What's New in the 2021 ESC Guidelines on CVD Prevention: Global Spotlights, The Ten Commandments for the 2021 ESC Guidelines on CVD Prevention

Quick Takes

  • The ESC CVD Prevention Guidelines are an update of the 2016 guidelines, which encourage management strategies at both an individual level and a population level.
  • The SCORE2 and SCORE2-OP risk scores have been updated and are now calibrated to four geographic European regions and include estimations of lifetime risk.
  • These guidelines classify individuals into four groups (e.g., apparently healthy, those with established atherosclerotic CVD, those with specific risk conditions). Stepwise treatment intensification is a new aspect of the guidelines, using therapeutic goals aligned with published ESC guidelines for LDL cholesterol, blood pressure, and glycemic control to allow for a shared decision-making approach.
  • The guidelines address population approaches to prevention including population-attributable risk, societal environmental factors, and modifiable social determinants of health.

Figure from Global Spotlights, The Ten Commandments for the 2021 ESC Guidelines on CVD Prevention (Figure 1)

Figure 1

Carballo et al., outline highlights from the 2021 ESC Guidelines on CVD prevention. These 'ten commandments' outline the areas of the guidelines that contain new or revised recommendations since the prior prevention guidelines were published in 2016. This includes the organization of a single guideline for primary care and for hospital care for use in clinical practice. Individuals were classified into risk groups based on clinical characteristics, with incorporation of geographic region for enhanced precision. These risk groups are to be used to assist in the stepwise treatment intensification approach to prevention.

The guidelines recommend incorporation of patient preferences for a shared decision approach. The SCORE2 and SCORE2-OP risk scores have been updated and are recommended for use in apparently healthy adults. These algorithms are calibrated by geographic region and personalized for age with greater attention for CVD prevention in older adults. Targeted goals for LDL cholesterol, blood pressure, and glycemic control remain consistent with previous guidelines. For triglycerides, recommendations for icosapent ethyl are outlined, and for prevention, the use of anti-inflammatory therapy with colchicine may now be considered. These guidelines also address use of antithrombotic therapies in prevention of CVD.

New attention to environmental exposures which are modifiable have been included. This includes attention to air and soil pollutants, as well as above-threshold noise levels as recognized factors that contribute to mortality and morbidity. Climate change was noted to be a major public health and environmental concern. It should also be noted that the guidelines now offer recommendations related to potential cost-benefit issues for prevention throughout the guidelines.

These guidelines provide a well-written, thoughtful set of recommendations for assessing CVD risk in clinical practice. The use of stepwise intensification of treatment, together with the new risk scores and emphasis on shared decision making, will allow clinicians to comprehensively manage prevention in everyday practice. Last, the incorporation of environmental risks is to be applauded, given the impact of modifiable environmental factors on CVD health.


  1. Carballo D, Visseren FJ, Mach F, Smulders Y. The 'Ten Commandments' for the 2021 ESC Guidelines on CVD Prevention. Eur Heart J 2022;43:174-176.
  2. Visseren FL, Mach F, Smulders YM, et al. 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice: Developed by the Task Force for Cardiovascular Disease Prevention in Clinical Practice With Representatives of the European Society of Cardiology and 12 Medical Societies With the Special Contribution of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2021;42:3227-3337.

Clinical Topics: Prevention

Keywords: Cholesterol, LDL, Fibrinolytic Agents, Public Health, Blood Pressure, Decision Making, Shared, Glycemic Control, Patient Preference, Cardiovascular Diseases, Risk Factors, Triglycerides, Environmental Exposure, Primary Health Care, Colchicine, Morbidity, Hospitals, Primary Prevention

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