Cardiovascular prevention et rehabilitation
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Cardiovascular prevention et rehabilitation

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01/01/2007

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Published 01 January 2007
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SEPTEMBER 2007 VOLUME 14 SUPPLEMENT 2
Contents
1) Executive Summary E1
2) References E34
3) FullText S1
Chapter1 Introduction S2
Chapter2 Thescopeoftheproblem:pastandfuture S3
Chapter3 Preventionstrategiesandpolicyissues S6
Chapter4 Howtoevaluatescienti¢cevidence S8
Chapter5 Priorities,totalriskestimationandobjectives S11
Chapter6 Principlesofbehaviourchangeandmanagementofbehaviouralriskfactors S20
Chapter7 Smoking S22
Chapter8 Nutrition,overweightandobesity S26
Chapter9 Physicalactivity S36
Chapter10 Bloodpressure S42
Chapter11 Plasmalipids S56
Chapter12 Diabetesandmetabolicsyndrome S63
Chapter13 Psychosocialfactors S71
Chapter14 In£ammationmarkersandhaemostaticfactors S73
Chapter15 Geneticfactors S74
Chapter16 Newimagingmethodstodetectasymptomaticindividualsathighriskforcardiovascularevents S78
Chapter17 Genderissues:cardiovasculardiseaseinwomen S81
Chapter18 Renalimpairmentasariskfactorincardiovasculardisease S82
Chapter19 Cardioprotectivedrugtherapy S83
Chapter20 Implementationstrategies S86
4) References S88EUROPEAN JOURNAL OF CARDIOVASCULAR PREVENTION
AND REHABILITATION
Official journal of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR)
of the European Society of Cardiology (former Working Groups on Epidemiology &
Prevention and Cardiac Rehabilitation and Exercise Physiology)
JOINT EDITORS
Pantaleo Giannuzzi David A. Wood
Fondazione Salvatore Maugeri, IRCCS, Scientific Institute Imperial College, London, UK
of Veruno, Veruno, Italy
SENIOR CONSULTING EDITOR
Hugo Saner
University Hospital, Inselspital, Bern, Switzerland
ASSOCIATE EDITORS
Birna Bjarnason-Wehrens Dirk De Bacquer Hannah McGee
German Sport University Cologne Department of Public Health, Ghent Royal College of Surgeons in Ireland
Cologne, Germany Ghent, Belgium Dublin, Ireland
Joep Perk
Ugo Corra `Hans Bjo ¨rnstad Oskarshamm Hospital
Scientific Institute for Clinical careHaukeland University Hospital Oskarshamm, Sweden
and Research of VerunoBergen, Norway Max PetzoldVeruno, Italy
Nordic School of Public Health
Alain Cohen-Solal Go ¨teborg, SwedenRainer HambrechtHo ˆpital Beaujon
Clinical Center Links der Weser Annika RosengrenClichy, France
Bremen, Germany Go ¨teborg University
Go ¨teborg, SwedenRonan Conroy Torben Jørgensen
Veikko SalomaaRoyal College of Surgeons in Ireland Glostrup University Hospital
National Public Health InstituteDublin, Ireland Glostrup, Denmark
Helsinki, Finland
Guy De Backer Ulrich Keil Troels Thomsen
¨University Hospital Ghent University of Munster National Board of Health
¨Ghent, Belgium Munster, Germany Copenhagen, Denmark
INTERNATIONAL EDITORIAL BOARD
Stamatis Adamopoulos, Greece Hans-Werner Hense, Germany Neil Poulter, UK
Philippe Amouyel, France Peter Heuschmann, Kalevi Pyorala, Finland¨ ¨ ¨
Werner Benzer, Austria David Hevey, Ireland Srinath Reddy, IndiaMats Borjesson, Sweden¨ John Horgan, Ireland ˇZeljko Reiner, CroatiaFranc ¸ois Cambien, France
Rodney Jackson, New Zealand Andrzej Rynkiewicz, PolandFranc ¸ois Carre ´, France
Konrad Jamrozik, UK´ ´ Susana Sans, SpainRenata Cıfkova, Czech Republic
Derek Johnston, UKMassimo Piepoli, Italy Jean-Paul Schmid, Switzerland
Domenico Corrado, Italy Martin Karoff, Germany Philippe Sellier, France
