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2021 ESC Clinical Practice Guidelines on cardiovascular disease prevention in clinical practice

30 Aug 2021
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Recent developments in prediction of cardiovascular disease (CVD) risk and treatment benefit, as well as novel treatments and treatment goals, necessitated new, up-to-date guidelines. Today, Professor Frank Visseren (University Medical Centre Utrecht, the Netherlands) and Professor François Mach (Geneva University Hospital, Switzerland), Chairs of the Guidelines Task Force, unveiled the 2021 ESC Guidelines on CVD prevention in clinical practice.1

Estimation of CVD risk remains the cornerstone of the guidelines and appears at the forefront of proposed new management schemes. Targets for blood lipids, blood pressure, and glycaemic control in diabetes are as recommended in recent ESC guidelines on dyslipidaemias, hypertension or diabetes. However, a new stepwise treatment-intensification approach is advocated to achieve these targets, with consideration of CVD risk, treatment benefit of risk factors, risk modifiers, comorbidities, and patient preferences.

“Individualised decisions using risk estimation and a stepwise approach to therapies is more complex than a one-size-fits-all approach,” said Prof. Visseren, “but reflects the diversity of patients and patient characteristics in everyday clinical practice, and is essential to give the right patient the right treatment.” A new section is devoted to communication of risk in the shared decision-making process. The aims are for individuals to understand their risk, the anticipated risk reduction with preventive actions, the pros and cons of intervention, and their own priorities.

For the first time, the guidelines explicitly state that smoking cessation is recommended regardless of weight gain, as weight gain does not lessen the benefits of cessation. Regarding exercise, adults of all ages should strive for at least 150−300 minutes a week of moderate-intensity, or 75−150 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination. New in the guidelines is a recommendation to reduce sedentary time and engage in at least light activity throughout the day to reduce all-cause and CV mortality and morbidity.

Regarding nutrition, recommendations now include the adoption of a Mediterranean or similar diet; restricting alcohol intake to a maximum of 100 g per week (a standard drink contains 8 to 14 g); eating fish, preferably fatty, at least once a week; and restricting consumption of meat, particularly processed meat. For the first time, the guidelines state that bariatric surgery should be considered for obese individuals at high risk of CVD when a healthy diet and exercise do not result in maintained weight loss.

It is now recognised that patients with mental disorders need intensified attention and support to improve adherence to lifestyle changes and drug treatment. In addition, the guidelines state that atherosclerotic CVD patients with stress should be considered for referral to psychotherapeutic stress management to reduce stress symptoms and improve CV outcomes.

The guidelines extend to policy interventions at the population level, with a new section that recommends putting in place measures to reduce air pollution, reducing the use of fossil fuels, and limiting carbon dioxide emissions.

Professor Mach commented, “CVD prevention requires an integrated, interdisciplinary approach that puts healthy people and patients at the centre, and considers other health conditions and environmental factors including air pollution.”

Prevention is key – read all the latest recommendations in the European Heart Journal!


1. Visseren F, Mach F, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021. doi:10.1093/eurheartj/ehab484