Cardiovascular Disease Prevention Clinical Practice Guidelines (ESC, 2021)

European Society of Cardiology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 07, 2021

Guidelines on cardiovascular disease (CVD) prevention were published in August 2021 by the European Society of Cardiology (ESC) in European Heart Journal (also see reference).[1,2] The cornerstone of the guidelines remains estimating an individual's risk of CVD, and there is also a focus on CVD prevention in older people. A new stepwise treatment-intensification approach to achieve targets for blood lipids, blood pressure (BP), and glycemic control in diabetes is presented, as are the Systemic Coronary Risk Estimation 2 (SCORE2) and Systemic Coronary Risk Estimation 2-Older Persons (SCORE2-OP) algorithms published in June 2021.[1,2]

Select Key Messages

Risk factors, risk assessment, and risk modifiers

Cholesterol level, BP, tobacco use, diabetes, and adiposity are the major risk factors for atherosclerotic cardiovascular disease (ASCVD). An individualized, stepwise approach is used to treat these risk factors to reach therapeutic goals in apparently healthy people, individuals with established ASCVD, and those with diabetes.

Although frailty is also a functional risk factor of CV and non-CV morbidity and mortality, its assessment is for creating an individualized care plan with predefined priorities rather than to determine eligibility for any specific therapy.

To estimate the 10-year CVD risk in apparently healthy people aged 40-69 years, use the SCORE2 algorithm; for those aged 70 years or older, use the SCORE2-OP algorithm. Current risk scores may underestimate or overestimate CVD risk in differing ethnic minority groups.

Routinely assess family history; follow up a positive family history of premature ASCVD with a full evaluation of CVD risk. Also assess CVD risk in obese patients.

Coronary artery calcium (CAC) scoring is the best-established imaging modality to improve CVD risk stratification. Do not routinely measure additional circulating and urine biomarkers.

Clinical conditions

CKD is an independent risk factor for ASCVD, which, in turn, is the main cause of death in CKD. CVD risk is raised by chronic inflammatory conditions. Human immunodeficiency virus (HIV) infection is linked to a heightened risk of lower extremity artery disease (LEAD) and coronary artery disease (CAD).

Improved CV and kidney outcomes are associated with the use of inhibitors of renin−angiotensin−aldosterone system (RAAS), as well as with inhibitors of sodium-glucose cotransporter 2 (SGLT2).

Atrial fibrillation (AF) is associated with an increased risk of mortality and of CVD. Overt heart failure (HF) and an asymptomatic presentation with left ventricular dysfunction also raises the risk of CVD events (myocardial infarction, ischemic stroke, CV death).

An overlap exists between malignancy and CV risk factors. Chronic obstructive pulmonary disease (COPD) is a major CVD risk factor (particularly ASCVD, stroke, HF).

Risk factors and interventions at the individual level

Regular physical activity (PA) is a mainstay of ASCVD prevention. Particularly recommended is aerobic PA with resistance exercise and reducing sedentary time.

Smoking cessation quickly lowers the CVD risk and is the most cost-effective strategy for ASCVD prevention.

Reducing low-density lipoprotein cholesterol (LDL-C) with statins, ezetimibe, and—if needed and cost-effective—proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, lowers the risk of ASCVD proportionally to the absolute achieved LDL-C reduction.

Confirm suspected hypertension with repeated office BP measurements at different visits, or with ambulatory or home BP monitoring (ABPM/HBPM). BP-lowering pharmacotherapy is recommended in many adults when office BP is ≥140/90 mmHg and in all adults when BP is ≥160/100 mmHg.

Statin therapy can be beneficial for primary prevention in many hypertensive patients at sufficient risk. Antiplatelet therapy is indicated for secondary prevention.

It is essential that patients with type 2 diabetes are treated with a multifactorial approach, including lifestyle changes. Newer antihyperglycemic drugs are particularly important for these patients who also have existing ASCVD and (heightened risk of) HF or renal disease, generally irrespective of glycemia levels.

For more information, please go to Risk Factors for Coronary Artery Disease, Primary and Secondary Prevention of Coronary Artery Disease, and Hypertension.

Other related guidelines include Cardiovascular Disease Prevention and Management Clinical Practice Guidelines (C-CHANGE 2018), Cardiovascular Disease Primary Prevention Clinical Practice Guidelines (ACC/AHA 2019), Novel CV Risk Reduction Therapies in Type 2 Diabetes and CVD: Consensus Decision Pathways (ACC, 2019), and Clinical Practice Guidelines on Cardiovascular Disease Risk Reduction in Type 2 Diabetes (ACC, 2020).


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