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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Giuseppe Germano
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
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.
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.
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.
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.
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.
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.