The 2016 version of the European Guidelines on Cardiovascular Prevention

Recently the 2016 version of the European Guidelines on Cardiovascular Disease Prevention has been published by 10 major organizations within the framework of the ‘Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice’.¹ The document is an update of the 2012 publication² and it follows the same structure: what is cardiovascular prevention, who needs it, and how and where should it be offered? The reader will observe that there are only few and minor changes regarding pharmacotherapy for the prevention of cardiovascular disease (CVD).

A major novelty is that the guidelines include a public health chapter with recommendations on prevention at the population level. For the first time the prevention guidelines provide advice to politicians and healthcare providers based upon updated scientific evidence.

Who needs CVD prevention?

Assessment of risk should be offered to all who may have an elevated risk of CVD, such as those who smoke, patients with high blood pressure or with diabetes mellitus (DM), and persons with known elevated lipid values or with a history of familial hypercholesterolaemia. CV risk assessment is even indicated if there are diseases that increase risk such as rheumatoid arthritis, sleep apnoea disorder, or erectile dysfunction. The 2016 version of the guidelines recommend that risk assessment for this cohort of persons should be repeated every 5 years. General screening for women >50 years old and men >40 may be considered if resources are available, but there is no scientific support for screening in the younger age groups. The 2012 ranking of CV risk on four levels remains the same: very high risk, high risk, medium risk, and low risk. Even the recommended target values and treatments are unchanged for each level.

Lifestyle: the prime target for prevention

Counselling patients on healthy habits remains a cornerstone in prevention, and the new document places even greater emphasis on lifestyle: successful treatment for patients with CVD, hypertension, hyperlipidaemia, or DM states can only be achieved if the patients’ habits are addressed. This should include advice on tobacco (no exposure to tobacco in any form), food habits (a diet low in saturated fat and high intake of whole grains, vegetables, fruit, and fish), and physical activity (at least 150 min/week of moderate aerobic physical activity or 75 min/week of heavy aerobic physical activity or a combination of both). Overweight should be controlled [body mass index (BMI) 20–25 kg/m²) and for waist circumference a level <94 cm (men) or < 80 cm (women) is recommended.

Medication for CVD prevention: anything new?

The target values for lipid control are unchanged: for the very high risk patient <1.8 mmol/L (<70 mg/dL), for high risk individuals <2.6 mmol/L (<100 mg/dL). Statins remain the drug of choice in the treatment of hyperlipidaemia. Adding a selective cholesterol absorption inhibitor is only recommended as an add-on option if target values are not reached on a maximal dose of statins. Bile acid sequestrants are not recommended as they are usually poorly tolerated. As for the use of PCSK-9 (proprotein convertase subtilisin kexin 9) inhibitors, the outcome of ongoing major trials is still pending.

The decision to commence blood pressure- (BP) lowering treatment depends on the BP level and on the patients’ individual CV risk. The target value for the treatment is a BP < 140/90 mmHg for those <60 years. For patients >60 years and even for patients >80 years more specific guidance is provided, assuming that these older people are in good general condition. In most cases, combined therapy will be needed to reach the target values.

In the choice of medication, the guidelines do not give any preferences in general but a valuable table has been added to guide the clinicians in prescribing antihypertensive treatment in specific conditions.

It still remains uncertain what the optimal out-of-office (home and ambulatory) BP targets are and whether the treatment strategies based on control of out-of-office BP provide an advantage over strategies based on conventional (office) control.

The recommended target glycated haemoglobin (HbA_1c) to reduce the risk for CVD and microvascular complications is, for most DM patients, both type I and II, <53 mmol/mol (7%) but at the early onset of type II DM a lower value might be desirable. Lipid-lowering treatment with statins is recommended for all, but antiplatelet therapy is not recommended in DM patients who are free from CVD.

Given the global obesity pandemic, health workers are once again reminded that a healthy lifestyle and weight loss for overweight persons is of paramount importance to prevent type II DM and CVD. There are several new and promising antidiabetic drugs undergoing major trials, but even here the outcome of these studies is still awaited.

Adherence to preventive treatment

Patients’ adherence to the given treatment remains a major challenge: in primary CVD prevention, some patients may tend not to consider themselves as sick. Thus, taking drugs for the rest of their life may become problematic. A special chapter has therefore been dedicated to adherence and compliance with clear stepwise guidance. The use of a simplified medication where several substances are combined in a single tablet (so-called polypill) may in this context be an alternative to improve compliance.

Where should CVD prevention be provided?

The general practitioner plays a key role in CVD prevention, but it is recommended that even nurses and other health professionals become increasingly involved, especially for the follow-up of patients with a high CVD risk. During the hospital stay and at discharge, advice on lifestyle should be given to CVD patients. After an acute coronary syndrome or following treatment for heart failure, they should be offered an opportunity to participate in a cardiac rehabilitation programme. Participation in these programmes should start soon: within the first weeks after discharge.

CVD prevention at the population level

The chapter on population health contains conventional grading of the scientific evidence and recommendations for action at the population level. Among the recommendations we note especially the following. (i) Tobacco: the price should be increased to reduce its use, price differences that drive cross-border trade should disappear, and neutral packaging should be introduced. Smoking should not be allowed in public places or in places where children are, especially in private homes or cars. (ii) Alcohol: advertising of alcoholic drinks should be reduced and the limit for alcohol during driving should be reduced further (zero tolerance). Alcohol prevention should be given greater priority in primary care. (iii) Food products: legislation is needed to reduce the amount of energy, salt, saturated fat, and added sugar in food products. Pricing as a tool to limit the use of these products should be an option. Information on nutrient content should be uniform on the front of packs and sufficiently legible. (iv) Physical activity: cities or buildings should be designed so that physical activity is facilitated. Increased efforts should also be made to make school grounds inviting in terms of physical activity.

This chapter on public health with its convincing scientific evidence should lead to an increased interest among policymakers and to better collaboration with national bodies such as professional and patient associations. It calls upon doctors and other health professionals to take a greater place in striving for good public health.

Finally, the chapter ‘what should or can be done and what should not be done’ at the end of the document is interesting and a novelty: 24 statements ‘to do’ (such as ‘a healthy diet is recommended as a cornerstone of prevention to all’) and merely five statements ‘not to do’ (such as’ CVD risk screening in men <40 years and women <50 years without any known risk factors is not recommended’). Certainly, a better balance between what ‘to do’ and what ‘no to do’ would be of greater interest for the clinician. This remains a challenge for forthcoming prevention guidelines.

Conflict of interest: none declared.

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