William Dafoe, Canada Kay-Tee Khaw, UK Jarmila Siegelova, Czech RepublicGilles Dagenais, Kornelia Kotseva, Bulgaria Anna Stro ¨mberg, SwedenJaap Deckers, Netherlands
Robert Lewin, UKAsterios Deligiannis, Greece Rod Taylor, UK
Miguel Mendes, PortugalJohan Denollet, Dag Thelle, Sweden
Pierre Ducimetie `re, France Catherine Monpe `re, Netherlands
David Thompson, Hong KongDorian Dugmore, UK Jonathan Myers, USA
Andrew Tonkin, AustraliaAlun Evans, Ireland Peter Nilsson, Sweden
Ole Færgeman, Denmark Serena Tonstad, NorwaySania Nishtar, Pakistan
Paolo Fioretti, Italy Hugh Tunstall-Pedoe, UK
Tim Noakes, South AfricaBarry Franklin, USA Luc Vanhees, BelgiumNeil Oldridge, USAZlatko Fras, Slovenia
Heinz Vo¨ller, GermanyKristina Orth-Gome ´r, SwedenDan Gaita, Romania
Lars Wilhelmsen, SwedenAndrzej Pajak, PolandIan Graham, Ireland
Jacqueline Witteman, NetherlandsRichard Pasternak, USADieterick Grobbee, Netherlands
Antonio Pellicia, Italy Salim Yusuf, CanadaIrene Hellemans,AIMS AND SCOPE
EUROPEAN JOURNAL OF CARDIOVASCULAR PREVENTION
AND REHABILITATION
The offi cial journal of the European Association for Cardiovascular Prevention and Rehabilitation
(EACPR) of the European Society of Cardiology (former Working Groups
on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology)
MISSION
European Journal of Cardiovascular Prevention and Rehabilitation embraces all the scientifi c, clinical
and public health disciplines that address the causes and prevention of cardiovascular disease, as well as
cardiovascular rehabilitation and exercise physiology. It is the primary journal of the European Association for
Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology. It serves the interests of
complementary working groups in the European Society of Cardiology and other European professional societies such
as hypertension, atherosclerosis, diabetes, internal medicine, behavioural medicine and general practice. It provides an
avenue for reports of the European Heart Network, national heart foundations, non-governmental and governmental
organizations, and the European Union.
AIMS
The aims of the journal refl ect those of the Association who support it:
• To stimulate and disseminate research in cardiovascular epidemiology, prevention, rehabilitation, exercise physiology
and public health.
• To become the academic forum for all those in Europe and elsewhere with an interest in these scientifi c, educational,
clinical and public health issues.
• To improve cardiovascular prevention and rehabilitation in clinical practice and the community, and to improve the
prognosis and quality of life of cardiovascular patients and those at risk of cardiovascular disease.
SCOPE
• Behavioural medicine • Nutrition
• Cardiovascular epidemiology • Obesity
•rehabilitation • Occupational health
• Controlled clinical trials • Peripheral vascular disease
• Diabetes • Pharmacoepidemiology
• Early detection of asymptomatic disease • Physical activity
(including markers) • Prevention of CVD
• Exercise physiology, testing and training • Psychosocial factors and stress
• Genetic–environmental interactions • Public health
• Health economics • Quality of life
• Health services research • Risk factors and risk prediction
• Heart disease • Socio-demographic factors
• Hypertension • Sports cardiology
• Imaging in atherosclerosis • Stroke
• Lipids and atherosclerosis • Tobacco
• Methodology and statistics
INDEXING
European Journal of Cardiovascular Prevention and Rehabilitation is already indexed by Index Medicus/
Medline. It has an impact factor of 3.00.
