ESC: 2016 Guidelines onCVD Prevention in...

ESC: 2016 Guidelines on CVD Prevention inClinical Practice

Δ. ΡΙΧΤΕΡ, MD, FESC, FAHA Διευθυντής Β Καρδιολογικής Κλινικής Κλινικής

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2016 European Guidelines on cardiovascular disease preventionin clinical practiceThe Sixth Joint Task Force of the European Society of Cardiology and Other Societies onCardiovascular Disease Prevention in Clinical Practice (constituted by representatives of10 societies and by invited experts).Developed with the special contribution of the European Association for CardiovascularPrevention & Rehabilitation (EACPR).

ESC Chairperson Co- ChairpersonMassimo F. Piepoli Arno W. Hoes

Task Force Members: Stefan Agewall (Norway), Christian Albus (Germany), Carlos Brotons (Spain),Alberico L. Catapano (Italy), Marie-Therese Cooney (Ireland), Ugo Corrà (Italy), Bernard Cosyns (Belgium),Christi Deaton (UK), Ian Graham (Ireland), Michael Stephen Hall (UK), F. D. Richard Hobbs (UK), Maja-Lisa Løchen (Norway), Herbert Löllgen (Germany), Pedro Marques-Vidal (Switzerland), Joep Perk (Sweden), Eva Prescott (Denmark), Josep Redon (Spain), Dimitrios J. Richter (Greece), Naveed Sattar (UK), Yvo Smulders (The Netherlands), Monica Tiberi (Italy), H. Bart van der Worp (The Netherlands), Ineke van Dis (The Netherlands), W. M. Monique Verschuren (The Netherlands)

Additional Contributor : Simone Binno (Italy)

ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in the Appendix.ESC entities having participated in the development of this document:Associations: European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA).Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care.Working Groups: Cardiovascular Pharmacotherapy

www.escardio.org/guidelines European Heart Journal 2016 - doi:10.1093/eurheartj/ehw 106

On behalf of the6th Joint TaskForce on the

CardiovascularDisease

Prevention inClinical Practice

Massimo F Piepoli3

International Federation of Sports Medicine

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Guidelines based upon the principles of teaching

Plato, 424-347 b.C.

1. What is CVD prevention2. Who needs CVD prevention3. How is CVD prevention applied4. Where should CVD prevention be offered

www.escardio.org/guidelines

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Population-approachto prevent CVD

• PreventionParadox : “ A large number ofpeople exposed to a small risk may generatemanymore cases of CVD than a smallnumber exposed to a high risk”

• Population approach is cost saving andefficient:A 10% population-widereduction in bloodcholesterol, blood pressure and smokingwould save approximately three timesmore lives than treating 40% of high-riskindividualswith a statin, three half-doseanti-hypertensivesand aspirin.


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Recommendationfor cost-effectiveprevention ofcardiovasculardisease NEWNEW


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Population-approachto prevent CVD NEWNEW

• Topics: • Levels:• Governmental restrictions• Diet and mandate

• Physical activity • Media and education• Tobacco use • Labelling and information• Alcohol abuse • Economic incentives

• Schools• Workplaces• Community Setting


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Recommendationsfor population-basedapproaches tosmoking and other tobacco use (1) NEWNEW


6th Joint task Force on the preventionof CVDin clinical practice

Whystressassessmentof totalCVDrisk ?

• Multiple risk factors usually contributeto the atherosclerosis thatcauses CVD

• These risk factors interact, sometimesmultiplicatively

• Thus the aim should be to reduce totalrisk; if a target cannot be reachedwithone risk factor, total risk can still bereduced by trying harder with others.

• There is no reason to suppose that thisprinciple doesnotapply to allcountries

TheSCOREdatabase12 European cohort studies– Somewith multiple componentcohorts–Mainly population studies

In round figures:• 205,000 persons• 3 million person-yearsof observation• Over 7,000 fatal cardiovascularevents

Low, High, Very High Risk CountriesHigh risk countries : Bosnia and Herzegovina,Croatia, Czech Republic, Estonia,

Hungary, Lithuania, Montenegro, Morocco, Poland, Romania, Serbia, Slovakia andTurkey

Very high risk countries:Albania, Algeria, Armenia, Azerbaijan, Belarus,Bulgaria, Egypt, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Macedonia FYR,

Moldova, Russian Federation, Syrian Arab Republic, Tajikistan, Turkmenistan,Ukraine, Uzbekistan.

