Primary care clinicians key to achieving optimal cardiovascular health

American Heart AssociationNov 13 2024

Primary care clinicians and practices are uniquely positioned to help people achieve optimal cardiovascular health through screening, diagnosing and treating the health behaviors and factors outlined in the American Heart Association's Life's Essential 8 health metrics to reduce the risk for heart disease and stroke, according to a new scientific statement published today in the Association's peer-reviewed journal Circulation: Cardiovascular Quality and Outcomes.

Cardiovascular disease is the leading cause of death in the U.S., however, an estimated 1 of every 4 deaths due to cardiovascular disease could be avoided by addressing modifiable risk factors with lifestyle changes and treatment. The Association's Life's Essential 8 are key measures for improving and maintaining optimal cardiovascular health and reducing the risk of heart disease, stroke and other major health conditions. Life's Essential 8 outlines four health behaviors-;diet, physical activity, nicotine exposure and sleep; and four health factors-; body mass index, blood lipids, blood glucose and blood pressure.

Primary care plays a central role in people's health and health care across their lifetime. Primary care professionals have the potential to greatly improve the identification and treatment of cardiovascular risk factors and health behaviors in their patients."

Madeline R. Sterling, M.D., M.P.H., M.S., FAHA, Chair of the statement writing group, associate professor of medicine at Weill Cornell Medicine, New York

Notably, recent data show that primary care, rather than specialty care, is the dominant source of care that can support patients in addressing the health behaviors and factors outlined in the American Heart Association Life's Essential 8 for optimal cardiovascular health.

Each area within Life's Essential 8 is modifiable with behavioral changes or medication management, and primary care professionals are often typically the ones who routinely screen for, diagnose and treat high blood pressure, blood sugar and cholesterol. Additionally, screening for and counseling on smoking cessation and weight are performed far more often in primary care compared to specialty care settings.

As highlighted in the scientific statement, effective primary care is person-centered, team-based, community-aligned and designed to achieve better health at lower costs. Primary care has been proven to improve the identification and treatment of cardiovascular health behaviors and risk factors, as outlined in Life's Essential 8, including:

• Nutrition and physical activity - Primary care clinicians and teams play a central role in counseling on nutrition and heart-healthy dietary plans, such as the Mediterranean Diet and the Dietary Approaches to Stop Hypertension (DASH) diet, as well as on the delivery of diet-related lifestyle and physical activity programs and interventions.
• Nicotine exposure - Nicotine exposure through tobacco use, vaping and secondhand smoke is the leading preventable cause of morbidity and mortality in the U.S. and is responsible for 20% of CVD deaths annually. Both behavioral and medication-based interventions are effective and can be addressed by primary care professionals.
• Sleep – Inadequate and/or poor-quality sleep are associated with risk factors for heart disease, including high blood pressure and Type 2 diabetes. Primary care professionals can screen for poor sleep, examine potential causes and initiate medication changes and referral to sleep specialists when needed.
• Weight management - Obesity affects 42% of adults in the U.S., and primary care is an ideal setting to screen for elevated weight, refer individuals to nutrition and weight loss programs, prescribe medications, and, when appropriate, provide referrals to bariatric surgery or other interventions. A recent systematic review and meta-analysis found that behavioral weight management interventions for adults with obesity delivered via primary care settings were effective for weight loss.
• Blood pressure, blood sugar and cholesterol - Screening for risk factors such as elevated blood pressure, blood glucose and lipids are cornerstones of primary prevention for cardiovascular disease and achieved in the primary care setting. Primary care clinicians and practices are able to counsel on lifestyle, and they can prescribe treatment approaches that often include educational interventions, blood pressure self-monitoring, coaching programs to improve patient-guided management, interventions such as nutrition counseling and/or medications. One current review of 42 randomized control trials found that both individual and organizational level interventions (nurse and pharmacist management, community health workers, etc.) in primary care were effective at improving glycemic control among people with poorly managed Type 2 diabetes. Similar results have also been noted for people with high blood pressure treated in primary care settings.

According to the American Heart Association's 2024 Heart Disease and Stroke Statistics report, the incidence of cardiovascular disease has declined in the U.S. However, only 1 in 5 adults in the U.S. have what is considered optimal cardiovascular health, which is associated with greater longevity and improved quality of life.

There are also marked disparities in care and health based on social and environmental factors, such as socioeconomic status, race and community factors, such as safe spaces to exercise and access to healthy foods.

"Primary care as a field can address some of these disparities by providing preventive care to screen patients for cardiovascular disease risk factors, encouraging people to adopt heart-healthy lifestyle behaviors to prevent health problems from developing or worsening, and initiating treatment to improve cardiometabolic health if necessary," said Jeremy Sussman, M.D., M.P.H., M.S., associate professor of medicine at the University of Michigan and vice chair of the scientific statement.

Despite the potential to promote Life's Essential 8, primary care professionals and practices face challenges that may limit their success in supporting patients to reduce cardiovascular risks. Research shows the benefits of having a higher ratio of primary care clinicians per person include a lower total cost of care and reduced illness and mortality. However, there are concerns about a shrinking primary care workforce that faces high levels of burnout, difficulties with coordination of care with other health professionals and insufficient financial support and reimbursement. Lack of health insurance coverage, unequal access to care and limited health resources in rural settings may also create barriers to better health.

"Primary care as a profession is under-valued and under-resourced, accounting for 35% of health care visits in the U.S., while accounting for only 5% of health care expenditures," said Sterling. "For primary care to have a maximum impact on the variables outlined in Life's Essential 8, it must be supported, promoted and valued by the health care community, public health systems and policymakers."

The statement highlights ways to address these challenges, including payment reform, leveraging technology and promoting team-based care. It is notable that primary care professionals are among the lowest-paid clinicians in the U.S.

"Effective support of primary care would require federal and state legislation to increase the overall portion of health care spending to primary care and to update how care and supporting programs are paid," said Sussman.

A team-based care approach is also needed to support primary care professionals and promote collaboration via health system- and clinic-based initiatives. Technology and data infrastructure, such as electronic health records systems, clinical decision support tools and telehealth visits, can improve health care delivery and offer better support for primary care practices, and, in turn, patients. Evidence-based treatments also need to be incorporated into care more efficiently and consistently.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Primary Care Science Committee of the Council on Quality of Care and Outcomes Research and the Council on Cardiovascular and Stroke Nursing; the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and the Council on Lifestyle and Cardiometabolic Health. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association's official clinical practice recommendations.