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intheUSAandworldwide. websiteathttp://www.ejcpr.comforInstitutionsareavailablethroughovidEuropean guidelines on cardiovascular disease
prevention in clinical practice: executive summary
Fourth Joint Task Force of the European Society of Cardiology and
Other Societies on Cardiovascular Disease Prevention in Clinical
Practice (Constituted by representatives of nine societies
and by invited experts)
1 1Authors/Task Force Members: Ian Graham , Chairperson, Dan Atar , Oslo (Norway),*
2,3 4Knut Borch-Johnsen , Gentofte (Denmark), Gudrun Boysen , Copenhagen (Denmark),
5 6 1Gunilla Burell , Uppsala (Sweden), Renata Cifkova , Praha (Czech Republic), Jean Dallongeville ,
1 1 7Lille (France), Guy De Backer , Gent (Belgium), Shah Ebrahim , London (UK), Bjørn Gjelsvik ,
5 7Oslo (Norway), Christoph Herrmann-Lingen , Marburg (Germany), Arno Hoes , Utrecht
1 8 1(The Netherlands), Steve Humphries , London (UK), Mike Knapton , London (UK), Joep Perk ,
1 1Oskarshamn (Sweden), Silvia G. Priori , Pavia (Italy), Kalevi Pyorala , Kuopio (Finland),
9 1 1Zeljko Reiner , Zagreb (Croatia), Luis Ruilope , Madrid (Spain), Susana Sans-Menendez ,
1 8Barcelona (Spain), Wilma Scholte Op Reimer , Rotterdam (The Netherlands), Peter Weissberg ,
1 1 1London (UK), David Wood , London (UK), John Yarnell , Belfast (UK), Jose Luis Zamorano ,
Madrid (Spain)
Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands),
Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland)
European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France),
John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway),
Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands),
Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany),
Michal Tendera (Poland), Petr Widimsky (Czech Republic), Jose ´ Luis Zamorano (Spain)
Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany),
Enzo Bonora(Italy), Paul N.Durrington (UK), RobertFagard (Belgium), SimonaGiampaoli (Italy), HarryHemingway (UK),
Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy),
Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden
(Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgo ¨zoglu
(Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)
1European Society of Cardiology (ESC) including European Association for Cardiovascular Prevention and Rehabilitation
2 3(EACPR) and Council on Cardiovascular Nursing, for the Study of Diabetes (EASD), International Dia-
4 5betes Federation Europe (IDF-Europe), European Stroke Initiative (EUSI), International Society of Behavioural
6 7Medicine (ISBM), European Society of Hypertension (ESH), European Society of General Practice/Family Medicine (ESGP/
8 9FM/WONCA), Heart Network (EHN), European Atherosclerosis Society (EAS).
European Journal of Cardiovascular Prevention and Rehabilitation 2007, 14(Supp 2): E1–E40
Corresponding author. Department of Cardiology, The Adelaide and Meath Hospital, Tallaght, Dublin 24, Ireland, Tel: þ353 1 414 4105; fax: þ353 1 414 3052;*
e-mail: ian.graham@amnch.ie
The content ofthese European SocietyofCardiology (ESC) Guidelineshas beenpublished for personaland educational use only.Nocommercial use isauthorized.
Nopart ofthe ESC Guidelines may be translated or reproduced inany formwithout written permissionfrom the ESC. Permission can beobtainedupon submission
of a written request to Lippincott Williams & Wilkins the publisher of the European Journal of Cardiovascular Prevention and Rehabilitation and the party,
authorized to handle such permissions on behalf of the ESC.
Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were
written. Health professionals areencouraged to takethemfullyintoaccount whenexercisingtheir clinical judgement.Theguidelinesdonot, however,over-ride
the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that
patient,and,whereappropriateandnecessary,thepatient’sguardianorcarer.Itisalsothehealthprofessional’sresponsibilitytoverifytherulesandregulations
applicable to drugs and devices at the time of prescription.
1741-8267 © 2007 The European Society of Cardiology. Published by Lippincott Williams & Wilkins E2 European Journal of Cardiovascular Prevention and Rehabilitation 2007, Vool 14 (suppl 2)l 14 (suppl 2)
Scientific background . . . . . . . . . . . . . . . . E20Table of Contents
Practical aspects: management . . . . . . . . . . E20
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . E3 Bloodpressure ..................... E20
Introduction . . . . . . . . . . . . . . . . . . . . . . . E4 Scientific background . . . . . . . . . . . . . . . . E20
The scope of the problem: past and future . . . . . E5 Risk stratification and target organ damage . E21
Scientific background . . . . . . . . . . . . . . . . E5 Practical aspects: management of hypertension. E22
Practical aspects: coronary artery disease . . . . E5 Whototreat? .................. E22
Heart failure. . . . . . . . . . . . . . . . . . . . . E6 Howtotreat? .................. E22
Aortic aneurysm and dissection . . . . . . . . . . E6 Antihypertensive drugs . . . . . . . . . . . . . E22
Peripheral arterial disease . . . . . . . . . . . . . E6 Desirable blood pressure . . . . . . . . . . . . . . E23
Stroke . . . . . . . . . . . . . . . . . . . . . . . . E6 Duration of treatment. . . . . . . . . . . . . . E23
Practical aspects: prevention and management Plasma lipids . . . . . . . . . . . . . . . . . . . . . . E23
of stroke . . . . . . . . . . . . . . . . . . . . . . . E6 Scientific background . . . . . . . . . . . . . . . . E23
Prevention strategies and policy issues . . . . . . . . E6 E23Practical aspects: management . . . . . . . . . .
