Health maintenance for adults

Diseases

Overview

Introduction

Health maintenance, or preventive health care, is an important component of primary care medicine. Studies show health benefits to routine health checks.[1] [2] [3] [4]

Cardiovascular disease (CVD) is the leading cause of mortality in the US, followed by cancer. The prevalence of CVD (comprising coronary heart disease, heart failure, stroke, and hypertension) in adults ages 20 years or over is 49% overall and increases with age in both males and females.[5] The lifetime risk of developing cancer is around 39.5%, with the majority of newly diagnosed cases occurring in those over 55 years of age.[6][7] [8]

Prevention and early detection involves periodic screening of risk factors for CVD, cancer, and and other conditions that impact general health, with the goal of intervening and preventing adverse health outcomes.[9] [10] Specific cancer screening recommendations for average-risk adults are available for breast, cervical, colorectal, lung, and prostate cancers.[11] [12] [13] [14] [15]

Once a disease or risk factor is detected, appropriate treatment can then be started as early as necessary. Multifactorial lifestyle interventions have been shown to be beneficial in reducing cardiovascular events and/or mortality in patients at high risk of CVD or with established CVD.[16]

Recommendations on preventive health care are available from the US Preventive Services Task Force.US Preventive Services Task Force recommendations

Advice regarding appropriate immunizations for adults is available from the Centers for Disease Control and Prevention.CDC: adult immunization schedule ACIP: vaccine-specific recommendations

This topic concerns preventive healthcare for nonpregnant adults. For guidance on routine medical care during the preconception period and in pregnancy, see Routine prenatal care .

Risk factors for cardiovascular disease (CVD)

Cardiovascular events become more common with age. Men have higher rates than women at a given age but, due to the longer life expectancy of women, CVD has a greater impact on women.[17] After the age of 65, the prevalence of certain CVD risk factors for women equals or overtakes that of men.[18] [19] Cardiovascular disease remains the leading cause of death in women globally.[20] Over 40% of US women ages 20 years or over have some form of clinical CVD‚ including hypertension, with substantial disparities by race and ethnicity; the prevalence of coronary heart disease, heart failure, and stroke are all highest in non-Hispanic black women.[21] [22] The American Heart Association (AHA) notes that CVD risk assessment in women is multifaceted and nuanced in that it surpasses the traditional risk factors and incorporates sex-specific biological risk factors (e.g., adverse pregnancy outcomes, age at menarche and menopause, presence of polycystic ovarian syndrome, use of hormonal contraception), and that there is substantial heterogeneity in CVD risk in women between different racial and ethnic groups.[22] [23] In both sexes, racial and ethnic differences in cardiovascular disease mortality persist despite a significant reduction in the cardiovascular disease burden in the US general population.[24] The estimated 10-year risk is consistently higher in black people with the age- and sex-adjusted prevalences of obesity, hypertension, and diabetes being significantly higher than white people in all time periods from 1999 to 2018.[24]

Coronary heart disease is more common in people who smoke cigarettes and who have an elevated blood pressure. Other established risk factors include elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, diabetes, chronic kidney disease, obesity, decreased physical activity, social deprivation, and a family history of early atherosclerotic CVD.[10] [25]

Risk factors for stroke include established CVD, elevated blood pressure, cigarette smoking, diabetes, left ventricular hypertrophy, and atrial fibrillation.[26]

It is now well established that unfavorable social determinants of health and health care inequalities adversely affect cardiovascular health, and impact on prevention of CVD.[27] [28] [29] Examples include, but are not limited to, reduced health literacy, barriers to healthcare access, adverse neighborhood and built environment characteristics, economic instability, institutional racism, and racial, sex, gender and sexuality-based discrimination.[30] The AHA states that any effective preventive care program must first consider health care disparities, and that strategic planning within healthcare services is imperative to mitigate against them, for example via staff and patient education, promoting community engagement, enhancing multispeciality collaboration, and by leveraging healthcare technology, example, electronic medical records and telehealth.[31]

Screening for CVD risk factors

An American Heart Association Presidential Advisory offers an enhanced approach to assessing cardiovascular health that includes 8 components: healthy diet, participation in physical activity, avoidance of nicotine, healthy sleep, healthy weight, and healthy levels of blood lipids, blood glucose, and blood pressure.[32]

Adults with an increased risk of CVD should be identified early in order to benefit from available treatments and prevention strategies. However, evidence for the optimum time to initiate screening and the frequency of screening is limited and based mainly on modeling and limited data.

The US Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use.[33]
Screening for hypertension with office blood pressure measurement is recommended by the USPSTF for all adults ages 18 years or older. Clinicians should obtain blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.[34]
The American Association of Clinical Endocrinologists and American College of Endocrinology guidelines recommend that all adults 20 years of age or older should be evaluated for dyslipidemia every 5 years, with more frequent testing recommended for certain disease conditions and/or risk factors, and as patients become older.[25] Screening may begin earlier for those with diabetes in childhood or a family history of dyslipidemia, and the 2018 American College of Cardiology/American Heart Association guidelines additionally recommend screening as early as age two years for those with a family history suggestive of early atherosclerotic cardiovascular disease (ASCVD).[35]
USPSTF recommends screening for prediabetes and type 2 diabetes in adults ages 35 to 70 years with overweight (BMI ≥25 kg/m²) or obesity (BMI ≥30 kg/m²).[36] Screening should be considered at BMI ≥23 kg/m² for Asian-Americans, and at an earlier age in people from a population with a disproportionately high prevalence of diabetes (American Indian/Alaska Native, Black, Hawaiian/Pacific Islander, Hispanic/Latino).[36] Those with normal test results should be re-screened every three years, and those who have prediabetes should be referred for effective preventive interventions.[36]

Assessing 10-year CVD risk

The net benefit that each patient receives from preventive therapies is directly related to the baseline cardiovascular risk (i.e., those at the highest risk will derive the greatest absolute risk reductions from preventive interventions). Therefore, it is critical to perform adequate risk stratification to serve as the basis for a risk discussion and framework to decide on the intensity of preventive strategies.

Individuals with clinical ASCVD have a high risk for recurrent events. Within this group, those with recurrent major ASCVD events (symptomatic peripheral arterial disease, ischemic stroke, myocardial infarction, or recent acute coronary syndrome) are at the greatest risk for repeat events.

For adult patients without known previous ASCVD, epidemiologists have developed relatively simple scoring systems to estimate global cardiovascular risk. They enable estimation of 10-year global risk based on key risk factors, including age, sex, smoking status, blood pressure, total cholesterol, and HDL cholesterol.[37] [38] ASCVD Risk Estimator is used in American Heart Association guidelines, although it may overestimate or underestimate risk in certain populations.ACC/AHA: ASCVD Risk Estimator Other calculators include the Framingham 2008 CVD risk assessment. Similarly, recommendations have been outlined to estimate the risk of stroke.[26] [39] [40] Healthcare providers should be familiar with the best risk prediction tool in their patient population.[41]

Guidelines recommend routinely assessing traditional CVD risk factors and calculating 10-year risk of CVD for all adults ages 40 to 75 years. For individuals ages 20 to 39 years, it is recommended to assess traditional CVD risk factors at least every 4 to 6 years.[10]

As the ASCVD Risk Estimator may not be appropriate for all patients, if an individual is considered borderline (5% to <7.5%) or intermediate (≥7.5% to <20%) risk, additional clinical and laboratory risk-enhancing factors may be considered for refining risk assessment. These include a family history of premature CVD (men ages <55 years, women <65 years), primary hypercholesterolemia (LDL-cholesterol ≥4.1 mmol/L [≥160 mg/dL] or non-HDL-cholesterol ≥4.9 mmol/L [≥190 mg/dL], chronic inflammatory conditions (particularly psoriasis, rheumatoid arthritis, HIV/AIDS), South Asian ancestry, a history of preeclampsia or preterm delivery, early menopause, chronic kidney disease (estimated GFR 15-59 mL/min/1.73 m²), metabolic syndrome, persistently elevated inflammatory markers, elevated lipid biomarkers, or ankle-brachial index 0.9.[10][35] [41]

In patients with borderline- or intermediate-risk after the use of risk scores and risk enhancers (if present), coronary artery calcium (CAC) may be used as a decision aid if it will affect the intensity of preventive strategies, particularly lipid-lowering therapies.[10][35] [41]

A shared decision making approach to prevention of cardiovascular disease is recommended, whereby clinicians use decision aids which calculate cardiovascular risk as part of a wider, individualized discussion with the patient around health care decisions, where patient education and patient-clinician collaboration is emphasized.[10] [42]

Strategies for CVD risk reduction

The following lifestyle modifications can have a significant impact on patients with or at risk for CVD.[16]

