2021 ESC Guidelines on CVD Prevention in Clinical Practice: Key Points

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;Aug 30:[Epub ahead of print].

The following are key points to remember from the European Society of Cardiology (ESC) Guidelines on Cardiovascular Disease (CVD) Prevention in Clinical Practice.

  1. The major risk factors for atherosclerotic cardiovascular disease (ASCVD) are high cholesterol, hypertension, cigarette smoking, diabetes mellitus, and adiposity. Risk factors are treated in a stepwise approach to reach the ultimate treatment goals in apparently healthy people, patients with established ASCVD, and patients with diabetes mellitus.
  2. Psychosocial stress is associated with risk of ASCVD. Frailty assessment is not a method to determine eligibility for any particular treatment, but rather serves to build an individualized care plan with predefined priorities.
  3. Air pollution is strongly associated with ASCVD. Air pollution contributes to mortality and morbidity, and specifically increases the risk of respiratory and CVDs. Environmental exposure has taken on new urgency, as air pollution, in addition to its health effects, has also been ascribed as a major contributor to climate changes, notably through the burning of fossil fuels leading to increasing emissions of carbon dioxide.
  4. Chronic kidney disease (CKD) is an independent risk factor for ASCVD, and ASCVD is the leading cause of death in CKD. Hypertension, dyslipidemia, and diabetes mellitus are prevalent among individuals with CKD and require a high-risk treatment strategy approach. Risk management includes lifestyle, smoking cessation, nutrition, sufficient renin-angiotensin-aldosterone system (RAAS) blockade, target blood pressure (BP) control, lipid management, and—in established CVD—aspirin.
  5. Mental disorders are common in the general population (12-month prevalence of 27%) and are associated with excess mortality. Excess mortality is mainly caused by behavior-dependent risk factors (e.g., smoking addiction) and an impaired capacity for self-care (e.g., treatment adherence).
  6. Regular physical activity is a mainstay of ASCVD prevention. Aerobic physical activity in combination with resistance exercise and the reduction of sedentary time are recommended for all adults. Achieving and maintaining a healthy weight through lifestyle changes has favorable effects on risk factors (BP, lipids, glucose metabolism) and lowers CVD risk.
  7. Stopping smoking rapidly reduces CVD risk and is the most cost-effective strategy for ASCVD prevention. There is strong evidence for medication-assisted interventions: nicotine-replacement therapy, bupropion, varenicline, and drugs in combination. The most effective are assistance using drug therapy and follow-up support. There should be restrictions on smokeless tobacco and e-cigarettes due to evidence of harm.
  8. Lower is better: The effect of low-density lipoprotein cholesterol (LDL-C) on the risk of CVD appears to be determined by both the baseline level and the total duration of exposure to LDL-C. Lowering LDL-C with statins, ezetimibe, and—if needed and cost-effective—PCSK9 inhibitors, decreases the risk of ASCVD proportionally to the absolute achieved reduction in LDL-C. When LDL-C goals according to level of risk cannot be attained, aim to reduce LDL-C by ≥50% and then strive to reduce other risk factors as part of a shared decision-making process with the patient.
  9. Lifestyle interventions are indicated for all patients with hypertension and can delay the need for drug treatment or complement the BP-lowering effect of drug treatment. BP-lowering drug treatment is recommended in many adults when office BP is ≥140/90 mm Hg and in all adults when BP is ≥160/100 mm Hg. Wider use of single-pill combination therapy is recommended to reduce poor adherence to BP treatment. A simple drug treatment algorithm should be used to treat most patients, based on combinations of a RAS blocker with a calcium channel blocker or thiazide/thiazide-like diuretic, or all three. Beta-blockers may also be used where there is a guideline-directed indication.
  10. The number of patients with multiple CV and non-CV comorbidities is rapidly increasing. Therapeutic competition should be considered in multimorbid patients, as the treatment of one condition might worsen a coexisting condition. A paradigm shift from disease-focused to patient-centered care for multimorbid CVD patients is recommended.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Exercise, Hypertension, Smoking, Stress

Keywords: ESC Congress, ESC21, Adiposity, Air Pollution, Blood Pressure, Carbon Dioxide, Cardiovascular Diseases, Cholesterol, LDL, Climate Change, Diabetes Mellitus, Diuretics, Dyslipidemias, Electronic Nicotine Delivery Systems, Exercise, Environmental Exposure, Geriatrics, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Mental Disorders, Myocardial Ischemia, PCSK9 protein, human, Pharmaceutical Preparations, Primary Prevention, Renal Insufficiency, Chronic, Renin-Angiotensin System, Risk Factors, Self Care, Smoking Cessation, Stress, Psychological, Tobacco Use Cessation Devices, Tobacco, Smokeless

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