Scientific background . . . . . . . . . . . . . . . . E6 Should statins be given to all persons with
Practical aspects: policy issues . . . . . . . . . . E7 cardiovascular disease? . . . . . . . . . . . . . . . E23
Prevention in clinical practice . . . . . . . . . . . E7 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . E25
How to evaluate scientific evidence . . . . . . . . . E7 Scientific background . . . . . . . . . . . . . . . . E25
Scientific background . . . . . . . . . . . . . . . . E7 Practical aspects: management . . . . . . . . . . E25
What is ‘evidence’? . . . . . . . . . . . . . . . . . E7 The metabolic syndrome . . . . . . . . . . . . . . . . E26
Grading of evidence . . . . . . . . . . . . . . . . E8 Scientific background . . . . . . . . . . . . . . . . E26
The problems of evidence and guidance . . . . . E8 Practical aspects: management . . . . . . . . . . E26
Practical aspects . . . . . . . . . . . . . . . . . . E8 Psychosocial factors . . . . . . . . . . . . . . . . . . E26
Priorities, total risk estimation, and objectives . . . E9 Scientific background . . . . . . . . . . . . . . . . E26
Introduction . . . . . . . . . . . . . . . . . . . . . E9 Practical aspects: management of psychosocial
Priorities . . . . . . . . . . . . . . . . . . . . . . . E9 risk factors in clinical practice . . . . . . . . . . E27
Total risk estimation . . . . . . . . . . . . . . . . E10 Inflammation markers and haemostatic factors . . . E27
How do I assess risk? . . . . . . . . . . . . . . . . E10 Scientific background . . . . . . . . . . . . . . . . E27
Conclusions . . . . . . . . . . . . . . . . . . . . . E12 Genetic factors . . . . . . . . . . . . . . . . . . . . . E28
Principles of behaviour change and management of Family history: scientific background . . . . . . . E28
behavioural risk factors . . . . . . . . . . . . . . . . E14 practical aspects . . . . . . . . . E28
Scientific background . . . . . . . . . . . . . . . . E14 Phenotypes: scientific background . . . . . . . . E28
The physician/caregiver–patient interaction as a Genotypes: scientific . . . . . . . . . E28
means towards behavioural change . . . . . . . . E14 DNA-based tests for risk prediction . . . . . . E28
Specialized and multimodal interventions . . . . E15 Practical aspects . . . . . . . . . . . . . . . . . . E28
Practical aspects: management of behavioural DNA-based tests for risk prediction . . . . . . E28
risk factors. . . . . . . . . . . . . . . . . . . . . . E15 Pharmacogenetics . . . . . . . . . . . . . . . . E28
Smoking ......................... E16 Severe familial dyslipidaemias and coronary
Scientific background . . . . . . . . . . . . . . . . E16 heart disease . . . . . . . . . . . . . . . . . . . E29
Practical aspects: prevention and management Familial hypercholesterolaemia (FH) . . . . . E29
of smoking . . . . . . . . . . . . . . . . . . . . . . E16 combined hyperlipidaemia (FCH) . . E29
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . E17 Familial high-density lipoprotein
Scientific background . . . . . . . . . . . . . . . . E17 deficiency syndromes . . . . . . . . . . . . . . E29
Practical aspects: management . . . . . . . . . . E17 New imaging methods to detect asymptomatic
Overweight and obesity . . . . . . . . . . . . . . . . E17 individuals at high risk for cardiovascular events . . E29
Scientific background . . . . . . . . . . . . . . . . E17 Scientific background . . . . . . . . . . . . . . . . E29
Body weight and risk . . . . . . . . . . . . . . . . E17 Gender issues: cardiovascular disease prevention
Which index of obesity is the best predictor of inwomen ........................ E30
cardiovascular risk and cardiovascular risk Scientific background . . . . . . . . . . . . . . . . E30
factors—body mass index (BMI), waist Practical aspects . . . . . . . . . . . . . . . . . . E30
circumference (WC), or waist–hip circumference Renal impairment as a risk factor in cardiovascular
