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Taiwan Society of Cardiology Prevention Guidelines: Novel Insights on Preventive Strategies

May 20, 2025   |  Henry Pronovost, MD, MSPH; Ian Everitt, MD, MPH; Aaron L Troy, MD, MPH; Asma Rayani, MBBS; Roger S. Blumenthal, MD, FACC

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  • The Taiwan Society of Cardiology (TSC) released new guidelines on the primary prevention of atherosclerotic cardiovascular disease in 2024.
  • The 2024 TSC guidelines vastly expand current approaches to primary prevention by introducing the ABC2D2EFG-I'M2 ACE framework, focusing on dietary recommendations and reviewing novel risk assessment models.

In September 2024, the Taiwan Society of Cardiology (TSC) published updated guidelines on the primary prevention of atherosclerotic cardiovascular disease (ASCVD).1,2 Taiwan experienced approximately 24,000 cardiovascular disease (CVD)-related deaths in 2022, of which 17,000 deaths were attributable to coronary artery disease.3 Rates of ASCVD continue to increase in Taiwan. The incidence of acute myocardial infarction steadily increased from 1997 to 2011, while aortic aneurysm rates grew from 7.35 per 100,000 to 29 per 100,000 between 2005 and 2011.4 This review highlights key differences between the 2024 TSC guidelines and the 2019 ACC/AHA Guideline on the Primary Prevention of CVD (Table 1).5

Table 1: Comparison of Key Recommendations: Taiwan Society of Cardiology (TSC) 2024 vs. ACC/AHA 2019 Prevention Guidelines

Focus Area TSC 2024 Recommendation ACC/AHA 2019 Recommendation Key Differences
Dietary patterns TEA diet: encourages use of soy products, tea, steaming/boiling cooking methods. Class 1 recommendation for tea consumption (>3 times/week) in those without hypertension. DASH diet: emphasizes vegetables, fruits, legumes, nuts, whole grains, and fish. No specific mention of tea or coffee. TSC includes recommendations that cater to specific ethnic groups like tea and soy products, which are not found in the ACC/AHA guideline.
Holistic health approach  Advocates for the role of mental health, socioeconomic factors, stress reduction, and adequate sleep in preventing ASCVD. Clinicians are encouraged to consider these factors when assessing risk (Class 2a). Mental health, stress, and sleep are not explicitly mentioned as CVD risk factors. TSC highlights link between mental health, sleep, and ASCVD, whereas ACC/AHA does not include this consideration.
Environment and pollution Reducing exposure to air pollution (PM2.5) and heavy metals (lead, mercury) is recommended. Actions to mitigate climate are strongly encouraged. Environmental factors are not discussed in the guideline. TSC adds a new public health component to prevention by addressing pollution and climate change as risk factors for ASCVD.
Risk assessment tools Two models discussed:
  1. TwCCCC: A point-based model considering age, sex, BMI, SBP, LDL, and HDL starting at age 35 years old.
  2. Coefficient-based model: detailed model including SBP, glucose, TG, uric acid, waist circumference, and duration of tobacco use.
 Recommends the ASCVD 10-year risk model, which starts at age 40 and considers variables like age, LDL-C, HDL-C, diabetes mellitus, and smoking. While both risk assessments in the respective guidelines are limited to their generalizability to global populations, risk assessment tools discussed in TSC guidelines are localized to Taiwanese cohorts and allow earlier risk assessments. The ACC/AHA guideline-recommended tool focuses on US populations and starts at an older age.
Frailty as a risk factor Frailty is included in the ABC2D2EFG-I'M2 ACE framework, highlighting its importance in ASCVD risk assessment in older adults. Frailty is not addressed in the ACC/AHA guideline. TSC guidelines recommend considering frailty as a unique risk modifier when assessing particularly older adults, whereas ACC/AHA does not include this consideration.
Unique risk factors Highlights inflammatory conditions like gout, hyperuricemia, and MAFLD as additional risk factors for ASCVD. Does not address these conditions as risk factors. TSC addresses region-specific metabolic conditions, gout, uric acid, and MAFLD, which are not covered in ACC/AHA 2019 guideline.

ACC/AHA = American College of Cardiology/American Heart Association; ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CVD = cardiovascular disease; DASH = Dietary Approaches to Stop Hypertension; DM = diabetes mellitus;
HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol;
MAFLD = metabolic dysfunction-associated fatty liver disease; PM2.5 = particulate matter (2.5 mcm); SBP = systolic blood pressure; TEA = Taiwanese Eating Approaches; TG = triglycerides; TSC = Taiwan Society of Cardiology; TwCCCC = Taiwan Chin-Shan Community Cardiovascular Cohort.