Dietary modification: dietary advice may include the use of low-salt, high-fiber, and low saturated-fat diets such as the Dietary Approaches to Stop Hypertension (DASH) diet.National Heart, Lung and Blood Institute: DASH eating plan [43] A Mediterranean diet has been associated with a lower risk of CVD.[44] [45] Reducing the intake of salt, trans fats, red meat and processed red meats, refined carbohydrates, and sweetened drinks should be recommended, and increasing the intake of fruit, vegetables, nuts, whole grains, lean vegetable or animal protein, and fish, should be encouraged.[10] [46] [47] [48] [49] Low-carbohydrate diets have been shown to be effective for weight loss and cardiovascular risk factor reduction.[50] The implementation of dietary change can be difficult for many patients, and it may be helpful to include a dietician in the patient's care. The USPSTF recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a health diet; those not at high risk may also be considered for behavioral counseling interventions.[51]
Weight: patients should be counseled on weight loss as appropriate with a target BMI <30 kg/m². USPSTF recommends that clinicians offer or refer adults with a BMI of 30 kg/m² or higher to intensive, multicomponent behavioral interventions.[52] Pharmacotherapy is recommended as an adjunct to diet and exercise in people whose BMI is ≥30 kg/m², or >27 kg/m² if associated with obesity-related comorbidity.[53] See: Obesity in adults .
Exercise: the American Heart Association (AHA) notes that fewer than one in four adults achieves the recommended amount of physical activity, and that physical activity levels are generally lower among those with elevated cardiovascular disease risk factors, among certain groups (e.g., older age, female, black race, lower socioeconomic status), and in some environments (e.g., rural).[54] Counseling on regular exercise and improving physical fitness through aerobic exercise is extremely important.[55] [56] [57] World Health Organization guidelines recommend that all adults should undertake 150-300 minutes of moderate-intensity aerobic physical activity, or at least 75-150 minutes of vigorous-intensity aerobic physical activity throughout the week.[58] Furthermore, the American Heart Association (AHA) notes that particular health benefits including improvements in muscle strength and function, as well as reductions in cardiovascular risk, have been demonstrated with resistance training (exercise that evokes muscle contraction against an external force); these benefits have been documented in people both with and without cardiovascular disease.[59] Before starting an exercise program, some patients (e.g., older or with cardiovascular impairment) should discuss a plan with their healthcare provider. The USPSTF recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote physical activity; those not at high risk may also be considered for behavioral counseling interventions.[51] An inverse relationship exists between daily step count and cardiovascular mortality, with increasing benefits seen with higher step counts.[60] For adults who face difficulties in exercising regularly, there is evidence from one cohort study that achieving 8000 daily steps only a couple days a week may have meaningful health benefits.[61]
Smoking cessation: smokers have an increased risk of myocardial infarction (MI) and stroke. The incidence of nonfatal MI is 5 times greater in cigarette smokers 30 to 49 years of age, 3 times greater in cigarette smokers 50 to 59 years of age, and twice as great in cigarette smokers 60 to 79 years of age compared with nonsmokers.[62] Studies in patients with heart disease suggest that this risk decreases after smoking cessation.[63] [64] The USPSTF advises clinicians to advise all people who stop to smoke using tobacco, and to provide behavioral interventions and US Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco.[33] The use of nicotine e-cigarettes for smoking cessation is controversial, and remains a topic of ongoing debate and research. USPSTF and the 2020 Surgeon General's report note insufficient evidence to evaluate the balance of benefits and risks of nicotine e-cigarettes for smoking cessation, and that clinicians should direct smokers to FDA-approved smoking cessation medicines instead.[33] See: Smoking cessation .

Aspirin and other antiplatelet agents

There is no justification for the routine administration of low-dose aspirin for the primary prevention of CVD among adults at low estimated CVD risk.[10] Use of prophylactic aspirin in adults <40 years of age or >70 years of age may be of no benefit or harmful, such that its use in these populations should only be considered in the context of other known CVD risk factors.[10]
The US Preventive Services Task Force (USPSTF) recommends that the decision to use low-dose aspirin for primary prevention of CVD in adults ages 40 to 59 years with a 10% or greater 10-year CVD risk be individualized.[65] Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. The USPSTF recommends against the use of aspirin for the primary prevention of CVD in adults ages over 60 years.[65]
For both men and women, aspirin increases the risk of gastrointestinal (GI) bleeding and hemorrhagic stroke.[66] [67] Risk of major GI and extracranial bleeding with aspirin is proportional to cardiovascular risk.[66]
The decision about whether to prescribe aspirin must be based on the patient's risk of cardiovascular events.[68] If the risk of CVD is high, the benefits of aspirin may outweigh the adverse effects; conversely, low-risk patients should not take aspirin, as the adverse effects exceed the benefits.[67] [69] The benefits of aspirin exceed the adverse effects when the 10-year cardiovascular risk is >10%.[70] [71] For those with 5% or lower risk, aspirin is not warranted. For those with 10-year risk of 5% to 10%, the decision is not clear-cut and should be based on patient preferences.
Other antiplatelet agents commonly used for prevention of occlusive vascular events include clopidogrel and dipyridamole. Although not currently recommended for primary prevention, antiplatelet therapy is recommended for secondary prevention in patients with noncardioembolic ischemic stroke or transient ischemic attack to reduce the risk of recurrent ischemic stroke and other cardiovascular events.[72]