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SCORESCORE chartchart: 10-year riskof fatal CVD based on thefollowing risk factors: age,sex, smoking, systolicblood pressure, totalcholesterol


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Risk categories

Very high-risk Subjects with any of the following:

• Documented CVD, clinical or unequivocal on imaging. Documented clinical CVD includes previous AMI, ACS, coronary revascularization and other arterial revascularization procedures, stroke and TIA, aortic aneurysm and PAD.Unequivocally documented CVD on imaging includes significant plaque on coronary angiography or carotid ultrasound. It does NOT include some increase in continuous imaging parameters such as intima–media thickness of the carotid artery.

• DM with target organ damage such as proteinuria or with a major risk factor suchas smoking or marked hypercholesterolaemia or marked hypertension.

• Severe CKD (GFR <30 mL/min/1.73 m 2).

• A calculated SCORE ≥10%.

High-risk Subjects with:

• Markedly elevated single risk factors, in particular cholesterol >8 mmol/L (>310 mg/dL) (e.g. in familial hypercholesterolaemia) or BP ≥180/110 mmHg.

• Most other people with DM (with the exception of young people with type 1 DM and without major risk factors that may be at low or moderate risk).

• Moderate CKD (GFR 30–59 mL/min/1.73 m 2).

• A calculated SCORE ≥5% and <10%.

SCORE is ≥1% and <5% at 10 years. Many middleaged subjects belong to this Moderate-risk

category.

Low-risk SCORE <1%.


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And what about the other 100+ CV risk factors?

• hs-CRP ?• Lp(a) ?• stress ?• body mass index? waist-hip ratio ?• intima-media thickness?• coronary calcium score?• …• etcetera


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Examples of risk modifiers that(1) have risk reclassificationpotential and (2) are feasible


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Risk Factor Targets

* Smoking: No exposure to tobacco in any form.* Diet : Low in saturated fat with a focus on wholegrain

products, vegetables, fruit and fish.• Physical activity:At least 150 minutes a week of

moderate aerobic PA (30 minutes for 5 days/week) or 75minutes a week of vigorous aerobic PA (15 minutes for 5days/week) or a combination thereof.

• Body weight:BMI 20–25 kg/m2.• Waist circumference:

<94 cm (men)or <80 cm (women).* HbA1c in patients with DM : < 7.0% (< 53 mmol/mol)


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Major new key messages since 2012. WHO?WHO?

• Relevant groups• In women risk is deferred by approximately 10 years• In persons > 60 years of age the risk thresholds

should be interpreted more leniently and uncritical initiation of drug treatments should be discouraged.

• In younger patients, low absolute risk may implicate a very high relative risk, and use of the relative risk chart may help


BPgoals:Aneverendingstory

• BPgoalsisoneof thekeyissuestoreducemorbidityandmortalityassociatedtoHTN

• FewstudieshavefixedBPgoalsat differentlevelstoaddressthequestion

• Meta-analysishavetriedtoanswertheissuepoolingstudieswithdifferentselectioncriteriaandmethodologicalapproach

• In theabsenceofgroundedinformation,guidelines(NICE,CEP,ESH-ESC,JNC8,ISH-ASH)recommendationsaremainlybasedinexpertopinions

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WhatisnewinHypertension:Bloodpressuregoals(I)

• SBPshouldbeloweredto< 140 mmHg(andDBPto< 90mmHg)inall treatedhypertensivepatients< 60 yearsold.(I,B)

• Inpatients> 60 yearsoldwithSBP≥ 160 mmHg,thetreatmentgoalisto reduceSBPtobetween150 and140mmHg.(I,B)

• In fit patients<80 yearsold, a targetSBP< 140 mmHgmaybeconsideredif treatmentiswelltolerated.Insomeofthesepatientsa targetSBP<120 mmHgmaybeconsideredwhentheyareat (very)highriskandcantoleratemultipleantihypertensivedrugs(IIb,B)

