC) scoring to refine statin decisions; CAC=0 generally permits withholding statin (except in smokers, diabetes, family history of premature ASCVD).
Prescribe moderate-intensity statin for all adults 40–75 years with diabetes regardless of risk score; use high-intensity statin if multiple ASCVD risk factors present.
Start high-intensity statin (LDL-C reduction ≥50%) for primary severe hypercholesterolemia (LDL-C ≥190 mg/dL) without risk calculation.
Recommend a plant-forward diet (vegetables, fruits, nuts, whole grains, legumes, fish, lean protein); minimize trans fats, processed/red meat, refined carbohydrates, sodium, and sugar-sweetened beverages.
Counsel ≥150 min/week moderate-intensity or ≥75 min/week vigorous-intensity aerobic activity; reduce sedentary behavior.
Metformin is first-line pharmacotherapy for T2DM; add an SGLT-2 inhibitor or GLP-1 receptor agonist in patients with T2DM and additional ASCVD risk factors for cardiovascular benefit.
Initiate antihypertensive therapy at BP ≥130/80 mm Hg in adults with clinical ASCVD, diabetes, CKD, or 10-year ASCVD risk ≥10%; target <130/80 mm Hg.
Use nonpharmacologic therapy alone for elevated BP and stage 1 hypertension (130–139/80–89) with 10-year ASCVD risk <10%.
Ask all adults about tobacco use at every visit; strongly advise cessation and offer behavioral counseling plus FDA-approved pharmacotherapy (nicotine replacement, bupropion, or varenicline); ENDS not recommended for cessation.
Do not routinely use low-dose aspirin for primary prevention; may be considered (Class IIb) in select adults 40–70 years at higher ASCVD risk not at increased bleeding risk; avoid in adults >70 years or anyone with increased bleeding risk.
For overweight/obese adults, recommend comprehensive lifestyle intervention with calorie restriction and ≥150 min/week activity to achieve ≥5% weight loss.

Thresholds & Doses

ASCVD risk categories: low <5%, borderline 5–<7.5%, intermediate ≥7.5–<20%, high ≥20% 10-year risk.
Reassess traditional risk factors every 4–6 years in adults ≥20 years.
Statin indication thresholds: LDL-C ≥190 mg/dL (any age ≥20); diabetes age 40–75; 10-year ASCVD risk ≥7.5% with risk discussion.
CAC ≥100 Agatston units or ≥75th percentile favors statin; CAC=0 supports deferring statin in most.
BP treatment target <130/80 mm Hg; antihypertensive initiation at ≥130/80 if ASCVD risk ≥10%, diabetes, CKD; otherwise ≥140/90.
T2DM defined as HbA1c ≥6.5%.
Physical activity: ≥150 min/week moderate OR ≥75 min/week vigorous aerobic activity.
Obesity: BMI ≥30 kg/m²; overweight BMI 25–29.9 kg/m²; elevated waist circumference ≥102 cm men, ≥88 cm women.
Weight loss diet: 1200–1500 kcal/day women, 1500–1800 kcal/day men; deficit ≥500 kcal/day; clinically meaningful loss ≥5%.
Sodium goal <1500 mg/day (or ≥1000 mg/day reduction); potassium 3500–5000 mg/day.
Alcohol: ≤2 drinks/day men, ≤1 drink/day women (1 standard drink = 14 g alcohol).
Aspirin dose for primary prevention ≤100 mg daily; avoid in adults >70 years.
Risk-enhancing factors include: family history premature ASCVD (men <55, women <65), LDL-C 160–189, hs-CRP ≥2.0 mg/L, Lp(a) ≥50 mg/dL or ≥125 nmol/L, apoB ≥130 mg/dL, ABI <0.9, triglycerides ≥175 mg/dL nonfasting, eGFR 15–59 mL/min/1.73 m².
Nicotine patch: 21 mg if ≥10 cigarettes/day, 14 mg if <10; varenicline titrated to 1 mg BID; bupropion SR 150 mg BID.

Citations

Top 10 Take-Home Messages — overarching framework for primary prevention
Section 2.2 Assessment of Cardiovascular Risk; Table 3 — PCE use and risk-enhancing factors
Section 4.3 Adults With High Blood Cholesterol; Figure 3 — statin indications by risk strata
Section 4.4 Adults With High Blood Pressure; Figure 4; Table 7 — BP thresholds and nonpharmacological interventions
Section 4.2 Adults With Type 2 Diabetes Mellitus; Figure 2 — metformin, SGLT-2i, GLP-1RA algorithm
Section 4.5 Treatment of Tobacco Use; Table 8 — cessation pharmacotherapy dosing
Section 4.6 Aspirin Use — Class IIb recommendation and bleeding risk considerations
Section 3.2 Exercise and Physical Activity; Table 4 — activity intensity definitions and dose