Blood pressure control

Treatment options include lifestyle modifications and antihypertensive drugs.[55]
Dietary salt restriction has been shown to reduce systolic blood pressure and should be encouraged for all patients.[73] ACC/AHA guidelines recommend an optimal goal of <1500 mg/day.[74]
CVD risk assessment tools are used to guide initial approach to therapy and whether the person should receive antihypertensive medication or can be managed with lifestyle modifications.American College of Cardiology: ASCVD Risk Estimator plus

Evidence from several randomized trials supports the effectiveness of reducing blood pressure (BP) with medications as a means of reducing cardiovascular risk.[75] [76] [77] [78]
BP goals are evolving as more studies are being carried out.[79]
American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a BP target of <130/80 mmHg for adults, regardless of age, with confirmed hypertension and known CVD, or a 10-year atherosclerotic CVD risk (using the atherosclerotic CVD [ASCVD] risk estimator) of 10% or more.[74] American College of Cardiology: ASCVD Risk Estimator plus
For people with diabetes, the American Diabetes Association (ADA) recommends that BP targets in those with concomitant hypertension are individualized by assessing cardiovascular risk, potential adverse effects, and patient preference.[80] The ADA recommends a BP goal of <130/80 mmHg for patients with diabetes.[80] See: Diabetic cardiovascular disease .
Hypertension among young adults below the ages 40 years is common.[81] Earlier treatment of hypertension may effectively limit end-organ damage, such as left ventricular hypertrophy or renal insufficiency, which affects later cardiac risk.[81]
In older adults, because of differences in the general health between individuals, the decision to treat should be on an individual basis, and BP lowering should be gradual and carefully monitored by the physician.[82] [83] [84]
The SPRINT trial results showed benefit of tighter blood pressure control in people ages >75 years, regardless of frailty or walking speed.[85] One systematic review found insufficient evidence regarding the benefits of hypertension treatment for frail people ages >80 years taking multiple medications, concluding that treatment should be individualized.[86] Older people >80 years should not be denied treatment or have treatment withdrawn solely based on the age.[83] [87]
The ACC/AHA guideline defines stage 1 hypertension as BP 130-139/80-89 mmHg.
The ACC/AHA guideline recommends that people with stage 1 hypertension and assessed as at low risk of CVD (<10% 10-year atherosclerotic CVD risk) may initially be managed with lifestyle modifications and reassessment in 3-6 months to determine if pharmacologic therapy is necessary.[74] Most patients will require drug therapy to achieve target BP control.
For stage 1 hypertension, combination therapy or monotherapy where appropriate can be initiated.[74] The ACC/AHA guideline recommends initiating a single antihypertensive agent for people with a 10-year atherosclerotic CVD risk ≥10% or known cardiovascular disease, diabetes, or chronic kidney disease (CKD).[74] If BP cannot be controlled with a single agent, a drug from a different class of antihypertensives is added.
The ACC/AHA guideline defines stage 2 hypertension as BP ≥140/90 mmHg.[74]
People with stage 2 hypertension will require more than one drug for BP control. Therefore, the initiation of two concurrent antihypertensives of different classes is recommended.[74] Treatment with a single-dose combination pill may improve medication adherence and BP control.[88]
The choice of antihypertensive agent is driven by efficacy, adverse-effect profile, cost, and individual patient factors. Diuretics, ACE inhibitors, angiotensin-II receptor antagonists and calcium-channel blockers are effective first-line agents.[89] There is little evidence to show that any one particular antihypertensive is superior than any other for the primary prevention of CHD.[90]
ACE inhibitors or angiotensin-II receptor antagonists may be effective in younger people, especially white people. A thiazide (or thiazide-like) diuretic or calcium-channel blocker is preferred in black people.[74] In people with diabetes who have cardiovascular disease or increased albumin excretion, ACE inhibitors or angiotensin-II receptor antagonists are recommended.[80]
See Essential hypertension .

