ESC guideline offers individualized, stepwise approach to CVD prevention
The new European Society of Cardiology guideline on CVD prevention in clinical practice offers a stepwise approach to managing CVD risk in various populations,
“We wanted to make ... one guideline for all, but we also wanted to make a more personalized cardiovascular disease prevention guideline, instead of a one size fits all,” guideline task force chairperson Frank L.J. Visseren, MD, PhD, internist, epidemiologist and professor and chair of the department of vascular medicine at University Medical Center Utrecht, the Netherlands, said during a presentation at the ESC Congress. “In clinical practice, patients are very, very different. We introduced a stepwise approach to individualized cardiovascular disease prevention.”
The approach is organized by apparently healthy people, patients with CVD, patients with type 2 diabetes, and patients with risk factors such as chronic kidney disease and familial hypercholesterolemia, Visseren said. “For each category, there are prevention goals for all, then you move on to Step 1, risk factor treatment, and then Step 2 for intensified prevention and treatment goals.”
Asymptomatic individuals
For apparently healthy people, all are recommended to stop smoking, adopt healthy lifestyle practices and maintain systolic BP below 160 mm Hg, Yvo M. Smulders, MD, professor of internal medicine at Amsterdam University Medical Center, said during a presentation. These people should have 10-year CVD risk estimated by SCORE2 if aged 69 years or younger or SCORE2-OP if aged 70 years or older, he said. Low-to-moderate, high and very high risk are defined differently by age (younger than 50 years, 50 to 69 years and 70 years or older), and risk factor treatment is recommended in those at very high risk and should be considered in those at high risk. In general, for those warranting Step 1 risk factor treatment, the LDL goal should be less than 100 mg/dL and the systolic BP goal should be less than 140 mm Hg (or < 130 mm Hg if tolerated), he said.
Assessment of stress symptoms, psychosocial stressors and factors unique to certain ethnicities should be considered as risk modifiers, and coronary artery calcium score may be considered as a risk modifier, Smulders said. Using genetic risk scores, circulating or urinary biomarkers and imaging tests other than CAC scoring and carotid ultrasound are not recommended as risk modifiers, according to the guideline.
Step 2 intensified prevention and treatment should be based on 10-year and lifetime CVD risk, comorbidities, frailty and patient preferences, he said. The systolic BP goal in this population should be less than 130 mm Hg and the LDL goal should be less than 70 mg/dL in those at high risk and less than 55 mg/dL in those at very high risk, according to the guideline.
Ezetimibe is recommended if LDL goals cannot be achieved with statins and PCSK9 inhibitors may be considered if LDL goals cannot be achieved with statins and ezetimibe, Smulders said. Antihypertensive drug therapy should be initiated in any patient with grade 2 hypertension, according to the guideline.
“We have introduced the concept of different absolute risk thresholds for different age categories,” Smulders said. “We have introduced explicit treatment considerations for intermediate groups, which include lifetime benefit of treatments, and we’ve introduced the stepwise approach to reaching treatment targets.”
Patients with diabetes
The guideline stratifies patients with diabetes into moderate risk (diabetes duration of less than 10 years, no evidence of target organ damage, no additional atherosclerotic CVD risk factors), high risk (no ASCVD or target organ damage but do not meet conditions for moderate risk) and very high risk (ASCVD with or without target organ damage), Naveed Sattar, FMedSci, FRCPath, FRCPGlas, FRSE, professor and honorary consultant in cardiovascular and medical sciences at the University of Glasgow, U.K., said during a presentation. Metformin should be first-line therapy for all in this group, according to the guideline.
Those at moderate risk generally do not need additional prevention goals, while those at high risk should have a target systolic BP goal of less than 140 mm Hg (< 130 mm Hg if tolerated) and a target LDL goal of less than 100 mg/dL and those at very high risk should have a target systolic BP goal of less than 140 mm Hg (< 130 mm Hg if tolerated), at least a 50% reduction in LDL with a target of less than 70 mg/dL and should take antithrombotic therapy and an SGLT2 inhibitor or a GLP-1 receptor antagonist, he said.
Those at high risk who qualify for Step 2 intensified treatment should have the same LDL and systolic BP goals as those at very high risk without intensified treatment and should take an SGLT2 inhibitor or a GLP-1 receptor antagonist if they are not already, while those at very high risk who qualify for Step 2 intensified treatment should have a systolic BP target of less than 130 mm Hg, an LDL goal of less than 55 mg/dL and should take an SGLT2 inhibitor or a GLP-1 receptor antagonist, and they may be considered for dual antiplatelet therapy and newer therapies for CVD prevention such as colchicine and icosapent ethyl (Vascepa, Amarin).
In addition, weight loss should be considered in those with overweight or obesity, the target HbA1c for CVD prevention should be less than 7% and an SGLT2 inhibitor is recommended in patients with type 2 diabetes and chronic kidney disease and/or HF with reduced ejection fraction, Sattar said.
“This will probably be extended in the near future to HF [with preserved EF] based on the results of EMPEROR-Preserved,” Sattar said.
Patients with established CVD
For patients with established CVD, the Step 1 risk factor management should be smoking cessation and healthy lifestyle practices, a 50% or more reduction of LDL with a target of less than 70 mg/dL, a systolic BP target of less than 140 mm Hg (< 130 mm Hg if tolerated) and antithrombotic therapy, David Carballo, MD, MPH, cardiologist at Geneva University Hospital, Switzerland, said during a presentation.
For those with established CVD requiring intensified treatment, the systolic BP goal should be less than 130 mm Hg, the LDL goal should be less than 55 mg/dL and they may be considered for dual antiplatelet therapy and newer therapies for CVD prevention such as colchicine and icosapent ethyl, he said.
In this population, ezetimibe is recommended if LDL goals cannot be met with statin therapy and PCSK9 inhibitors are recommended of LDL goals cannot be met with statins plus ezetimibe, he said. If recurrent CVD events occur or other risk factors are not sufficiently controlled, colchicine may be considered, he said.
“This approach to treatment intensification is to be used as a tool to help physicians and patients pursue these targets in a way that fits patient profiles and preferences, in a sense reflecting routine clinical practice in which treatment strategies are initiated and then intensified as a shared decision process involving health care professionals and patients,” Carballo said.
The European Association of Preventive Cardiology contributed to the guideline, which was simultaneously published in the European Heart Journal.
Reference:
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Visseren FLJ, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Presented at: European Society of Cardiology Congress; Aug. 27-30, 2021 (virtual meeting).
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