European guidelines on cardiovascular disease prevention in clinical practice.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Medical Priorities

The present recommendations define the following priorities for cardiovascular disease (CVD) prevention in clinical practice:

Patients with established coronary heart disease, peripheral artery disease, and cerebrovascular atherosclerotic disease
Asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular diseases because of:
- Multiple risk factors resulting in a 10-year risk of >5% now (or if extrapolated to age 60) for developing a fatal CVD event
- Markedly raised levels of single risk factors: cholesterol >8 mmol/l (320 mg/dl), low-density lipoprotein (LDL) cholesterol >6 mmol/l (240 mg/dl), blood pressure >180/110 mmHg
- Diabetes type 2 and diabetes type 1 with microalbuminuria
Close relatives of:
- Patients with early onset atherosclerotic cardiovascular disease
- Asymptomatic individuals at particularly high risk
Other individuals encountered in routine clinical practice

Total cardiovascular risk as a guide to preventive strategies: the Systematic Coronary Risk Evaluation (SCORE) system

These guidelines recommend a new model for total risk estimation based on the SCORE System:

The SCORE risk assessment system is derived from a large dataset of prospective European studies and predicts any kind of fatal atherosclerotic end-point (i.e., fatal CVD events over a 10 year period).
In SCORE the following risk factors are integrated: gender, age, smoking, systolic blood pressure (SBP) and either total cholesterol or the cholesterol/high-density lipoprotein (HDL) ratio.
Since this chart predicts fatal events, the threshold for being at high risk is defined as >5%, instead of the previous >20% in charts using a composite coronary endpoint.
Refer to figures 1 and 2 and tables 1 and 2 to assess total CVD risk from printed charts.

Management of CVD risk in clinical practice

Strategic steps that may be used to enhance the effectiveness of behavioural counseling include (adapted from the Report of the US Preventive Services Task Force):

Develop a therapeutic alliance with the patient.
Ensure that patients understand the relationship between behaviour, health, and disease.
Help patients to understand the barriers to behavioural change.
Gain commitments from patients to behavioural change.
Involve patients in identifying and selecting the risk factors to change.
Use a combination of strategies including reinforcement of patients’ own capacity for change.
Design a lifestyle modification plan.
Monitor progress through follow-up contact.
Involve other health care staff wherever possible.

Stop smoking tobacco

Ask: systematically identify all smokers at every opportunity.
Assess: determine the patient’s degree of addiction and his/her readiness to cease smoking.
Advise: urge strongly all smokers to quit.
Assist: agree on a smoking cessation strategy including behavioural counselling, nicotine replacement therapy, and/or pharmacological intervention.
Arrange: schedule of follow-up visits.

Make healthy food choices

Foods should be varied, and energy intake must be adjusted to maintain ideal body weight.
The consumption of the following foods should be encouraged: fruits and vegetables, whole grain cereals and bread, low fat dairy products, fish, and lean meat.
Oily fish and omega-3-fatty acids have particular protective properties.
Total fat intake should account for no more than 30% of energy intake, and intake of saturated fats should not exceed a third of total fat intake. The intake of cholesterol should be less than 300 mg/day.
In an isocaloric diet, saturated fat can be replaced partly by complex carbohydrates, partly by monounsaturated and polyunsaturated fats from vegetables and marine animals.

Increase physical activity

Physical activity should be promoted in all age groups.
Although the goal is at least half an hour of physical activity on most days of the week, more moderate activity is also associated with health benefits.
30 to 45 minutes, 4 to 5 times weekly at 60 to 75% of the average maximum heart rate
For patients with established CVD, advice must be based on a comprehensive clinical judgement including the results of an exercise test

Management of other risk factors

Overweight and obesity

Weight reduction is strongly recommended for obese people (body mass index [BMI] >30 kg/m²) or overweight individuals (BMI >25 and <30 kg/m²) and for those with increased abdominal fat as indicated by waist circumference >102 cm in men and >88 cm in women

Blood pressure

The decision to start treatment depends not only on the level of blood pressure, but also on an assessment of total cardiovascular risk and the presence or absence of target organ damage. In patients with established CVD the choice of antihypertensive drugs depends on the underlying cardiovascular disease.
- Drug therapy should be initiated promptly in individuals with a sustained SBP >180 mmHg and/or a diastolic blood pressure (DBP) >110 mmHg regardless of their total cardiovascular risk assessment.
- Individuals at high risk of developing CVD with sustained SBP of >140 mmHg and/or DBP >90 mmHg also require drug therapy. For such individuals, drugs should be used to lower blood pressure to <140/90 mmHg.
- Similar elevation of blood pressure in low-risk people without target organ damage should be followed closely, and lifestyle advice should be given. Drug treatment might be considered after asking the patients’ preference.
- With few exceptions, individuals with SBP< 140 mmHg and/or DBP <90 mmHg do not need drug therapy.
- Patients with a high or very high cardiovascular risk profile and patients with diabetes can benefit from reducing blood pressure below the goal of SBP<140 mmHg and/or DBP <90 mmHg.
Antihypertensive drugs should not only lower blood pressure effectively. They should have a favourable safety profile and be able to reduce cardiovascular morbidity and mortality.
For most patients, the goal of therapy is blood pressure less than 140/90 mmHg, but for patients with diabetes and individuals at high total CVD risk, the blood pressure goal should be lower.

