May 3, 2012 (Dublin, Ireland) — The emphasis is on the lifelong prevention of cardiovascular disease, say the experts, likening the new European Society of Cardiology (ESC) cardiovascular disease prevention guidelines to the owner's manual of a new car. While the car is all bright and shiny and new, owners still need to read the instructions because only a maintained engine hums along at full capacity.
This approach to cardiovascular disease prevention, which ideally starts with young parents and continues with children throughout their years in school, is intended to emphasize heart-healthy lifestyles and behaviors. For adults, risk-adjusted prevention can be coordinated through nurse-based activities and by the preventive efforts of general practitioners and cardiologists.
"I would say the heavy points of the guidelines are for clinicians in primary practice," Dr Joep Perk (Linnaeus University, Teleborg, Sweden), the chair of the fifth edition of the European Joint Societies Task Force on Cardiovascular Disease Prevention in Clinical Practice, told heartwire . "You can look at this like a car that breaks down. We can do some repairs, but we have to look at why the car broke down in the first place. We need to start taking care of patients much, much earlier. Drugs are perfect because they compensate for things that have gone wrong, but wouldn't it better if we saw to it where we didn't need drugs at all? Primary prevention is absolutely the core of our message."
The new guidelines are published today in the European Heart Journal and were presented at EuroPrevent 2012. With an emphasis on getting the guidelines implemented in clinical practice, the newest iteration is shorter and condensed in order to be more practical for busy physicians dealing with their patients. Merely writing the guidelines, without an emphasis on implementation, "would simply be a waste of time," Dr Ian Graham (Trinity College, Dublin, Ireland), one of the authors of the new guidelines, told the media during a morning press conference announcing their publication.
Highlighting Lifestyle and Role of Physicians
The guidelines highlight various principles of behavioral change as well as the specific lifestyle risk factors--smoking, physical inactivity, diet, and psychosocial factors--that could be modified to reduce the risk of cardiovascular disease. In addition, the guidelines recommend that all men and women of a certain age see their doctor for a complete cardiovascular risk assessment.
"We believe that every adult, at least once in his or her lifetime, should have a complete checkup on risk," said Perk. "For males it's above the age of 40, and for females it's above the age of 50. Once in your lifetime, get your blood pressure checked, get your cholesterol checked, get your lipids checked, and see what your options are. We know that 80% of all myocardial infarctions could be prevented with simple lifestyle measures."
In the new guidelines, there is nothing drastically new with regard to treating hypertension. Similarly, recommendations on the management of hyperlipidemia are unchanged from the previous guidelines, with LDL cholesterol remaining the primary treatment target. In patients at very high risk for cardiovascular disease, LDL-cholesterol levels should be reduced to <70 mg/dL or by more than 50% when the target LDL cholesterol can't be reached. For high-risk patients, target LDL cholesterol is less than 100 mg/dL.
One difference in the new guidelines is the simplification of the management of patients with diabetes. All diabetic patients should be treated aggressively because of their heightened risk for cardiovascular and microvascular disease. The new target HbA1c level for the prevention of diabetes is less than 7%, up from less than 6.5%, and metformin should be used as first-line therapy. Statins are recommended for all diabetics, but aspirin is no longer recommended for primary prevention in people with diabetes.
In addition, the new European guidelines recommend the use of P2Y12 inhibitors ticagrelor (Brilinta, AstraZeneca) or prasugrel (Efient, Lilly/Daiichi) and aspirin in patients with acute coronary syndromes. Clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis), on the other hand, is reserved for patients who can't tolerate either of these two new antiplatelet medications.
Nurse-Led Prevention Clinics and Rehab
During the morning press conference, Perk emphasized the importance of nurse-led clinics and nurse-led multidisciplinary prevention programs, stating it was a "mistake" not to use nurses in this setting, given the data showing that these programs are more effective than usual care in reducing cardiovascular risk. The writing committee also stated that cardiac rehabilitation centers can help improve compliance with lifestyle recommendations and are a cost-effective intervention following an acute coronary event (it is a class I recommendation from the ESC, American Heart Association, and American College of Cardiology). With usual care, compliance with treatment tends to drop off after six months following discharge.
"The rehab program is not an add-on or a gimmick after acute care; we can actually save more lives if patients follow rehab programs and we eliminate lifestyle risk factors," said Dr Stephan Gielen (University of Leipzig, Germany), the president-elect of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR). He noted that participation in a cardiac rehab program can reduce the risk of recurrent events 70% compared with usual care alone.
Still, the highlight of the new document remains prevention. During the press conference, Robbie Walsh, a 39-year-old postal worker from Dublin, Ireland, who had a heart attack just over a year ago, told his story. Smoking approximately 20 to 25 cigarettes per day and paying little attention to his diet, Walsh said the symptoms of his MI were unconventional, starting with pain in his lower back and throat. An angiogram revealed a blockage in one of his coronary arteries, and he underwent CABG surgery. He credits the scare and the support of the team at his cardiac rehabilitation center with helping him turn around his lifestyle.
"With a young body, we have a wonderful machine called the heart, but people often don't read the instructions," said Perk. "You have to put a little bit of pressure on the accelerator every once in a while by exercising and you can't fill it with just any type of [gas]. Your heart, your body is also a machine, and it needs to be maintained before it breaks down."
To help drive home the message of cardiovascular prevention, the guidelines also recommend communicating risk to patients based on their "risk age." The risk age of an individual is the age of a person with an equivalent level of risk but with ideal cardiovascular risk factors. For example, a 40-year-old male might have a cardiovascular risk age of 65 years. In contrast, Perk noted that telling a patient they have a 10% ten-year risk of disease can often be distorted by the overly optimistic, who see themselves as 90% likely to dodge the risk of a heart attack. Risk age can be derived from the SCORE chart and from the latest version of HeartScore.
Heartwire from Medscape © 2012 Medscape, LLC
Cite this: New ESC Cardiovascular Disease Guidelines Emphasize Primary Prevention - Medscape - May 03, 2012.