Comparison of American and European Guidelines for CVD Prevention

Fegers-Wustrow I, Gianos E, Halle M, Yang E.
Comparison of American and European Guidelines for Primary Prevention of Cardiovascular Disease: JACC Guideline Comparison. J Am Coll Cardiol 2022;79:1304-1313.

The following are key points to remember from this review, which compares the most recent American and European guidelines for primary prevention of cardiovascular disease (CVD):

  1. The European Society of Cardiology (ESC) recently published updated recommendations for CVD prevention in 2021, while the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for CVD prevention were published in 2019.
  2. A holistic approach to prevention includes optimal lifestyle factors, CV risk assessment tools, and intensification of risk factors and indications are contained in both guidelines. Both guidelines also include recommendations for using risk modifiers to refine risk calculations.
  3. The ESC guidelines recognize the importance of nonclassical risk factors, including environmental issues; impacting CV health at the population level; and calls for legislative action at the local, regional, and national levels.
  4. The ESC guidelines focus on the new European Systemic Coronary Risk Estimation 2 (SCORE2) and SCORE2-OP as recommended risk calculators. SCORE2-OP is tailored for older adults. These tools now include fatal and nonfatal CVD to estimate 10-year atherosclerotic CVD (ASCVD) risk (which is more aligned with the Pooled Cohort Equation [PCE] tool that the ACC/AHA guidelines recommend). In addition, in contrast to the PCE, the SCORE2 tool stratifies into region-specific and age-specific risk categories.
  5. Differences in these risk assessment tools include recommendations for biomarkers and imaging. The AHA/ACC includes recommendations for using C-reactive protein, Apo-B, lipoprotein (a) [Lp(a)], and triglycerides, which are not included in the ESC guidelines. The ESC guidelines also do not include imaging such as coronary artery calcium (CAC), computed tomography angiography, or carotid IMT or ankle-brachial index, although CAC imaging was classified as a Class IIb recommendation. ESC concerns for the imaging tools included availability and cost-effectiveness for population-based screening.
  6. The ESC includes a more extensive list of non-CVD conditions as risk modifiers compared to the AHA/ACC guidelines. However, overlap between guidelines includes chronic kidney disease (CKD), inflammatory conditions, HIV and obstetric conditions, erectile dysfunction, and social determinants to guide risk discrimination.
  7. Lifestyle recommendations are included in both guidelines. The ESC consists of aerobic exercise and resistance training, while the AHA/ACC only includes recommendations for aerobic exercise. Both guidelines recommend a DASH, Mediterranean, or plant-based diet. Both recommend smoking cessation counseling and pharmacologic options for smoking cessation. Recommendations for the treatment of obesity include both caloric restriction and pharmacologic weight loss methods, while the ACC/AHA is limited to caloric restriction.
  8. Although the importance of cholesterol management is emphasized in both guidelines, the ECS differs related to risk assessment, diabetes, and CKD. The ESC includes goals for non–high-density lipoprotein cholesterol, triglycerides, and Lp(a). The ESC also recommends specific low-density lipoprotein targets based on risk level.
  9. Optimal blood pressure (BP) is emphasized in both guidelines, with the importance of lifestyle modification included in both. However, definitions and treatment thresholds differ between guidelines. The ESC contains six levels of BP, and recommendations are tailored to age groups. The ACC/AHA includes four levels and recommends a BP <130/80 mm Hg for all ages.
  10. Diabetes is recognized as a growing pandemic in both guidelines. Lifestyle modification and weight loss, if needed, are included in both guidelines for glycemic control. Use of a sodium glucose cotransporter 2 inhibitor (SGLT2i) or glucagon-like peptide-1 receptor agonist is a Class IIb recommendation for patients with diabetes mellitus (DM) and additional ASCVD risk factors to reduce CVD risk in the AHA/ACC guidelines. The ESC has a Class I indication for SGLT2i for patients with DM with a history of CKD or heart failure with reduced ejection fraction. Both guidelines support a hemoglobin A1c target of <7%.
  11. Aspirin for primary prevention is not recommended in either guideline. However, aspirin can be considered in high ASCVD risk individuals with low bleeding risk (Class IIb).
  12. ESC emphasizes nontraditional risk factors such as psychological stress, mental health, migraines, and sleep disorders (including obstructive sleep apnea). The ESC guidelines also include a newer focus on elderly adults, including frailty as a risk modifier. Environmental factors are also included in the ESC guidelines as a risk modifier.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Homozygous Familial Hypercholesterolemia, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Interventions and Imaging, Computed Tomography, Nuclear Imaging, Diet, Exercise, Sports and Exercise and Imaging

Keywords: Apolipoproteins B, Aspirin, Atherosclerosis, Biomarkers, Blood Pressure, Cardiovascular Diseases, Cholesterol, Computed Tomography Angiography, C-Reactive Protein, Diabetes Mellitus, Diagnostic Imaging, Diet, Erectile Dysfunction, Exercise, Frailty, Glycated Hemoglobin A, Hypercholesterolemia, Life Style, Lipoproteins, Obesity, Primary Prevention, Renal Insufficiency, Chronic, Resistance Training, Risk Assessment, Sleep Wake Disorders, Smoking Cessation, Sodium-Glucose Transporter 2 Inhibitors, Triglycerides, Weight Loss

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