ratio (WHR)? . . . . . . . . . . . . . . . . . . . . . E18 disease prevention . . . . . . . . . . . . . . . . . . . E31
Imaging and fat distribution . . . . . . . . . . . . E18 Scientific background . . . . . . . . . . . . . . . . E31
Practical aspects: management of obesity and Practical aspects: management . . . . . . . . . . E31
overweight. . . . . . . . . . . . . . . . . . . . . . E18 Cardioprotective drug therapy . . . . . . . . . . . . E31
Physical activity and body weight . . . . . . . . . E18 Scientific background . . . . . . . . . . . . . . . . E31
Diet and behavioural interventions . . . . . . . . E19 Antiplatelet therapies . . . . . . . . . . . . . . E31
Drug treatment of overweight . . . . . . . . . . . E19 b-Blockers . . . . . . . . . . . . . . . . . . . . E31
Physical activity . . . . . . . . . . . . . . . . . . . . . E19 ACE ihibitors . . . . . . . . . . . . . . . . . . . E31
Scientific background . . . . . . . . . . . . . . . . E19 Anticoagulation . . . . . . . . . . . . . . . . . E31
Estimating physical activity. . . . . . . . . . . E19 Practical aspects: management . . . . . . . . . . E32
Practical aspects: management . . . . . . . . . . E19 Antiplatelet therapy: aspirin . . . . . . . . . . E32
Heart rate . . . . . . . . . . . . . . . . . . . . . . . . E20 clopidogrel . . . . . . . E32European guidelines on cardiovascular disease prevention in clinical practice Fourth Joint Task Force E3
b-Blockers . . . . . . . . . . . . . . . . . . . . E32 experts involved in the Task Force, it is submitted to
ACE inhibitors . . . . . . . . . . . . . . . . . . E32 outside specialists for review. The document is revised,
Calcium channel blockers . . . . . . . . . . . . E32 andfinallyapprovedbytheCPGandsubsequentlypublished.
Diuretics . . . . . . . . . . . . . . . . . . . . . E32 Afterpublication,disseminationofthemessageisofpara-
Anticoagulation . . . . . . . . . . . . . . . . . E32 mount importance. Pocket-sized versions and personal
Implementation strategies . . . . . . . . . . . . . . . E32 digital assistant (PDA)-downloadable versions are useful
Scientific background . . . . . . . . . . . . . . . . E32 at the point of care. Some surveys have shown that
Barriers to the implementation of guidelines. E33 the intended end-users are sometimes not aware of the
–patient relationship . . . . . . . . . .Doctor E33 existence of guidelines, or simply do not translate them
Practical aspects . . . . . . . . . . . . . . . . . . E33 into practice, so this is why implementation programmes
Important arenas for training . . . . . . . . . E33 for new guidelines form an important component of the dis-
Implementation strategies . . . . . . . . . . . E33 semination of knowledge. Meetings are organized by the
References . . . . . . . . . . . . . . . . . . . . . . . . E34 ESC, and directed towards its member National Societies
andkeyopinionleadersinEurope.Implementationmeetings
can also be undertaken at national levels, once the guide-
lines have been endorsed by the ESC member societies,Preamble
and translated into the national language. Implementation
Guidelines and Expert Consensus Documents summarize and programmes are needed because it has been shown that
evaluate all currently available evidence on a particular the outcome of disease may be favourably influenced by
issue with the aim to assist physicians in selecting the best the thorough application of clinical recommendations.
management strategies for a typical patient, suffering Thus, the task of writing Guidelines or Expert Consensus
from a given condition, taking into account the impact on documents covers not only the integration of the most
outcome, as well as the risk–benefit ratio of particular diag- recent research, but also the creation of educational tools
nostic or therapeutic means. Guidelines are not substitutes and implementation programmes for the recommendations.