Plasma lipids

In general, total plasma cholesterol should be below 5 mmol/l (190 mg/dl), and LDL cholesterol should be below 3 mmol/l (115 mg/dl).
For patients with clinically established CVD and patients with diabetes, the treatment goals should be lower: total cholesterol <4.5 mmol/l (175 mg/dl) and LDL cholesterol <2.5 mmol/l (100 mg/dl)
Asymptomatic people at high multifactorial risk of developing cardiovascular disease, whose untreated values of total and LDL cholesterol are already close to 5 and 3 mmol/l, respectively, seem to benefit from further reduction of total cholesterol to <4.5 mmol/l (175 mg/dl), and from further reduction of LDL cholesterol to <2.5 mmol/l (100 mg/dl), with moderate doses of lipid-lowering drugs.
In asymptomatic individuals, the first step is to assess total cardiovascular risk and to identify these components of risk that are to be modified.
- If the 10-year risk of cardiovascular death is <5% and will not exceed 5% if the individual’s risk factor combination is projected to age 60, professional advice concerning a balanced diet, physical activity, and stopping smoking should be given to keep the cardiovascular risk low.
- Risk assessment should be repeated at 5-year intervals.
- Note that assessment of total risk does not pertain to patients with familial hypercholesterolemia, since total cholesterol >8 mmol/l (320 mg/dl) and LDL cholesterol >6 mmol/l (240 mg/dl) by definition places a patient at high total risk of CVD.
If the 10-year risk of cardiovascular death is >5%, or will become >5% if the individual’s risk factor combination is projected to age 60, a full analysis of plasma lipoproteins should be performed, and intensive lifestyle advice, particularly dietary advice, should be given.
In contrast, if total risk remains >5%, lipid lowering drug therapy should be considered to lower total and LDL cholesterol even further.
- The goals in such persistently high-risk individuals are to lower total cholesterol to <4.5 mmol/l (175 mg/dl) and to lower LDL cholesterol to <2.5 mmol/l (100 mg/dl).
- These lower values are not goals of therapy for patients with higher untreated values.
In some patients, goals cannot be reached even on maximal therapy, but they will still benefit from treatment to the extent to which cholesterol has been lowered.

Diabetes

It has been demonstrated that progression to diabetes can be prevented or delayed by lifestyle intervention in individuals with impaired glucose tolerance.
Regarding the prevention of cardiovascular events, there are also good reasons to aim for good glucose control in both types of diabetes.
- In type 1 diabetes, glucose control requires appropriate insulin therapy and concomitant professional dietary therapy.
- In type 2 diabetes, professional dietary advice, reduction of overweight, and increased physical activity should be the first treatment aiming at good glucose control.
Drug therapy must be added if these measures do not lead to a sufficient reduction of hyperglycemia.
Recommended treatment targets for type 2 diabetes are:
- Haemaglobin A1c: <6.1%
- Venous plasma glucose (fasting/preprandial): <6.0 mmol/l; <110 mg/dl
- Self-monitored blood glucose
  - Fasting/preprandial: 4.0 to 5.0 mmol/l; 70 to 90 mg/dl
  - Postprandial: 4.0 to 7.5 mmol/l; 70 to 135 mg/dl
- Blood pressure: <130/80 mmHg
- Total cholesterol: <4.5 mmol/l; <175 mg/dl
- LDL cholesterol: <2.5 mmol/l; <100 mg/dl

Metabolic syndrome

The diagnosis of the metabolic syndrome is made when three or more of the following features are present:
- Waist circumference >102 cm in males, >88 cm in females
- Serum triglycerides >1.7 mmol/l (>150 mg/dl)
- HDL cholesterol <1 mmol/l (<40 mg/dl) in males or <1.3 mmol/l (<50 mg/dl) in females.
- Blood pressure >130/85 mmHg.
- Plasma glucose >6.1 mmol/l (>110 mg/dl).
People with the metabolic syndrome are usually at high risk of cardiovascular disease
Lifestyle has a strong influence on all the components of the metabolic syndrome and therefore the main emphasis in the management of the metabolic syndrome should be in professionally supervised lifestyle changes, particularly efforts to reduce body weight and increase physical activity.
Elevated blood pressure, dyslipidemia, and hyperglycemia (in the diabetic range) may, however, need additional drug treatment as recommended in the present guidelines.

Other prophylactic drug therapies

In addition to drugs needed to treat blood pressure, lipids, and diabetes, the following drug classes should also be considered in the prevention of CVD in clinical practice:
- Aspirin or other platelet-modifying drugs in virtually all patients with clinically established CVD
- Beta-blockers in patients following myocardial infarction or with left ventricular dysfunction due to coronary heart disease (CHD)
- Angiotensin-converting enzyme (ACE) inhibitors in patients with symptoms or signs of left ventricular dysfunction due to CHD and/or arterial hypertension
- Anti-coagulants in those patients with CHD who are at increased risk of thromboembolic events
- In asymptomatic high risk people there is evidence that low-dose aspirin can reduce the risk of cardiovascular events in people with diabetes, in people with well controlled hypertension, and in men at high multifactorial CVD risk.

Screening close relatives

Close relatives of patients with premature coronary heart disease (men <55 years and women <65 years) and persons who belong to families with familial hypercholesterolemia or other inherited dyslipidemias should be examined for cardiovascular risk factors, because all of these persons are at increased risk of developing cardiovascular disease.

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