A Newly Proposed Acronym for Modifiable Risk Factors: ABC2D2EFG-I'M2 ACE

The TSC guideline introduces a novel and holistic acronym for the modifiable risk factors and targets for ASCVD prevention, ABC2D2EFG-I'M2 ACE: Adiposity, Blood pressure, Cholesterol and Cigarette smoking, Diabetes mellitus and Dietary pattern, Exercise, Frailty, Gout/hyperuricemia, Inflammation/infection, Metabolic syndrome and Metabolic dysfunction-associated fatty liver disease (MAFLD), Atmosphere (environment), Chronic kidney disease, and Easy life (sleep well and no stress). Although similar to the AHA Life's Essential 86 criteria and the ABCDE approach,7 the ABC2D2EFG-I'M2 ACE acronym emphasizes several risk factors not discussed in the 2019 ACC/AHA prevention guideline, including the following:

  • Atmosphere: Special attention is given to links between ambient air pollution, fossil fuel emissions, and heavy metal exposures. Class 1 recommendations are given to limiting short- and long-term ambient particulate matter (2.5 mcm) (PM2.5) and heavy metal exposures. Also given a Class 1 recommendation are measures to mitigate climate change by reducing fossil fuel use and limiting carbon dioxide emissions.
  • Gout/hyperuricemia: A Class 1 recommendation is given for measuring serum uric acid levels as a means of identifying individuals who may be at an elevated risk of ASCVD. However, use of urate-lowering therapy in patients with hyperuricemia for ASCVD prevention is not recommended (Class 3) because no benefit of urate-lowering therapies on cardiovascular events has been shown.8
  • Metabolic syndrome and MAFLD: MAFLD has a significant association with CVD risk, independent of traditional risk factors.9 Assessment and management of MAFLD is absent from the 2019 ACC/AHA guideline. Ultimately, there is a large overlap in both the pharmacologic and nonpharmacologic management of MAFLD and ASCVD prevention. However, the identification of MAFLD as a significant risk enhancer of CVD is a timely contribution. The Taiwan Association for the Study of the Liver-TSC published a separate statement reviewing evidence behind pharmacologic therapy.10
  • Easy life: Mental disorders and socioeconomic stress constitute a small focus of the TSC guidelines. There is mounting evidence that taking mental health disorders and socioeconomic status into consideration improves classic ASCVD risk prediction.11 A Class 2a recommendation is given to prescribing appropriate medications to patients with mental disorders and making clinicians aware of the association of socioeconomic stress with the development of ASCVD.

Specific Dietary Recommendations to Reduce ASCVD Risk

Specific recommendations regarding optimal intake of healthy foods, teas, coffees, and alcohol are discussed in the TSC recommendations. Healthy Taiwanese Eating Approaches (TEA) are linked to a lower risk of cardiometabolic disease.12 This diet, although similar to the Dietary Approaches to Stop Hypertension (DASH) diet in recommending higher consumption of plant-based foods, also includes soy products, tea, and foods prepared with boiling and steaming cooking methods. A Class 1 recommendation is given to consuming water or tea as the primary source of hydration.

Moderate coffee consumption (<3 cups/day) and habitual tea drinking (>3 times/week) are given a Class 2a recommendation to reduce ASCVD risk in people without severe hypertension. The 2019 ACC/AHA prevention guideline gives a Class 1 recommendation to a diet emphasizing vegetables, fruits, legumes, nuts, whole grains, and fish but does not specifically comment on teas.

Risk Assessment Models

The TSC guidelines recommend the use of a risk assessment calculator to estimate ASCVD risk, similar to the AHA Predicting Risk of CVD Events (PREVENT) risk score used in the United States, starting at age 35 years. Two risk calculator models are recommended, the first of which is the point-based Taiwan Chin-Shan Community Cardiovascular Cohort (TwCCCC),13 which assigns points to the variables of age, sex, body mass index, systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). The other risk model used is a coefficient-based prediction model constructed by Chang et al., and derived from a nationwide survey from 1993-1997 in Taiwan.14 This model incorporates more variables than the TwCCCC and includes SBP, LDL-C, HDL-C, triglycerides, total cholesterol, serum glucose, uric acid, waist circumference, duration of tobacco use, diabetes mellitus, and hypertension.

Although an association between serum uric acid levels and cardiovascular risk has been demonstrated, it is unclear whether this constitutes a modifiable risk factor. In fact, the routine use of urate-lowering therapy is explicitly not recommended (Class 3). Therefore, the routine measurement of a patient's uric acid level (given a Class 1 recommendation by TSC) may not be a high-value preventive strategy. Similarly, Class 1 recommendations for limiting PM2.5 exposures and preventing climate change, while important from a societal level, may be difficult to address at the individual patient level. Many of the ABC2D2EFG-I'M2 ACE risk factors are challenging to modify in clinical practice and are more amenable to public health intervention (Figure 1).