for textbooks. The legal implications of medical guidelines The loop between clinical research, writing of guidelines,
have been discussed previously. and implementing them in clinical practice can then only
A great number of Guidelines and Expert Consensus Docu- be completed if surveys and registries are performed to
ments have been issued in recent years by the European verify that real-life daily practice is in keeping with what
Society of Cardiology (ESC) as well as by other societies is recommended in the guidelines. Such surveys and regis-
and organizations. Because of the impact on clinical prac- tries also make it possible to evaluate the impact of
tice, quality criteria for development of guidelines have implementation of the guidelines on patient outcomes.
been established in order to make all decisions transparent Guidelines and recommendations should help the physicians
to the user. The recommendations for formulating and to make decisions in their daily practice; however, the ulti-
issuing ESC Guidelines and Expert Consensus Documents mate judgement regarding the care of an individual patient
can be found on the ESC web site (http://www.escardio. must be made by the physician in charge of his/her care.
org/knowledge/guidelines/rules).
In brief, experts in the field are selected and undertake a Classes of recommendations
comprehensive review of the published evidence for man-
Class I Evidence and/or general agreement that aagement and/or prevention of a given condition. A critical
given treatment or procedure is beneficial,evaluation of diagnostic and therapeutic procedures is per-
useful, and effectiveformed, including assessment of the risk–benefit ratio.
Class II Conflicting evidence and/or a divergence ofEstimates of expected health outcomes for larger societies
opinion about the usefulness/efficacy of the
are included, where data exist. The level of evidence and
given treatment or procedure
the strength of recommendation of particular treatment
Class IIa Weight of evidence/opinion is in favour of
options are weighed and graded according to predefined usefulness/efficacy
scales, as outlined in the tables below. Class IIb Usefulness/efficacy is less well established by
Theexpertsofthewritingpanelshaveprovideddisclosure evidence/opinion
statements of all relationships they may have which might Class III Evidence or general agreement that the given
treatment or procedure is not useful/be perceived as real or potential sources of conflicts of
effective, and in some cases may be harmfulinterest. These disclosure forms are kept on file at the Euro-
pean Heart House, headquarters of the ESC. Any changes in
conflict of interest that arise during the writing period must
Levels of evidencebe notified to the ESC. The Task Force report was entirely
supported financially by the ESC and was developed
LevelofevidenceA Data derived from multiple randomized
without any involvement of industry.
clinical trials or meta-analyses
The ESC Committee for Practice Guidelines (CPG) super- LevelofevidenceB Data derived from a single randomized
vises and coordinates the preparation of new Guidelines clinical trial or large non-randomized
and Expert Consensus Documents produced by Task Forces, studies
expert groups, or consensus panels. The Committee is also LevelofevidenceC Consensus of opinion of the experts and/
orsmallstudies,retrospectivestudies,responsible for the endorsement process of these Guidelines
registriesand Expert Consensus Documents or statements. Once the
document has been finalized and approved by all theE4 European Journal of Cardiovascular Prevention and Rehabilitation 2007, Vool 14 (suppl 2)l 14 (suppl 2)
(1) More detailed guidance was sought from the WorldIntroduction
Organization of National Colleges, Academies and aca-
The rationale for an active approach to the prevention of demic associations of general practitioners/family phys-
atherosclerotic cardiovascular disease (CVD) is based on icians (WONCA, or the ‘World Organization of Family
five key points: Doctors’ for short) and from the ESC Working Group on
Cardiovascular Nursing, since these bodies represent
theprofessionalsthatareheavilyengagedinthepractical
Why develop a preventive strategy in clinical deliveryofpreventiveadviceinmanyEuropeancountries.
practice? (2) The current ESC approach to grading evidence was
(1) Cardiovascular disease (CVD) is the major cause of examined in detail. Concern was expressed that the
premature death in Europe. It is an important cause of
present system, while logical, tends to give priority todisability and contributes substantially to the escalating
costs of healthcare. drug treatments since these are more amenable to
(2) The underlying atherosclerosis develops insidiously over double-blind randomized controlled trials than lifestyle
many years and is usually advanced by the time that measures, even if observational studies indicate power-
symptoms occur.
ful benefits from, for example, smoking cessation. For
(3) Death from CVD often occurs suddenly and before
this reason, the gradings have not been included in themedical care is available, so that many therapeutic
interventions are either inapplicable or palliative. present documents, and further debate on this topic is
(4) The mass occurrence of CVD relates strongly to life- strongly recommended.
