Perspective:

The following are 10 points to remember about the European guidelines for cardiovascular disease (CVD) prevention in clinical practice:

1. Although improvements have been observed for several risk factors, significant gaps remain. At present, the proportion of adults with established coronary artery disease (CAD) at goal is suboptimal, including 48% smoking cessation rate for current smokers, 34% of adults meet recommended activity levels, 18% of adults have a body mass index (BMI) <25 kg/m², 50% meet blood pressure goals of <140/90 mm Hg, and 55% meet goal low-density lipoprotein (LDL) targets.

2. Risk factors for CAD often track together. Identification of risk is paramount to reducing the burden of CAD, including identification of young adults at high lifetime risk. Total risk assessment should be offered to patients who ask for such assessment, have one or more risk factors, have a family history of premature CVD or a major risk factor such as hyperlipidemia, and/or have symptoms suggestive of CVD. Special efforts to assess risk are recommended for populations at risk, including those with low socioeconomic status characteristics.

3. Risk assessment such as SCORE is meant to facilitate risk in apparently healthy adults. SCORE estimates the 10-year risk of first fatal atherosclerotic events (such as myocardial infarction [MI], stroke, or aortic aneurysm). The assessment of fatal events as opposed to fatal and nonfatal is important due to the improved precision related to hard endpoints such as death, and the ability to re-calibrate the risk assessment tool with changes in mortality trends for geographic region and time variation. Additional advantages include ease of use, objective assessment which demonstrated change over time or age, and use of relative risk, which can identify younger adults at higher lifetime risk. Risk factor screening including the lipid profile may be considered in adult men ≥40 years old and in women ≥50 years of age or postmenopausal.

4. Asymptomatic women and older adults will benefit from risk scoring to assist in prevention management. For women, the leading cause of mortality is CVD. Adults with low SES, lack of social support, increased or chronic stress, and depression/anxiety have increased risk of CVD with worse clinical outcomes. Risk assessment and prevention management can significantly impact CVD burden in these groups. Core questions for the assessment of psychosocial risk are outlined in this guideline.

5. Novel biomarkers of risk add only limited additional value to current assessments such as the SCORE algorithm. High-sensitivity C-reactive protein and homocysteine may be used among adults at moderate risk for CVD. Imaging methods may also be relevant on the assessment of adults at moderate risk. Such testing includes ankle-brachial index, carotid ultrasound for intima-media thickness, coronary calcium score, magnetic resonance imaging, and ophthalmoscopy of retinal artery atherosclerosis.

6. Additional conditions which increase the risk for CVD include influenza, obstructive sleep apnea, erectile dysfunction, autoimmune diseases, periodontitis, and chronic kidney disease. Annual influenza vaccination and evaluation for sleep apnea is recommended. Radiation exposure and transplantation can increase risk for CVD events. In all these groups, risk assessment and management of risk factors is key.

7. Behavioral change that leads to a healthy lifestyle is a critical component of prevention. Cognitive behavioral therapy can be an effective means toward lifestyle modification. Factors including developing a patient-centered plan for change, a therapeutic alliance, and discussion of barriers to change assist with change. A healthy diet should be low in saturated fatty acids (<10% of total energy), <5 g of salt/day, 30-45 g of fiber, two or more servings per week of fish, 4-6 servings per day of fruits and vegetables, and moderate alcohol intake. A Mediterranean-type dietary pattern is preferable. A healthy weight is associated with decreased risk, with the lowest all-cause mortality for BMI between 20 and 25 kg/m².

8. Elevated blood pressure is a major risk factor for CVD; presence of CVD, renal disease, or CVD risk factors will influence blood pressure goals. Lifestyle interventions to reduce weight and/or sodium intake if indicated are cornerstones of therapy. Pharmacologic therapy depends on risk factors present. Antihypertensive therapy is beneficial in adults 80 years or older. Evidence of subclinical organ damage in hypertension predicts CVD mortality independently of SCORE risk. Many patients benefit from combination therapy; approximately 10% will require three or more agents. LDL cholesterol is the primary target of therapy, as well as for screening and risk estimation. High-density lipoprotein cholesterol is a strong risk factor and can be used for risk estimation, but is not recommended as a therapeutic target. For patients with acute coronary syndrome, a goal LDL <70 mg/dl is recommended.

9. For patients with diabetes mellitus, intensive management of glucose reduces microvascular complications, and to a lesser extent, CVD. Intensive blood pressure management in patients with diabetes mellitus reduces risk for micro- and macro-vascular events. Goal glycated hemoglobin for diabetes mellitus patients is <7%. Aspirin is no longer recommended for patients with diabetes mellitus for primary prevention.

10. Policy and system changes are an important component of prevention efforts. Smoking bans in public places can reduce incidence of MI. Nurse-led clinics or nurse-coordinated multidisciplinary prevention programs are more effective than usual care in reducing CV risk in a variety of health care settings, and self-help groups can increase independence and improve quality of life. The introduction of quality improvement programs improves discharge recommendations. Cardiac rehabilitation is cost-effective in reducing risk of CV events.