Zoom In, Zoom Out: New European Prevention Guidelines Tackle Both the Big Picture and Targeted Groups

The sixth joint task force of the European Society of Cardiology and nine other societies has released its new Joint European Cardiovascular Prevention Guidelines. This new guidance places a greater emphasis on population-based approaches to prevention, on disease-specific interventions, and on conditions specific to women, younger individuals, and ethnic minorities.

 “Age-adjusted coronary artery disease mortality has declined since the 1980s, particularly in high-income regions, and rates are now less than half what they were in the early 1980s in many countries in Europe, due to preventive measures including the success of smoking legislation,” Massimo F. Piepoli, MD, PhD, chairperson of the guidelines Task Force, told TCTMD in an e-mail. “However, inequalities between countries persist and are particularly unfavorable in Eastern regions and new developing countries.”

It is for these reasons that the guidelines emphasize a population-level approach to prevention, which aims at reducing the risk of disease, or a risk factor for disease, across a whole population, thus, consistently leading to greater reduction in disease burden than a large shift by high-risk individuals alone.

“If prevention was practiced as instructed it would markedly reduce the prevalence of cardiovascular disease by 80% and even cancer by 40%,” Piepoli said. “Reducing the population risk of CVD by just 1% could result in 25,000 fewer cases of CVD and a cost savings of approximately €40 million per year in the average European country.”

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Specifically, the guidelines call upon healthcare professionals to play a role in advocating for evidence-based, population-level interventions through changes to laws or healthcare policies in areas such as food, physical activity, and smoking. For example, Piepoli said, governments could reduce the number of calories and levels of salt, saturated fat, and sugar in food portions, as well as portion sizes.

In addition to calling for population-level changes, the new guidelines detail revised and adjusted risk factor targets for things such as blood pressure or lipids, incorporating the latest scientific evidence.

The Task Force also addressed specific interventions for common cardiovascular conditions such as heart failure, CAD, peripheral artery disease, or atrial fibrillation. The guidelines review interventions for these conditions among groups such as women, the aging, younger patients, or patients with cancer, and in specific environments such as home-based settings or nursing homes.

Piepoli highlighted aspects of the new guidelines that deserve the attention of clinicians:

• Use of systematic cardiovascular risk assessment for all individuals at increased cardiovascular risk, such as those with a family history of premature CVD, familial hyperlipidemia, major cardiovascular risk factors, or comorbidities that increased cardiovascular risk. The guideline suggests repeating risk assessment every 5 years or more often for individuals with risks close to the threshold mandating treatment.
• For those people aged 60 or older, especially those at very high-risk for cardiovascular disease, the cardiovascular risk threshold for drug treatment should be interpreted more leniently and uncritical initiation of drug treatments should be discouraged.
• Simplifying treatment regimens to the lowest acceptable level, with repetitive monitoring and feedback. In cases of persistent non-adherence, multi-session or combined behavioral interventions may be required.
• Increased physical activity and adoption of a healthy lifestyle in all settings and populations groups, starting with children, is also recommended. As a goal, the guidelines suggest at least 150 minutes of moderate intensity or 75 minutes a week of vigorous intensity aerobic physical activity. Physical activity can be recommended in low-risk individuals without any further assessment.
• Health care personnel and caregivers should set an example by following a healthy lifestyle, such as not smoking or using tobacco products at work, Piepoli said.

Finally, another key message of the guidelines focuses on air pollution and maintaining a healthy environment.

“The detrimental impact of air pollution on heart diseases, both on ischemic and arrhythmic events with higher occurrence of hypertension and heart failure has been the object of previous position papers of European and American scientific societies,” Piepoli said. “A healthy environment is essential for preventing CVD.”

Sources: 
Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). European Heart Journal. 2016;Epub ahead of print.

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