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Highlights from the new ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice (version 2012)

The aim of the 2012 European Guidelines on CVD Prevention in Clinical Practice from the Fifth Joint Task Force (JTF) of the European Societies on Cardiovascular Disease Prevention in Clinical Practice is to give an update of the present knowledge in preventive cardiology for physicians and other health workers. The reader will find answers to the key questions of CVD prevention in the five sections: what is CVD prevention, why is it needed, who should benefit from it, how can CVD prevention be applied, and when is the right moment to act, and finally where prevention programmes should be provided.



An updated scenario on disease and prevention was provided. Atherosclerotic cardiovascular diseases, especially coronary heart disease (CHD), remain the leading cause of death before the age of 75 years in Europe, 38%* are due to cardiovascular disease (CVD) in women and 37%* in men, with increasing rates in many Eastern countries.

*updated figures according to the new European statistics

Why is prevention of cardiovascular disease needed?

  • Prevention is effective: over 50% of the reductions seen in CHD mortality relate to changes in risk factors and 40% to improved treatments. Much of the burden of cardiovascular diseases can potentially be relieved by primary prevention, that is, reducing the incidence in the apparently healthy population.
  • Preventive efforts should be life-long, from birth (if not before) to old age.
  • Population and high-risk preventive efforts should be complementary.
  • Despite gaps in our understanding, there is ample evidence to justify intensive public health and individual preventive efforts.

The primary care physician plays a pivotal role in providing prevention on the individual level but finds implementing preventive strategies difficult without the help of guidelines on total cardiovascular risk assessment included, many of those pre-existing focused on single risk factors, without rigor or presenting conflicts of interest. 

The European Heart Journal published in July 2012 an update of the guidelines which include the adoption of classes of recommendations, level and quality of evidence, steps forward the generalization of news on CVD prevention.

Who should benefit from it?

  • In apparently healthy persons, CVD risk is most frequently the result of multiple interacting risk factors.
  • A risk estimation system such as SCORE*  can assist in making logical management decisions, and may help to avoid both under- and over-treatment. 
  • Certain individuals  declare themselves to be at high CVD risk without needing risk scoring and require immediate attention to all risk factors.
  • In younger persons, a low absolute risk may conceal a very high relative risk, and use of the relative risk chart may help in advising them of the need for intensive lifestyle efforts. While women appear to be at lower CVD risk than men, this is misleading as risk is deferred by approximately 10 years rather than avoided.
  • All risk estimation systems are relatively crude and require attention to qualifying statements.
  • Additional factors affecting risk can be accommodated in electronic risk estimation systems such as HeartScore. 
  • The total risk approach allows flexibility: if perfection cannot be achieved with one risk factor, risk can still be reduced by trying harder with others. 

A series of key recommendations is listed below

  • DNA-based tests for common genetic polymorphisms do not presently add significantly to diagnosis, risk prediction or patient management and cannot be recommended.
  • High-sensitivity CRP should not be measured in asymptomatic low-risk individuals and high-risk patients to assess 10-year risk of CVD.
  • Subclinical organ damage predicts cardiovascular death independently of SCORE, and a combination of both may improve risk prediction, particularly in individuals at low and moderate risk; measurement of carotid intima-media thickness (IMT) and/or screening for atherosclerotic plaques by carotid artery scanning, and measurement of ankle-brachial index should be considered for cardiovascular risk assessment in asymptomatic adults at moderate risk.
  • All persons with obstructive sleep apnoea should undergo medical assessment, including risk stratification and risk management.
  • Sedentary subjects should be strongly encouraged to start light–intensity  exercise programmes.
  • All smokers should be given advice to quit and be offered assistance.
  • Nutritional counselling:saturated fatty acids to account for <10% of total energy intake, through replacement by polyunsaturated fatty acidstrans unsaturated fatty acids: as little as possible, preferably no intake from processed food, and <1% of total energy intake from natural originn<5 g of salt per day30–45 g of fibre per day, from wholegrain products, fruits and vegetables200 g of fruit per day (2-3 servings)200 g of vegetables per day (2-3 servings)fish at least twice a week, one of which to be oily fishconsumption of alcoholic beverages should be limited to 2 glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women

Hypertension

The above lifestyle measures are recommended in all patients with hypertension and in individuals with high normal BP.
Promptness in the initiation of pharmacological therapy of hypertension depends on the level of total CV risk. A delay in achieving BP control in high-risk hypertensive patients is associated with a worse outcome. All major antihypertensive drug classes (i.e. diuretics, ACE inhibitors, calcium antagonists, angiotensin receptor antagonists and beta-blockers) do not differ significantly in their BP-lowering efficacy. Antihypertensive treatment is beneficial in patients aged 80 years. Beta-blockers and thiazide diuretics are not recommended in hypertensive patients with multiple metabolic risk factors increasing the risk of new-onset diabetes.

Diabetes

In patients with diabetes, an ACE inhibitor or a renin-angiotensin recept or blocker is recommended. Initiation of antihypertensive drug therapy in patients with diabetes and high normal BP is presently unsupported by prospective trial evidence (without subclinicalorgan damage, particularly microalbuminuria or proteinuria). Combination therapy is needed to control BP in most patients. Trial evidence of outcome reduction has been obtained particularly for: diuretic+ACEi or diuretic+ARB or diuretic+Ca antagonist. In 15-20% patients a combination of 3 drugs is needed, the most rational appears ARB+Ca antagonist+diuretic.

Hyperlipidemia 

Increased plasma total cholesterol and LDL cholesterol are among the main risk factors for CVD. Hypertriglyceridaemia and low HDL cholesterol are important independent CVD risk factors. Total cholesterol is recommended to be used for the estimation of total CV risk by means of the SCORE system but not as a target for treatment. It should be considered as treatment target only if other analyses are not available. 

  • LDL cholesterol is recommended to be used as the primary lipid analysis for screening and risk estimation and is recommended as target for treatment.
  • HDL cholesterol is a strong risk factor and is recommended to be used for risk estimation but is not recommended as a target for treatment.

Statins

Statin therapy has a beneficial effect on atherosclerotic CVD outcomes.

Statins reduce hypercholesterolaemia but also CV morbidity and mortality as well as the need for coronary artery interventions. In high doses they also seem to halt progression or even contribute to regression of coronary atherosclerosis. Therefore, they should be used as the drugs of first choice in patients with hypercholesterolaemia or combined hyperlipidaemia. Selective cholesterol absorption inhibitors are not used as monotherapy to decrease LDL-cholesterol concentrations. Bile acid sequestrants also decrease total and LDL cholesterol but tend to increase triglyceride concentration.

Side effects of statins. Higher activity of liver enzymes in plasma is occasional and in most cases reversible: 5-10% of patients receiving statins develop myopathy and rhabdomyolysis is extremely rare. Patients with dyslipidaemia, particularly those with established CVD, diabetes or metabolic syndrome, and asymptomatic high-risk individuals, may not always reach treatment targets.

Therefore combination treatment may be needed. 

  • If LDL cholesterol target level is not achieved with statin alone, statin + bile acid sequestrant or statin + ezetimibe can be used. 
  • Statin + niacin increase HDL cholesterol and decrease triglycerides better than either of these drugs alone but flushing is the main adverse effect of niacin - affects compliance. 
  • Fibrates, particularly fenofibrate + statin decrease high triglycerides and increase HDL cholesterol and further lower LDL cholesterol.

My intention here was to report information extracted from the guidelines which should be applicable in clinical practice. And a significant amount of information is available in the full text of the guidelines, the pocket edition and in a special leaflet for primary care.