2021 ESC Guidelines on Cardiovascular Disease Prevention

Estimation of cardiovascular disease risk remains a cornerstone in the new 2021 ESC Guidelines. A novel stepwise treatment intensification approach with age-specific thresholds is recommended to control risk factors.

The new 2021 Guidelines on Cardiovascular Disease (CVD) Prevention were presented by Prof. Frank Visseren (Guidelines Task Force Chair; University Medical Center Utrecht, the Netherlands) at the ESC Congress 2021 and published simultaneously in the European Heart Journal [1,2]. “We wanted to make more personalised CVD prevention guidelines instead of a one-size-fits-all and focus more on the elderly,” said Prof. Visseren in his overview of the new guidelines.

The most important changes in the 2021 CVD Prevention Guidelines include:

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  • A stepwise approach to individualised CVD prevention.
  • Applying the SCORE2 and SCORE2-OP for 4 geographic regions.
  • Age-specific risk thresholds in seemingly healthy people.
  • Estimation of lifetime CVD risk and treatment benefit as an option.
  • Shared decision making by taking patient-specific conditions, preferences, (lifetime) CVD risk, and treatment benefit into account.
  • Recommendations on the environment.
  • Signalling potential cost issues.

The SCORE2 tool now considers the risk of non-fatal and fatal heart attacks and strokes, rather than just the risk of fatal events as in the previous SCORE tool. The SCORE2 algorithm can be found in the freely available ESC CVD Risk app. The separate SCORE2-OP is applied for people aged 70 years and over.

Categories of individuals considered for prevention

Recommendations on CVD prevention are given in a stepwise approach, divided into 4 categories:

1. 
   
   1. Seemingly healthy people.
   2. Patients with established atherosclerotic cardiovascular disease (ASCVD).
   3. Patients with diabetes mellitus (DM).
   4. Patients with specific risks, such as familial hypercholesterolaemia or chronic kidney disease.

Notably, the new guidelines stratify countries into 4 risk levels: low risk, moderate risk, high risk, and very high risk. In addition, geographic risk regions were introduced due to the known west-east and north-south gradient of CV risk in Europe.

The guidelines include a flowchart in which step 1 indicates prevention goals for all, and step 2 indicates intensified prevention and treatment goals necessary due to individual risk factors (see Figure 1). “Estimation of lifetime CVD risk and treatment benefit was included because the older you are, the less you can gain; when you start young, your risk reduction is much larger,” Prof. Visseren explained.

Figure 1: Examples of a stepwise approach to risk stratification and treatment option in patients with diabetes and special risk factors. Modified from [1]

ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DM, diabetes mellitus; FH, familial hypercholesterolaemia; TOD, target organ damage.

 

Novel risk thresholds according to age in seemingly healthy persons

Prof. Yvo Smulders (VU Universiteit Medical Center, the Netherlands) discussed the prevention in apparently healthy people [3]. “The flowcharts in the guidelines present a general approach,” he said. In STEP 1, all apparently healthy persons should stop smoking, receive lifestyle recommendations, and their systolic blood pressure (SBP) should be <160 mmHg. Further requirements are dependent on the age group and the estimated 10-year CVD risk.

Decisions on risk-factor treatment are dependent both on the individual CVD risk and the age group. In healthy persons with a very high CVD risk, risk-factor treatment is generally recommended, in contrast to those with low-to-moderate risk. “The new guidelines want you to briefly stop and think before you start treatment,” Prof. Smulders said. So-called risk modifiers, such as stress symptoms and psychosocial stress should be considered. In the elderly, polypharmacy, frailty, and comorbidity have to be taken into account

Prof. Naveed Sattar (University of Glasgow, Scotland) pointed out 2 important new recommendations for type 2 diabetes: those with concomitant heart failure with reduced ejection fraction should be treated with an SGLT2 inhibitor due to the proven outcome benefits [4]. For those recently diagnosed with diabetes who are motivated to try, considerable weight loss combined with low-calorie diets followed by food reintroduction and weight-maintenance phases is recommended as this can lead to DM remission.

Anti-inflammatory therapy for patients with established ASCVD

As Dr David Carballo (Geneva University Hospitals, Switzerland) pointed out, a novel recommendation in the 2021 Guidelines is anti-inflammatory therapy with low-dose colchicine (0.5 mg o.d.) for patients with established ASCVD [5]. Finally, novel content is added to draw attention to environmental exposures with CVD risk-modifying potential including air and soil pollution, above threshold noise levels, and effects of climate change.

 

1. 
   
   1. Visseren FLJ, et al. Eur Heart J 2021;42(34):3227–3337.
   2. Visseren FLJ. Introduction, novel concepts in the 2021 ESC prevention guidelines. Session: 2021 ESC Guidelines on Cardiovascular Disease Prevention, ESC Congress 2021, 27–30 August.
   3. Smulders Y. Management of ASCVD risk in apparently healthy people. Session: 2021 ESC Guidelines on Cardiovascular Disease Prevention, ESC Congress 2021, 27–30 August.
   4. Sattar N. Management of ASCVD risk in people with diabetes mellitus. Session: 2021 ESC Guidelines on Cardiovascular Disease Prevention, ESC Congress 2021, 27–30 August.
   5. Carballo D. Management of ASCVD risk in patients with established ASCVD and on a population level. Session: 2021 ESC Guidelines on Cardiovascular Disease Prevention, ESC Congress 2021, 27–30 August.

 

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Posted on 26 October 202126 July 2024