Lipid lowering for primary prevention of CVD

Several randomized studies support the effectiveness of statins for reducing cardiovascular events in adults with a wide range of baseline lipid levels. These studies compared a fixed dosage of statin with a placebo, with both groups receiving low-intensity dietary counseling. Meta-analysis found that statins reduced the relative risk of CHD by 23% and stroke by 17%.[91] [92] [93] [94]
Data suggest that CVD risk can be reduced with statins in as little as 2.5 years of therapy.[95]
For primary prevention of CVD, the USPSTF recommends that clinicians prescribe a statin for adults ages 40 to 75 years who have one or more CVD risk factors (e.g, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk of 10% or greater.[96]
Those with 10-year risk of 7.5% to less than 10% may selectively be offered a statin.[96]
Guidance from the American College of Cardiology/American Heart Association on primary prevention of CVD is as follows. In adults ages 40 to 75 years and low-density lipoprotein (LDL)-cholesterol ≥70 to <190 mg/dL (without diabetes mellitus), the following should be considered:[10]
High risk (10-year risk: ≥20%): initiate statin to reduce LDL-cholesterol ≥50%
Intermediate risk (10-year risk: ≥7.5% to <20%): if risk estimate and risk enhancers favor statin, initiate moderate-intensity statin to reduce LDL-cholesterol by 30% to 49%
Borderline risk (10-year risk: 5% to <7.5%): if risk enhancers present then a risk discussion should take place regarding moderate-intensity statin therapy
Low risk (10-year risk: <5%): no pharmacologic treatment should be initiated

Lipid lowering interventions for hypercholesterolemia

Lifestyle modifications continue to be an emphasis in the current recommendations and remain the first line of therapy for hypercholesterolemia.[35] [55] There is clear evidence that dietary reduction in total and saturated fat, weight loss in overweight people, and aerobic exercise leads to a decrease in LDL-cholesterol (LDL-C) and an increase in HDL-cholesterol (HDL-C).[55] [97]
For pharmacologic treatment of hypercholesterolemia, the ACC/AHA guidelines recommend high-intensity statin therapy if tolerated in adults ages over 21 years if the person has clinical CVD or low-density lipoprotein cholesterol ≥190 mg/dL.[35]
A moderate-intensity statin has been defined by the American College of Cardiology/American Heart Association as one that generally lowers LDL-C level by 30% to 49%, while a high-intensity statin has been defined as one that lowers LDL-C level by ≥50%.[35]
Treatment targets for use of statin medications are typically guided by individual risk for cardiovascular disease, usually estimated with a 10-year risk calculator.American College of Cardiology: ASCVD Risk Estimator plus
Complete statin intolerance is rare; however, for these patients, a trial of non-statin LDL-cholesterol (LDL-C) lowering drugs may be considered as an alternative to statins, with referral to a lipid specialist.[98]
For patients who do not achieve adequate LDL-C lowering on maximally tolerated statin therapy, addition of non statin therapies may be considered, including ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (monoclonal antibodies) or bile acid sequestrants.[35] [98]
See: Hypercholesterolemia .

Management of prediabetes

Progression to diabetes from prediabetic states can be reduced by 50% over 3 to 4 years through modest weight loss (7% of body weight) using diet and regular physical activity.[99] [100]
Evidence suggests that referral to diabetes prevention programs (including digital diabetes prevention programs) is a clinically effective strategy.[99] [101]
Although therapeutic approaches can reverse prediabetes, lifestyle modification provides the strongest evidence of effectiveness and should remain the recommended approach to address this condition.[102]
A number of pharmacologic agents may reduce progression from prediabetes to diabetes; including metformin.
See:Type 2 diabetes in adults

Hormone replacement

Treatment of menopausal symptoms may be indicated if menopausal symptoms interfere with a woman's daily functioning and quality of life. There is little evidence to suggest that hormone replacement therapy (HRT) has any cardiovascular protective benefit. In postmenopausal women, HRT should not be prescribed for either primary or secondary prevention because there is a slightly increased risk of stroke and venous thromboembolic events in this patient population.[103] [104]
See:Menopause

Citations

Key Articles

Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Sep 10;140(11):e596-646.[Abstract][Full Text]
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082-143.[Abstract][Full Text]
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-467.[Abstract][Full Text]
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-248.[Abstract][Full Text]
American Academy of Family Physicians. Summary of recommendations for clinical preventive services. Jul 2017 [internet publication].[Full Text]

Other Online Resources

US Preventive Services Task Force recommendations
CDC: adult immunization schedule
ACIP: vaccine-specific recommendations
ACC/AHA: ASCVD Risk Estimator
National Heart, Lung and Blood Institute: DASH eating plan
American College of Cardiology: ASCVD Risk Estimator plus
National Cancer Institute: breast cancer risk assessment tool
National Cancer Institute: colorectal cancer risk assessment tool
COVID-19 ACIP vaccine recommendations

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