Figure 1: Taiwan Society of Cardiology 2024 Guidelines: Distinct Recommendations for ASCVD Prevention

Figure 1

The ACC/AHA guideline focuses on routine and robust assessment of common clinically modifiable risk factor visits (diet, cholesterol, smoking, etc.). Incorporating mental health, particulate matter exposure, frailty, and other holistic factors into preventive strategies could inspire novel patient, population, and policy-level interventions to help improve clinical outcomes and reduce cardiovascular risk.

References

  1. Chao TH, Lin TH, Cheng CI, et al. 2024 guidelines of the Taiwan Society of Cardiology on the primary prevention of atherosclerotic cardiovascular disease — part I. Acta Cardiol Sin. 2024;40(5):479-543. doi:10.6515/ACS.202409_40(5).20240724A.
  2. Chao TH, Lin TH, Cheng CI, et al. 2024 guidelines of the Taiwan Society of Cardiology on the primary prevention of atherosclerotic cardiovascular disease — part II. Acta Cardiol Sin. 2024;40(6):669-715. doi:10.6515/ACS.202411_40(6).20240724B
  3. Huang PH, Lu YW, Tsai YL, et al. 2022 Taiwan lipid guidelines for primary prevention. J Formos Med Assoc. 2022;121(12):2393-2407. doi:10.1016/j.jfma.2022.05.010.
  4. Wang SW, Huang YB, Huang JW, Chiu CC, Lai WT, Chen CY. Epidemiology, clinical features, and prescribing patterns of aortic aneurysm in Asian population from 2005 to 2011 [published correction appears in Medicine (Baltimore). 2016 Jan;95(2):e152f] [published correction appears in Medicine (Baltimore). 2016 Jan 15;95(2):e152f. doi: 10.1097/01.md.0000479778.00715.2f.]. Medicine (Baltimore). 2015;94(41):e1716. doi:10.1097/MD.0000000000001716.
  5. 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 [published correction appears in J Am Coll Cardiol. 2019 Sep 10;74(10):1429-1430. doi: 10.1016/j.jacc.2019.07.011.] [published correction appears in J Am Coll Cardiol. 2020 Feb 25;75(7):840. doi: 10.1016/j.jacc.2019.12.016.]. J Am Coll Cardiol. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010.
  6. Lloyd-Jones DM, Allen NB, Anderson CAM, et al. Life's Essential 8: updating and enhancing the American Heart Association's Construct of Cardiovascular Health: a Presidential Advisory from the American Heart Association. Circulation. 2022;146(5):e18-e43. doi:10.1161/CIR.0000000000001078.
  7. Blumenthal RS, Alfaddagh A. The ABCDE's of primary prevention of cardiovascular disease. Trans Am Clin Climatol Assoc. 2022;132:135-154.
  8. Chen Q, Wang Z, Zhou J, et al. Effect of urate-lowering therapy on cardiovascular and kidney outcomes: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2020;15(11):1576-1586. doi:10.2215/CJN.05190420.
  9. Zhou XD, Cai J, Targher G, et al. Metabolic dysfunction-associated fatty liver disease and implications for cardiovascular risk and disease prevention. Cardiovasc Diabetol. 2022;21(1):270. Published 2022 Dec 3. doi:10.1186/s12933-022-01697-0.
  10. Cheng PN, Chen WJ, Hou CJ, et al. Taiwan Association for the Study of the Liver-Taiwan Society of Cardiology Taiwan position statement for the management of metabolic dysfunction- associated fatty liver disease and cardiovascular diseases. Clin Mol Hepatol. 2024;30(1):16-36. doi:10.3350/cmh.2023.0315.
  11. De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci. 2018;20(1):31-40. doi:10.31887/DCNS.2018.20.1/mdehert.
  12. Pan WH, Wu SY, Yeh NH, Hung SY. Healthy Taiwanese Eating Approach (TEA) toward Total Wellbeing and Healthy Longevity. Nutrients. 2022;14(13):2774. Published 2022 Jul 5. doi:10.3390/nu14132774.
  13. Chien KL, Hsu HC, Su TC, et al. Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: a report from a cohort study in Taiwan. Int J Cardiol. 2012;157(2):263-268. doi:10.1016/j.ijcard.2012.03.017.
  14. Chang HY, Fang HL, Huang CY, et al. Developing and Validating Risk Scores for Predicting Major Cardiovascular Events Using Population Surveys Linked with Electronic Health Insurance Records. Int J Environ Res Public Health. 2022;19(3):1319. Published 2022 Jan 25. doi:10.3390/ijerph19031319.

Resources

Clinical Topics: Prevention, Dyslipidemia

Keywords: Primary Prevention, Taiwan, Cardiovascular Diseases, Risk, Risk Assessment