The guidelines of the Sixth Joint Task Force of the European Society of Cardiology and other societies on Cardiovascular Disease Prevention in Clinical Practice were published recently under the chairmanship of professors Massimo Piepoli of Italy and Arno Hoes of the Netherlands.

This article is based on the “to do and not to do” messages which form a summary at the end of the full text of the guidelines, with occasional additional information or comments. For ease of reading, the evidence grades have been removed but can readily be checked by downloading the full text on www.escardio.org

It should be stressed that guidelines are just that and not absolute rules, and should be interpreted in the light of the healthcare worker’s knowledge and experience and the local social, cultural and economic situation.

Cardiovascular risk assessment

Systematic cardiovascular (CV) risk assessment is recommended in individuals at increased CV risk, such as those with a family history of premature cardiovascular disease (CVD), familial hyperlipidaemia, major CV risk factors such as smoking, high blood pressure (BP), diabetes or raised lipid levels or comorbidities increasing CV risk. 

It is recommended to repeat CV risk assessment every five years, and more often for individuals with risks close to thresholds mandating treatment.

Systematic CV risk assessment in men < 40 years of age and women < 50 years of age with no known CV risk factors is not recommended. 

How to estimate cardiovascular risk 

Total CV risk estimation, using a risk estimation system such as SCORE, is recommended for adults > 40 years of age, unless they are automatically categorised as being already at high or very high risk based on documented CVD, diabetes (> 40 years of age), kidney disease or a highly elevated single risk factor – these people need active risk factor management anyway.

Routine assessment of circulating or urinary biomarkers is not recommended for refinement of CVD risk stratification.

Imaging such as CT calcium scoring can refine risk estimation in intermediate risk subjects. 

Carotid ultrasound IMT screening for CV risk assessment is not currently recommended, although new work on combined IMT and plaque imaging may refine this recommendation in future.

Categories of risk:

Very high risk

Subjects with any of the following:

•
Documented CVD, clinical (such as heart attack, acute coronary syndrome, stroke, aneurysm or peripheral vascular disease) or unequivocal on imaging

•
Diabetes mellitus with target organ damage such as proteinuria or with a major risk factor or factors such as smoking, marked hypercholesterolaemia or marked hypertension

•
Severe chronic kidney disease (CKD) GFR < 30ml/min/1.73m2

• A calculated SCORE ≥ 10%.

High risk

Subjects with:

•
Markedly elevated single risk factors, in particular cholesterol > 8mmol/l (> 310mg/dl) (eg. in familial hypercholesterolaemia) or BP ≥ 180/110mmHg

•
Most other people with diabetes (with the exception of young people with type 1 diabetes and without major risk factors who may be at low or moderate risk)

•
Moderate CKD (GFR 30-59ml/min/1.73m2)

•
A calculated SCORE ≥ 5% and < 10%.

Moderate risk

•
SCORE ≥ 1% and < 5% at 10 years. Many middle-aged subjects belong to this category.

Low risk

• SCORE < 1%.

Recommendations for how to intervene and goals

It is recommended that healthy adults of all ages perform at least 150 minutes a week of moderate intensity or 75 minutes a week of vigorous intensity aerobic physical activity (PA) or an equivalent combination thereof.

PA is recommended in low-risk individuals without further assessment. 

Avoidance of exposure to any form of tobacco is recommended. Smokers should be offered repeated advice on stopping, with offers to help aided by the use of follow-up support, nicotine replacement therapies varenicline and bupropion individually or in combination.

A healthy diet low in saturated fat with a focus on wholegrain products, vegetables, fruit and fish is recommended as a cornerstone of CVD prevention in all individuals. 

It is recommended that subjects with healthy weight maintain their weight and that overweight and obese people aim for a progressive reduction in weight to a BMI of 20-25kg/m2 or a waist circumference of < 94cm (men) or < 80cm (women).

