AHA/ACCF 2009 Performance Measures for Primary Prevention of Cardiovascular Disease in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for Primary Prevention of Cardiovascular Disease): Developed in Collaboration With the American Academy of Family Physicians; American Association of Cardiovascular and Pulmonary Rehabilitation; and Preventive Cardiovascular Nurses Association

Abstract

The AHA/ACCF Primary Prevention of Cardiovascular Disease Performance Measures Writing Committee (the Writing Committee) was charged to develop performance measures for the prevention of CVD. These performance measures do not specifically address prevention of stroke, although because risk factors for heart disease and stroke overlap, their use should contribute to the prevention of stroke as well. These measures are intended for adults (18 years of age and older) evaluated in the outpatient setting. The Writing Committee designed most of the measures, including all of the lifestyle measures, to begin at age 18 because we recognize that risk for atherosclerosis accumulates over a lifetime and, although it is never too late to make changes to prevent heart disease, the greatest benefit accrues with early lifestyle changes. The relation between cardiovascular risk factors and the extent and severity of coronary atherosclerosis in the teenage years and earlier is well established on the basis of autopsy studies.10,11 Evidence from long-term follow-up studies demonstrates that a favorable risk factor profile during the working years is associated with a longer, healthier life and reduced medical care expenses after age 65.12–17 These observations indicate the value of prevention of risk factors in the first place, beginning in childhood and youth, as called for by the AHA’s “Guidelines for Primary Prevention of Atherosclerotic Cardiovascular Disease Beginning in Childhood.”18 Although the greatest long-term benefit occurs with changes early in life, changes in adults are also encouraged because they have been demonstrated to reduce risk and prevent heart disease in both middle-aged and older adults. The Writing Committee also acknowledges that the field of primary prevention is rapidly evolving because of the contributions of observational research, registries, and clinical trials. Hence, modifications to these performance measures for primary prevention will be necessary as the field advances. The Writing Committee designed the performance measures to be applicable to the broadest possible population. A healthy lifestyle is believed to be beneficial across the entire spectrum of age, race, and sex. With respect to age, however, we recognize that there comes a time when the benefits of screening and treatment to avert future events may be of limited value because life expectancy is limited. Moreover, a number of the investigations establishing the benefits of primary prevention have not included elderly patients. In an effort to balance the competing interests of applying primary prevention as broadly as possible and being consistent with other organizations’ age criteria, the Writing Committee recommends the use of the proposed measures for patients older than 18 years of age both for accountability and for public reporting. Certain measures have an upper age limit of 80 years because of a paucity of evidence to support the measure in an older age group. In addition, there may be measurement circumstances in which a narrower target age range is appropriate, and those who implement measures may choose to specify an age range that is less broad. Certain measures, such as blood pressure control, may not be achievable in all patients. Good blood pressure control is a challenge for providers in selected patient subsets, including those with multiple comorbidities and some older patients with isolated systolic hypertension. In addition, patient adherence to medical regimens varies for many reasons. The Writing Committee recognizes that providers may care for patients with complex medical and socioeconomic conditions for whom attainment of target levels for risk factors is difficult. Thus, target levels for attainment of performance measure goals will vary by patient population and by practice setting; for internal quality improvement initiatives, they are set by the providers.