Primary cardiovascular prevention in individuals without established CVD
Cardiovascular risk reduction in individuals without established atherosclerotic CVD, myocardial infarction, ischaemic stroke, or peripheral atherosclerosis. Foundational interventions: blood pressure control, smoking cessation, physical activity, Mediterranean-pattern diet, statins when indicated by SCORE2. Nutraceutical supplements for this purpose are discussed separately.
5 drugs
Also known as: Primary prevention of cardiovascular disease in healthy adults
Marketing claims without evidence base
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
- DAscorbic acidNot recommended · Vitamins. AntioxidantsAscorbic acid (vitamin C) is an antioxidant often recommended for vascular health and to prevent heart attacks and strokes in people without heart disease. The benefit for this use has not been shown: vitamin C supplements do not lower the risk of heart attack, stroke, or death in people without established cardiovascular disease. What actually protects the heart and vessels are other steps – quitting smoking, managing blood pressure, cholesterol, and blood sugar, staying active, and eating well; extra vitamin C on top of a balanced diet adds nothing here.
- DCalcium (oral salts: carbonate, citrate, lactate, gluconate)Not recommended · Mineral supplements. CalciumIsolated supplemental calcium (above 1,000 mg daily) in adults without osteoporosis for cardiovascular risk reduction is not indicated. The 2010 BMJ meta-analysis (Bolland et al.) found a 24 % increase in myocardial infarction risk with isolated high-dose calcium. Subsequent data are mixed, but cardiology societies do not recommend isolated calcium as cardiovascular prevention. Standard prevention: blood pressure control, statins when clinically indicated, smoking cessation.
- DOmega-3 triglycerides (EPA and DHA)Not recommended · Lipid-modifying agents. Omega-3 polyunsaturated fatty acidsIn adults without established CVD, omega-3 PUFA capsules do not reduce cardiovascular or all-cause mortality. The 2020 Cochrane review (86 RCTs, more than 162,000 participants) found no clinically meaningful effect. The OMEMI trial (Circulation 2021) in older adults after myocardial infarction also showed no MACE reduction and increased atrial fibrillation. ESC 2021 does not recommend omega-3 for primary prevention. An evidence-based exception is the JELIS trial (Lancet 2007) in a Japanese population with high baseline fish intake: adding EPA 1.8 g daily to statins reduced MACE by 19%. This effect has not been reproduced in populations with low baseline fish intake. Over-the-counter supplements with 300–500 mg EPA+DHA per capsule do not affect cardiovascular risk and can increase atrial fibrillation risk with long-term high-dose use.
- FAlpha-tocopherolNot recommended · Fat-soluble vitamin EVitamin E was promoted for years as an antioxidant protecting the heart and vessels. HOPE-TOO (JAMA 2005, over 7000 patients aged 55 and older with vascular disease or diabetes) tested 400 IU/day alpha-tocopherol vs placebo for seven years: no difference in cardiovascular events, but more hospitalisations for heart failure. The Miller meta-analysis (Ann Intern Med 2005, 135 967 patients) linked doses above 400 IU/day with higher all-cause mortality. The 2012 Cochrane review of antioxidants found no reduction in cardiovascular events and signalled higher all-cause mortality. If vitamin E was prescribed for the heart, consider seeking a second opinion.
- FEstradiolNot recommended · Estrogens — natural and semisyntheticPer USPSTF 2022, AHA/ACC, and NAMS 2022, MHT is not recommended for cardiovascular disease or dementia prevention in asymptomatic postmenopausal women. The WHI 2002 trial showed increased ischemic stroke and venous thromboembolism with oral forms. Modern data with transdermal forms are more favorable, but routine use for primary CVD prevention is not justified.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit