Gregory Weiss, MD, provides an overview of the updated cardiovascular disease prevention guidelines from the European Society of Cardiology, which were released at ESC Congress 2021.
Cardiovascular disease remains the predominant cause of health-related morbidity and mortality worldwide.1 While some genetic factors contribute to both risk for and protection from cardiovascular disease (CVD), the European Society of Cardiology (ESC) estimates that up to 90% of heart attack, stroke, and peripheral arterial disease (PAD) risk can be attributed to smoking, poor diet, lack of physical activity, obesity, high blood pressure, raised blood lipids, diabetes, and alcohol consumption.2 The ESC considers promoting CVD prevention a priority and to that end presented updated guidelines at ESC Congress 2021.
Key to preventing CVD is the prevention of atherosclerotic build-up in the arterial system. Fatty atherosclerotic plaque is responsible for most cases of myocardial infarction (MI), stroke, PAD, and sudden cardiac death. The ESC believes that the best way to prevent serious cardiovascular events is through mitigating modifiable risk factors for CVD.2 It all starts with adopting a healthy lifestyle and maintaining it throughout a lifetime.
The ESC recommends that clinicians first identify who will benefit most from preventative treatments such as blood pressure medications and lipid-lowering therapies and considers this risk stratification the cornerstone of these guidelines.2 For patients at higher risk, such as those with high blood pressure, diabetes, and dyslipidemias, targets for all 3 should be set and treatment initiated with escalation as need to meet the needs of the individual patient.1 When patients already have such risk factors for CVD it is of utmost importance that those underlying conditions be treated aggressively.
In healthy people, especially young people who have not yet developed atherosclerotic disease, promoting a healthy lifestyle may stop CVD before it starts. Key to this approach is smoking cessation, maintaining a normal blood pressure, exercise and weight management as well as eating a balanced and healthy diet.2 Cardiologists and other clinicians can set targets for lifestyle modifications based on the 10-year risk for developing CVD using established risk measures.1
Frank Visseren, MD, PhD, an epidemiologist and professor in vascular medicine at the University Medical Center in Utrecht, the Netherlands, is the chairperson for the guidelines task force. He underscores the importance of tailoring preventative and treatment strategies to each patient:
“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.”
Five key modifiable risk factors were highlighted by the group: Smoking, exercise, nutrition, weight management, mental health, and population-level interventions.
The ESC believes that stopping smoking may be the most effective preventative measure of all with regards to CVD.1 All clinicians should encourage quitting at every visit. Guidelines now recommend smoking cessation regardless of weight gain.2
With regards to exercise, the ESC guidelines taskforce recommends that adults avoid sedentary time and strive for at least 150-300 minutes of moderate-intensity, or 75-150 minutes of high intensity exercise each week.2 For the first time the task force has included the use of wearable activity trackers as potentially beneficial in promoting activity and maintaining a healthy weight.1
Nutrition is a very important aspect of CVD prevention. The ESC task force recommends plant-based foods such as whole grains, fruits, vegetables, and nuts.2 New for the 2021 guideline is the recommendation that adopting a Mediterranean type of diet along with restricting alcohol intake should be suggested for all patients.2
The prior two recommendations are closely related to maintaining appropriate body weight and composition. The ESC recommends that overweight and obese patients lose weight in an effort to lower blood pressure, blood lipids, and the risk of diabetes.2 New to the 2021 guidelines is the recommendation that weight reduction surgery (bariatric) be considered for obese patients with high risk for CVD.2
Mental health has been linked to increase CVD risk.1 For the first time the ESC recommends we provide intensified support to patients with mental health problems while encouraging them to comply with lifestyle changes and medication therapy.2
Finally, the ESC taskforce highlights the steps we can take on a global level to promote cardiovascular health and prevent CVD. These measures include reducing pollution through reduced fossil fuel use and placing limits on carbon dioxide emissions.2 Further, they recommend more outdoor recreational space, reductions in marketing unhealthy food and E-cigarettes to children, and labeling food and alcohol with nutritional content warnings.2
Finally, the task force recommends that cardiovascular disease prevention should be an interdisciplinary effort with frontline clinicians, cardiologists, and other specialists working together to promote best practices and the implementation of these guidelines put forth by the European Society of Cardiology.