Eur Heart J 2016www.escardio.org/guidelines doi:10.1093/eurheartj/ehw106

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WhatisnewinHypertension:Bloodpressuregoals(II)

• In individuals>80 yearsandwithinitialSBP≥160 mmHg,itisrecommendedto reduceSBPtobetween150 and140mmHgprovidedtheyareingoodphysicalandmentalconditions(I,B)

• In frailelderlypatients,it shouldbeconsideredtobecarefulintermsoftreatmentintensity(e.g.numberofantihypertensivedrugs)andBPtargets,andclinicaleffectsof treatmentshouldbecarefullymonitored(IIa,B)

Eur Heart J 2016www.escardio.org/guidelines doi:10.1093/eurheartj/ehw106

BenefitsofintenseloweringBP:Thepayingtoll

CV and renalHypotension events

derivedsymptoms

BPgoals Hypotension

derivedevents

AdherencetoRx,QOL andSurvival

Benefitsandriskoneventsofmorevs.lessBPreduction

BPmmHg Primary All-cause CV CHD Stroke Heartoutcome mortality mortality disease Failure

ACCORD1 120 vs -12% +7% +6% -13% -41% -16%(diabetes) 140

(119-133)

SPRINT2 120 vs -25% -27% -43% -17% -11% -38%(highrisk) 140 (121-

136)

SPS33 130 vs -5% +12% -14% -12% -19%(post-stroke) 140 (127-

138 )

META- AroundANALYSIS 1304,5

• Independentof the levelof CVrisk1. ACCORDStudyGroup.N EnglJMed 2010;362:1575-158622. TheSprintResearchGroup.NEJM2015;373:2106-2116 • ByloweringSBPa fewmmHg belowvs.above3. TheSPS3StudyGroup.Lancet2013;382:507-515 130 mmHg absoluteriskreductionbecome4. Thomopoulos,Parati, Zanchetti.JHypertens2016;34:613-622 smaller5. Thomopoulos,Parati, Zanchetti.JHypertens2014;32;2285-2295

Today:Recommendationscomefromabove

“…onesizefitsall…”

BPgoals,theneverendingstory:Episodeon2016

FutureACCORD SPRINT SPS3 Meta- approach

analysis?

Tomorrow:Recommendationswillcomefrombottom-up

“…movingtopersonalfit…”

LDL-C is a major causal factor foratheroscleroticCVD

LDL-C: primary risk factor in CHD and causative for development of coronaryatherosclerosis6

Lipid disorders 1

Hypertension 1 (LDL↑, HDL↓, TG↑)

Metabolic syndrome 2

Smoking, physicalinactivity 1

Type 2 diabetes 1

Prior CVevent/manifest Increased High CRP, 4 chronic

atherosclerosis 3 CV risk kidney disease 5

Age, ethnicity, gender, Obesity 1

family history/geneticvariations 1

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Treatment goals for LDL-cholesterol

Recommendations Class Level

In patients at VERY HIGH CV risk, an LDL-C goal of <1.8 mmol/L (70 mg/dL) or a reduction of at least 50% if the baseline LDL-C I Bis between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) is recommended.

In patients at HIGH CV risk, an LDL-C goal of <2.6 mmol/L (100 mg/dL), or a reduction of at least 50% if the baseline LDL-I BC is between 2.6 and 5.2 mmol/L (100 and 200 mg/dL) is recommended.

In subjects at LOW or MODERATE risk an LDL-C goal of IIa C<3.0 mmol/l ( <115 mg/dL) should be considered.

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Lipids

LDL-C is the primary target:

Very high risk: < 1.8 mmol/L (< 70 mg/dL)OR a reduction of at least 50% if thebaseline LDL-C is between 1.8 and 3.5 mmol/L ( 70 and 135 mg/dL)

High risk : < 2.6 mmol/L (< 100 mg/dL) OR a reduction of at least 50% if thebaseline LDL-C is between 2.6 and 5.2 mmol/L ( 100 and 200 mg/dL).

Low to Moderate risk : < 3.0 mmol/L ( < 115 mg/dL)


Prediction is very difficult,especially if it’sabout the

future

Attributed to Nils Bohr

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