New ESC Guidelines on CVD Prevention

Megan Brooks

September 01, 2021

Estimating an individual's risk of cardiovascular disease (CVD) remains the cornerstone of the 2021 European Society of Cardiology (ESC) guidelines on CVD prevention in clinical practice.

The new guidelines were published online August 30 in the European Heart Journal to coincide with presentation at the ESC Congress 2021.   

They were developed by an ESC task force in collaboration with 12 medical societies and with special contribution of the European Association of Preventive Cardiology.

"A chief goal of the task force was to create a single CVD prevention guideline for everyone — for primary care, for hospital care, for guiding clinical practice — so one guideline for all," said co-chair of the guideline committee Frank Visseren, MD, PhD, University Medical Center Utrecht, Netherlands.

"We also wanted to make a more personalized CVD prevention guideline, instead of a one-size-fits-all. In clinical practice, people are very, very different and we really want to have a more individualized prevention guideline," said Visseren, as well as provide "more room for shared decision-making."

Prevention at the Individual and Population Levels

The new guidelines also give more attention to CVD prevention in older persons. "Many of our patients are over 70 years old and we really want to have more detail, more guidance on older persons," said Visseren.

The guideline is divided into two sections. One section covers CVD prevention at the individual level in apparently healthy people, in patients with established CVD, and in those with diabetes, familial hypercholesterolemia, or chronic kidney disease.

The other section covers CVD prevention at the population level, including public health policy, interventions, and the environment, including putting in place measures to reduce air pollution, use of fossil fuels, and limiting carbon dioxide emissions.

Targets for blood lipids, blood pressure, and glycemic control in diabetes remain in-line with recent ESC guidelines on dyslipidemias, hypertension, or diabetes.

However, the guidelines introduce a new stepwise treatment-intensification approach to achieve these targets, with consideration of CVD risk, treatment benefit of risk factors, risk modifiers, comorbidities, and patient preferences.

The 2021 CVD prevention guidelines also embrace the recently published Systemic Coronary Risk Estimation 2 (SCORE2) and Systemic Coronary Risk Estimation 2-Older Persons (SCORE2-OP) algorithms.

"The algorithms we are using are a bit old and we want to have more updated risk prediction, because that's the starting point of CVD prevention," Visseren said.

The guidelines also introduce age-specific risk thresholds for risk factor treatments in apparently healthy people and provide estimation of lifetime CVD risk and treatment benefit. This will allow clinicians to have "an informed discussion with patients on lifetime risk and potential treatment benefits," Visseren said.

For the first time, the guidelines recommend smoking cessation regardless of whether it leads to weight gain, as weight gain does not lessen the benefits of cessation.

Regarding exercise, adults of all ages should aim for at least 150 to 300 minutes a week of moderate, or 75 to 150 minutes a week of vigorous, aerobic physical activity. The guidelines recommend reducing sedentary time and engaging in at least light activity throughout the day.

Regarding nutrition, the guidelines advise adopting a Mediterranean or similar diet; restricting alcohol intake to a maximum of 100 g per week (a standard drink is 8 to 14 g); eating fish, preferably fatty fish, at least once a week; and restricting consumption of meat, particularly processed meat.

Also for the first time, the guidelines state that bariatric surgery should be considered for obese individuals at elevated risk of CVD when a healthy diet and exercise fail to lead to weight loss that is maintained.

They note that individuals with mental disorders need additional attention and support to improve adherence to lifestyle changes and drug treatment.

They advise consideration of referring patients with heart disease and significant stress and anxiety to psychotherapeutic stress management to reduce stress symptoms and improve CV outcomes.

Potential cost issues that could be considered when implementing the guidelines are also reviewed.

Visseren acknowledged and thanked the task force members for continuing their work on the guidelines over the 2 "challenging" years.

Setting the Bar Lower?

Discussant for the guideline presentation, Diederick Grobbee, MD, University Medical Center Utrecht, who was not involved in drafting the guidelines, said he does have one conflict of interest, which is a "passion for prevention."

From that perspective, he said the guideline panel "should be applauded; the once-every-5-year issuing of the prevention guidelines is a major event."

Grobbee noted that the working group "really tried to follow their ambitions and goals, in a way making the guidelines simpler, or perhaps setting the bar not initially as high as we used to do, which may, in fact, sometimes scare off physicians and patients alike."

"We've had prevention guidelines for quite some time now, yet looking at what is accomplished in practice is sobering," said Grobbee. Introducing a stepwise approach is "really appealing," he added.

Eur Heart J. Published online August 30, 2021. Full text

European Society of Cardiology (ESC) Congress 2021. Presented August 30, 2021.

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