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The fact that up to one-third of the 800,000 yearly cardiovascular disease (CVD) deaths in the United States may be preventable by diet and physical activity makes a compelling case for lifestyle interventions as a primary prevention strategy. The U.S. Preventive Services Task Force (USPSTF) recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. Although few US adults have ideal cardiovascular health, there exists a dose-response relationship whereby an increasing number of ideal cardiovascular health metrics is associated with lower CVD and all-cause mortality. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet have proven benefits in reducing CVD. Among individuals without CVD, high levels of physical activity are associated with an approximately 32% reduced risk of CVD death, and moderate levels are associated with approximately a 22% reduction. Resistance exercises confer additional benefits.

As part of the approach to primary prevention of cardiovascular disease (CVD), adults should have their CVD risk estimated using a population-appropriate risk equation. In the United States, the atherosclerotic cardiovascular disease (ASCVD) pooled cohort equations are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) to estimate risk in patients ages 40 to 79 years. A 10-year ASCVD risk estimate of 20% or higher is considered high, and patients having this level of risk should be offered and counseled to receive statin therapy. A 10-year risk estimate of 7.5% to less than 20% is considered intermediate, and clinicians should discuss the potential benefits of statin therapy for primary prevention in the context of the patient's preferences and values. In some situations, use of CVD risk enhancers, particularly coronary artery calcium assessed by computed tomography, may help inform the clinician-patient discussion. All patients should be counseled about healthy lifestyle modifications to reduce CVD risk. The AHA's Life's Simple 7 defines ideal cardiovascular health as no tobacco use; ideal blood pressure, blood glucose, and cholesterol levels; adequate physical activity; weight management; and healthy diet. An 8th component (sleep) was very recently added and 4 of the original components have been updated. These metrics provide goals that can drive efforts toward primordial prevention (ie, keeping risk factors themselves from developing).

Several drugs have shown benefits in primary and secondary prevention of cardiovascular disease (CVD). Aspirin should be used routinely for the secondary prevention of CVD. Low-dose aspirin should not be used for the primary prevention of CVD in adults ages 60 years and older. Aspirin can be considered for primary prevention in adults ages 40 to 59 years with a 10% or greater 10-year CVD risk. Moderate- to high-intensity statin therapy should be prescribed for most patients with known atherosclerotic CVD, those with a low-density lipoprotein (LDL) cholesterol level of 190 mg/dL or higher, and those ages 40 to 75 years with diabetes or with a 10-year risk of CVD of 7.5% or greater. Newer lipid-lowering drugs have shown benefits in lowering LDL cholesterol levels, but at high cost and with limited evidence of reduction of CVD outcomes. Polypills provide a method to deliver multiple proven drugs at lower cost and to a broader population. Sodium-dependent glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists should be added to metformin as the preferred second-line drug in the management of diabetes because of their proven ability to improve cardiovascular outcomes. No supplements have proven benefits in CVD prevention. Omega-3 fatty acids and folic acid have shown benefits when consumed in food.

Diabetes, hypertension, tobacco use, and obesity each substantially increases the risk of cardiovascular disease (CVD) and must be controlled as part of CVD prevention. Among patients with diabetes, the reduction of CVD risk from lower A1c goals must be balanced against the risks of hypoglycemia. The American Diabetes Association (ADA) recommends an A1c goal for adults of less than 7% if hypoglycemia can be avoided. A less stringent goal of less than 8% is appropriate in patients with limited life expectancy. A blood pressure (BP) goal of less than 140/90 mm Hg is prudent for all adults younger than 60 years. A goal of less than 140/90 mm Hg also is advised for initiating or intensifying pharmacotherapy in adults 60 years and older with a history of stroke or who are at high cardiovascular risk. BP targets should be individualized to balance the known benefits of lowering BP to 120/80 mm Hg with the risks of morbidity because of hypotension and adverse effects. Varenicline is the most effective drug for smoking cessation, and abstinence rates are increased by combining it with nicotine replacement therapy. Bariatric surgery is the most effective management for long-term weight loss and reduction of obesity-related comorbidities. Social drivers of health are the primary cause of CVD outcomes differences among races and ethnicities.

Hypertensive emergency occurs when the blood pressure (BP) level is severely elevated (ie, higher than 180 mm Hg systolic or higher than 120 mm Hg diastolic) and acute organ damage is present. Patients with hypertensive emergencies are treated initially in the emergency department and then admitted to the intensive care unit. Management is directed at the specific situation, with the rate and extent of BP level lowering tailored to the type and extent of organ damage. Patients with severely elevated BP level but without symptoms have asymptomatic severe hypertension. Most such patients have chronic hypertension. Management of asymptomatic severe hypertension starts (or restarts) with long-acting antihypertensive drugs, typically a combination of a renin-angiotensin system inhibitor, a thiazide diuretic, and/or a calcium channel blocker. Physicians should emphasize adherence to the drug regimen and monitor patients closely until the goal BP level is achieved.

Hypertension is prevalent in older adults, and blood pressure (BP) level lowering has been shown to be one of the most important clinical interventions to reduce the risk of cardiovascular events. The goal BP level for older adults is individualized based on age, cardiovascular risk, overall health status (particularly frailty), and patient preferences. Recent guidelines differ but a goal systolic BP level lower than 150 mm Hg is reasonable for nearly all adults 60 years and older. In patients with isolated systolic hypertension, the degree to which systolic BP level lowering can be tolerated may be limited if the diastolic BP level decreases below 60 to 65 mm Hg. Orthostatic hypotension is common among older hypertensive patients. Symptoms of light-headedness should prompt an evaluation for orthostatic hypotension and a possible decrease in drug treatment. For relatively healthy older adults at increased cardiovascular risk, a systolic BP level goal lower than 140 mm Hg may be pursued. Although more aggressive BP level lowering is associated with a greater decrease in the number of cardiovascular events, it also is associated with a higher number of adverse events.