In patients at very high CV risk, an LDL-C goal < 1.8mmol/l (< 70mg/dl), or a reduction of at least 50% if the baseline is between 1.8 and 3.5mmol/l (70 and 135mg/dl) is recommended.

In patients at high CV risk, an LDL-C goal < 2.6mmol/l (< 100mg/dl), or a reduction of at least 50% if the baseline is between 2.6 and 5.1mmol/l (100 and 200mg/dl) is recommended.

In treated hypertensive patients < 60 years old, SBP < 140mmHg and DBP < 90mmHg are recommended.

In patients > 60 years old with SBP ≥ 160mmHg, it is recommended to reduce SBP to between 150 and 140mmHg. In individuals > 80 years and with initial SBP ≥ 160mmHg, it is recommended to reduce SBP to between 150 and 140mmHg, provided they are in good physical and mental conditions.

BP targets in type 2 diabetes are < 140/85mmHg, but a lower target of < 130/80mmHg is recommended in selected patients (eg. younger patients at elevated risk for complications) for additional gains in terms of stroke, retinopathy and albuminuria risk.

BP targets in patients with type 1 diabetes are < 130/80mmHg.  

Drug treatment is recommended in patients with grade 3 hypertension irrespective of CV risk, as well as in patients with grade 1 or 2 hypertension who are at very high CV risk.

All major BP lowering drug classes (ie. diuretics, ACE-I, calcium antagonists, ARBs, and beta-blockers) do not differ in their BP-lowering and thus are recommended as BP lowering treatment.

A renin-angiotensin-aldosterone system blocker is recommended in the treatment of hypertension in diabetes, particularly in the presence of proteinuria or microalbuminuria.

Beta-blockers and thiazide diuretics are not recommended in hypertensive patients with multiple metabolic risk factors due to the increased risk of diabetes.

A target HbA1c for the reduction in risk of CVD and microvascular complications in diabetes mellitus (DM) of < 7.0% (<53 mmol/mol) is recommended for the majority of non-pregnant adults with either type 1 or type 2 DM.

In DM, metformin is recommended as therapy, if tolerated and not contra-indicated, following evaluation of renal function.  

Lipid lowering agents (principally statins) are recommended to reduce CV risk in all patients with type 2 or type 1 DM above the age of 40 years. 

Antiplatelet therapy is not recommended in individuals without CVD due to the increased risk of major bleeding

Medication and lifestyle adherence

Simplifying the treatment regimen to the lowest acceptable level is recommended, with repetitive monitoring and feedback. In the case of persistent non-adherence, multiple sessions combined with behavioural interventions if feasible are recommended.

It is recommended that health personnel and caregivers set an example by following healthy lifestyle, such as not smoking or using tobacco products at work.

CVD prevention implementation 

In primary care, it is recommended that GPs, nurses and allied health professionals within primary care work as a team to deliver CVD prevention for high risk patients.

In the acute hospital setting, it is recommended to implement strategies for prevention in CVD patients, including lifestyle changes, risk factor management and pharmacological optimisation after an acute event, before hospital discharge.

Participation in a cardiac rehabilitation programme for patients hospitalised for an acute coronary event or revascularisation, and for patients with heart failure, is recommended.

The joint guidelines represent the product of a partnership between the main contributor, the European Association of Cardiovascular Prevention and Rehabilitation and the following bodies: European Society of Cardiology (ESC); European Association for the Study of Diabetes (EASD); European Atherosclerosis Society (EAS); European Heart Network (EHN); European Society of Hypertension (ESH); European Stroke Organisation (ESO); International Diabetes Federation European Region (IDF Europe); International Federation of Sport Medicine (FIMS); International Society of Behavioural Medicine (ISBM) and WONCA Europe. 

The partnership is based on an understanding that the partners will endeavour to ensure compatibility between the Joint Guidelines and the more specialised guidelines of the participating organisations.

The full text of the guidelines is available free as a PDF on www.escardio.org. Pocket guidelines and a slide set will also be available shortly.