The European Society of Cardiology (ESC) Guidelines on cardiovascular disease prevention in clinical practice are published online today in European Heart Journal.
As much as 90% of the risk of a heart attack, stroke, or peripheral arterial disease (PAD) can be explained by smoking, poor eating habits, lack of physical activity, abdominal obesity, high blood pressure, raised blood lipid levels, diabetes, psychosocial factors, or alcohol. These guidelines focus on atherosclerotic cardiovascular disease (CVD), which affects the arteries. As the inside of the arteries become clogged up by fatty deposits, they can no longer supply enough blood to the body. This process is the main cause of heart attacks, strokes, PAD and sudden death where arteries become completely blocked. The most important way to prevent these conditions is to adopt a healthy lifestyle throughout life, especially not smoking, and to treat risk factors.
Recommendations are provided for healthy adults of all ages, as well as patients with established CVD or diabetes. Identifying who will benefit most from preventive treatments, such as blood pressure and lipid lowering therapies, is central to prevention efforts and therefore the estimation of CVD risk is the cornerstone of the guidelines.
Targets for blood lipids, blood pressure, and glycaemic control in diabetes remain as recommended in recent ESC guidelines on dyslipidaemias, hypertension or diabetes. The current guidelines introduce a stepwise approach to intensifying preventive treatments, while always taking into consideration potential benefit, other conditions, psychosocial factors and patient preferences. In healthy people, for example, the stepwise approach starts with recommendations for everyone: smoking cessation, adopting a healthy lifestyle, and maintaining a systolic blood pressure below 160 mmHg. The recommendations are then tailored according to the 10-year risk of CVD (calculated by a health professional using available risk scores).
“Individualized decisions using risk estimation and a stepwise approach to therapies is more complex than a one-size-fits-all approach, but reflects the diversity of patients and patient characteristics in everyday clinical practice, and is essential to give the right patient the right treatment,” said guidelines task force chairperson Professor Frank Visseren of the University Medical Center Utrecht, the Netherlands.
A new section is devoted to communication of risk in the shared decision making process. The aims are for individuals to understand their risk, the anticipated risk reduction with preventive actions, the pros and cons of intervention, and their own priorities. In healthy people, the standard approach is to calculate the likelihood of CVD within 10 years. Young people may find estimations of lifetime risk and lifetime benefit of preventive action more informative, since their 10-year risk is generally low.
Stopping smoking is potentially the most effective of all preventive measures, with substantial reductions in heart attacks or death. The CVD risk in smokers under 50 years of age is five-fold higher than in non-smokers. Quitting must be encouraged in all smokers, and passive smoking should be avoided where possible. For the first time, the guidelines explicitly state that smoking cessation is recommended, and remains beneficial, regardless of weight gain. While evidence suggests that e-cigarettes may be more effective than nicotine-replacement therapy for smoking cessation, the long-term effects on cardiovascular and lung health are unclear and dual use with tobacco cigarettes should be avoided.
Regarding exercise, adults of all ages should strive for at least 150−300 minutes a week of moderate-intensity, or 75−150 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination. For the first time it is recommended to reduce sedentary time and engage in at least light activity throughout the day. Also new is to consider wearable activity trackers to increase activity. The guidelines state: “Most important is to encourage activity that people enjoy and/or can include in their daily routines, as such activities are more likely to be sustainable.”
Regarding nutrition, a healthy diet is recommended for all individuals to prevent CVD. This should emphasize plant-based foods including whole grains, fruits, vegetables, pulses, and nuts. New recommendations include the adoption of a Mediterranean or similar diet; restricting alcohol intake to a maximum of 100 g per week (a standard drink contains 8 to 14 g); eating fish, preferably fatty, at least once a week; and restricting consumption of meat, particularly processed meat.
In terms of body weight, it is recommended that overweight and obese people lose weight to lower blood pressure, blood lipids, and the risk of diabetes, and thereby reduce the likelihood of CVD. For the first time, the guidelines state that bariatric surgery should be considered for obese individuals at high risk of CVD when a healthy diet and exercise do not result in maintained weight loss.
Mental disorders such as anxiety are associated with an increased risk of CVD and a worse prognosis for those already diagnosed with CVD. A new recommendation is to provide intensified support to patients with these conditions to improve adherence to lifestyle changes and drug treatment. Also new is to consider referral to psychotherapeutic stress management for patients with CVD and stress.
The guidelines recommend policy interventions at the population level to improve heart health and promote healthy choices. These include measures to lower air pollution, reduce fossil fuel use, and limit carbon dioxide emissions. Other measures are greater availability of school playground spaces, and legislation that restricts marketing unhealthy food to children on television, the internet, social media, and food packaging. E-cigarettes, which are addictive, should be subject to similar marketing controls as standard cigarettes, especially flavored varieties that appeal to children. Labeling alcohol with caloric content and health warnings may be considered.
As summarized by guidelines task force chairperson Professor François Mach of Geneva University Hospital, Switzerland, “CVD prevention requires an integrated, interdisciplinary approach that puts healthy people and patients at the center and considers other health conditions, and environmental factors including air pollution.”