Resistant hypertension is a blood pressure (BP) level that remains above the goal level despite adherence to at least three appropriately dosed antihypertensive drugs of different classes, one of which is a diuretic. Evaluation of suspected resistant hypertension starts with confirming adherence to the drug regimen. White coat hypertension should be ruled out with out-of-office BP level measurements, ideally using 24-hour ambulatory BP monitoring. Obesity, significant alcohol intake, and interfering drugs and other substances can contribute to resistant hypertension. Lifestyle modifications, including exercise and dietary sodium restriction, can be useful in management. Resistant hypertension may be due to secondary etiologies (eg, parenchymal kidney disease, obstructive sleep apnea, hyperaldosteronism). Adequate diuretic treatment is a key part of therapy. In addition to a diuretic, patients with resistant hypertension should take a dihydropyridine calcium channel blocker and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker. Spironolactone is an effective fourth drug. Other drug options include a beta blocker, a long-acting nondihydropyridine calcium channel blocker, or clonidine or guanfacine. When the BP level is not controlled despite adherence to a four-drug regimen, referral to a hypertension subspecialist should be considered.

When patients present with major or life-threatening bleeding due to warfarin use, rapid reversal with coagulation factors and vitamin K often is warranted. Oral vitamin K should be administered if the international normalized ratio is greater than 10 with no evidence of bleeding, but its use is not recommended if international normalized ratios are between 4.5 and 10. The most important factor in the risk of hemorrhage is the intensity of warfarin therapy. Increasing the time in the therapeutic range results in lower rates of thrombosis and bleeding. There are no available specific reversal agents or pharmacologic antidotes for the new oral anticoagulants. Use of anticoagulation management services (eg, intervention using automated hospital information system-generated triggers from laboratory and pharmacy data) in the outpatient and inpatient settings can be considered to decrease the risk of complications for patients taking anticoagulants. Services that incorporate clear communication, evidence-based drug management, and patient education are important to ensure safe use of anticoagulants. Management of heparin-induced thrombocytopenia should include heparin discontinuation and initiation of a nonheparin anticoagulant.

For patients with acute venous thromboembolism treated with warfarin, parenteral anticoagulation should be continued for a minimum of 5 days and until the international normalized ratio (INR) is 2 or greater for at least 24 hours. Early initiation of warfarin therapy is recommended. The goal therapeutic INR range for patients treated with warfarin is most commonly 2 to 3. During maintenance warfarin therapy, validated decision-support tools should be used to guide dosing. For patients with stable INRs, frequency of INR testing can be extended from every 4 weeks to up to 12 weeks. Self-testing and self-management can be safe options for patients receiving warfarin who are motivated and show competence. Patients starting anticoagulation therapy should receive education on treatment goals, adverse effects, and monitoring strategy. Physicians deciding whether to prescribe one of the new oral anticoagulants instead of warfarin should assess for possible drug interactions and for renal and hepatic impairment and should consider the financial cost to the patient. No routine coagulation assay monitoring is required for patients receiving apixaban, dabigatran, or rivaroxaban. Physicians who oversee oral anticoagulation therapy should do so in a systematic and coordinated fashion.

The risks of bleeding and thrombosis should be considered in decisions on whether to initiate anticoagulation therapy. Oral anticoagulation is indicated for patients with nonvalvular atrial fibrillation who are at intermediate or high risk of stroke (CHADS2 [Congestive heart failure, Hypertension, Age at least 75 years, Diabetes, previous Stroke or transient ischemic attack] score of 1 or higher). Apixaban, dabigatran, rivaroxaban, or warfarin can be considered for the prevention of stroke and systemic embolism in these patients. Hospitalized patients at high risk of thrombosis should receive prophylaxis with low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux, whereas those at low risk should not receive pharmacologic prophylaxis. Pharmacologic prophylaxis with low-molecular-weight heparin or low-dose unfractionated heparin is indicated for patients undergoing nonorthopedic surgery who are at high risk of thrombosis and those undergoing orthopedic surgery whose risk of bleeding is low. Patients presenting with acute coronary syndrome should receive intravenous unfractionated heparin or enoxaparin at hospital admission. Anticoagulation with warfarin is appropriate for patients with mechanical heart valves. Patients with deep venous thrombosis or pulmonary embolism should receive rivaroxaban, dabigatran, or warfarin.

Anticoagulation is an important component of the management strategy for several common medical conditions. It is indicated for the prevention of recurrent thrombosis in patients with venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, and ischemic stroke. Many surgical procedures also put patients at increased risk of VTE. Patients undergoing major orthopedic surgery should receive short-term anticoagulation. The Caprini Risk Assessment Model score can be used to estimate VTE risk and guide anticoagulation therapy recommendations for most nonorthopedic surgical patients. For patients with atrial fibrillation, assessment with the CHADS2 (Congestive heart failure, Hypertension, Age at least 75 years, Diabetes, previous Stroke or transient ischemic attack) score or a similar risk score is used to guide the decision on anticoagulation for stroke prevention. Anticoagulation also is used to prevent VTE in nonsurgical hospitalized patients at increased risk because of immobility or other factors. Patients with acute coronary syndrome should receive short-term anticoagulation. For patients with VTE in whom a reversible risk factor is identified, anticoagulation can be discontinued after 3 months. All patients with mechanical heart valves should receive lifelong anticoagulation.