The new European guidelines on cardiovascular disease prevention in clinical practice1 are an update of the version published in 2012.2 They represent an evidence-based consensus of the sixth European Joint Task Force involving 10 professional societies, including the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS), and the European Society of Hypertension (ESH). In this commentary, we review the essential recommendations of the guidelines.
Huge gains have been made in both the prevention and treatment of cardiovascular disease, but substantial inequalities exist between countries in terms of reduction in morbidity/mortality and increasing levels of obesity, diabetes and physical inactivity pose a very real threat to these positive gains.
Importantly, these gains remind us that prevention is effective—the elimination of health risk behaviours would make it possible to prevent at least 80% of cardiovascular diseases and even 40% of cancers. Thus, unsurprisingly, lifestyle measures are continually highlighted throughout the current guidelines. Stopping smoking after a myocardial infarction is thought to be the most effective aspect of secondary prevention, and clinicians are reminded to identify current smokers and suggest cessation strategies at every opportunity. There should also be emphasis placed on a well-balanced Mediterranean type dietary pattern, with avoidance of refined/processed food, and regular physical activity.
Cardiovascular risk assessment—using the systematic coronary risk evaluation (SCORE) risk estimation tool—is recommended in individuals at increased risk and may be considered in men more than 40 years of age and in women more than 50 years of age. SCORE differs from the UK QRISK2 score in that it estimates the 10-year risk of fatal cardiovascular disease, with levels of >5% and >10% being considered “high risk” and “very high risk” respectively.
In contrast to the recent US and UK guidelines, the revised European guidelines have retained low density lipoprotein (LDL) cholesterol targets: for very high risk (eg. established cardiovascular disease), a target of LDL cholesterol of <1.8mmol/L or a reduction of at least 50% if the baseline is between 1.8 and 3.5mmol/L is advised; for high risk (eg. SCORE >5%), the target is LDL cholesterol of < 2.6mmol/L.
Statins remain the drug of choice for treatment and the highest tolerated dose should be used in patients with established cardiovascular disease. In this subgroup, combination treatment with ezetimibe may be required to achieve therapeutic targets. Clinicians are reminded to screen for dyslipidaemia secondary to other conditions, especially hypothyroidism. Furthermore, they should consider evaluating patients for possible familial hypercholesterolaemia—especially in individuals with an LDL cholesterol of >5.1mmol/L or family history of premature cardiovascular disease.
Blood pressure targets remain at <140/90mmHg for those with cardiovascular disease. Type 2 diabetics with hypertension should have a treatment goal of 140/85mmHg while Type 1 diabetics should have a lower target of 130/80mmHg. Choice of antihypertensive can be tailored to the individual with asymptomatic patients with atherosclerosis benefiting from calcium channel blockers or angiotensin converting enzyme (ACE) inhibitors. After acute coronary syndrome, beta-blockers and ACE inhibitors are the first-line therapies.
Patients with existing coronary artery disease who are diabetic are at much higher risk than their non-diabetic counterparts of further vascular events. Despite this, the target HbA1c recommended for primary prevention in Type 1 and 2 diabetes of <53mmol/L (<7%) should be relaxed slightly in those with existing cardiovascular disease. Control of other risk factors in this population is again highlighted. Diabetic patients with clinically established cardiovascular disease benefit from antiplatelet therapy (aspirin). Its role in diabetic patients without cardiovascular disease remains unproven; therefore in these cases, it is currently not recommended.
In the acute setting, patients hospitalised for an acute coronary syndrome should have a full risk factor assessment and initiation of any treatment required as soon as possible; certainly prior to discharge. Patients should be provided with discharge paperwork and an ongoing management plan, which should ideally include participation in a specialised cardiac rehabilitation programme. These programmes have been shown to improve outcomes by combining exercise training, risk factor modifications and psychological support.
Going forward, in patients with established cardiovascular disease it is noted that annual control of lipids, glucose metabolism and creatinine is recommended.
In summary, preventative measures to minimise cardiovascular risk should be assessed both at the primary and secondary care level with all aspects including diet, physical activity and weight reduction being addressed. Clinicians should take opportunity as soon as possible after an acute event to introduce control not only with therapeutic intervention but also with behavioural strategies.
References
- Piepoli MF et al. European Heart Journal 2016; 37: 2315–81.
- Perk J et al. European Heart Journal 2012; 33: 1635–01.
Anne-Marie Beirne is a specialty registrar in Cardiology at Imperial College NHS Healthcare Trust, London, UK; Susan Connolly is a clinical lead for the Imperial Cardiovascular Health Programme, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