styles and to modifiable physiological and biochemical
(3) Allriskestimationsystems,includingSCORE,willoveresti-factors.
mate risk in countries that have experienced a decline in(5) Risk factor modifications have been shown to reduce
CVD mortality and morbidity, particularly in high risk CVD mortality, and underestimate risk if mortality has
patients. increased. The development of national guidance has
alwaysbeenrecommendedbytheTaskForceand,aspart
ofthisprocess,recalibrationoftheSCOREchartstoallow
By the early 1990s there was a plethora of similar yet con- for time trends in both mortality and risk factor distri-
fusingly different national and international guidelines for butions in individual countries is recommended. In the
the prevention of CVD. In order to try to define the areas Third Joint Guidelines, the need to address the problem
of agreement, the ESC, the European Atherosclerosis ofahighrelativebutlowabsoluteriskinyoungerpersons
Society and the European Society of Hypertension agreed was dealt with by extrapolating a young person’s risk to
to collaborate, resulting in a set of recommendations for age 60 to flag persons who will become at high absolute
the prevention of coronary heart disease (CHD) that was risk. If interpreted too literally, this approach might
1published in 1994. These guidelines were revised in 1998 result in excessive use of drug treatments in young
2,3and 2003 by the second and third Joint Task Forces. A people. Inthe present guidelines, this approach has been
strength of the guidelines is that, from the outset, it was replacedwithasimplerelativeriskcharttobeusedincon-
stressedthatCVDisusuallytheproductofmultipleinteract- junctionwiththeSCOREabsoluteriskchart.
ing risk factors. This resulted in the production of risk charts (4) A re-examination of the SCORE data sets indicated that
that attempt to simplify the estimation of total CVD risk, the impact of self-reported diabetes on risk may have
and a realization that risk management requires attention been underestimated. The issue of predicting total
to all modifiable risk factors. events as well as just CVD mortality also receives more
It was appreciated that the original partners needed attention, as do gender issues, central obesity, high-
assistance from other bodies and experts, in particular in density lipoprotein (HDL) cholesterol, heart rate, renal
the fields of behavioural medicine and diabetes. In addition, impairment, and manifestations of CVD other than CHD.
it is acknowledged that much practical preventive advice is
What's new in the Fourth Joint Task Force delivered by family doctors, nurses, and through voluntary
Guidelines on the Prevention of CVD?bodies such as Heart Foundations. These considerations
are reflected in the expanded partnership represented in (1) Increased input from general practice and
the present guidelines, and in the list of experts whose cardiovascular nursing
(2) Increased emphasis on exercise, weight, and input has been sought.
lifestyleThe Third Joint Task Force Guidelines saw a change from
(3) More detailed discussion on the limitations of CHD to CVD prevention, to reflect the fact that athero-
present systems of grading evidence
sclerosis may affect any part of the vascular tree. A new
(4) Re-defined priorities and objectives risk chart called SCORE (Systematic COronary Risk Evalu-
(5) Revised approach to risk in the young ation) was developed which was based on 12 European
(6) Total events considered as well as mortality cohort studies and allowed the estimation of 10-year risk
(7) More information from score on total events, of cardiovascular death. Separate charts were produced
diabetes, HDL cholesterol, and body mass index
for high and low risk regions of Europe. More explicit clinical
(BMI)
priorities were developed. Less emphasis was placed on the
(8) New sections on gender, heart rate, BMI/waist
terms ‘primary’ and ‘secondary’ prevention since risk is a circumference, other manifestations of CVD, and
continuum—asymptomatic persons may have investigational renal impairment
evidence of atherosclerotic disease. A rigorous external
review process was undertaken. TheseGuidelinesattempttofindareasofbroadagreement
The Fourth Joint Task Force has taken note of feedback in amongdifferentprofessionalbodiesandscientificdisciplines.
several areas: WiththehelpofWONCA,aparticularefforthasbeenmadetoEuropean guidelines on cardiovascular disease prevention in clinical practice Fourth Joint Task Force E5
harmonize the advice that may be given to primary care and
Table 1 All deaths from circulatory disease in Europe. All ages.second-line care health professionals. The production of
Year 2000 or circa
more detailed guidelines by the partner societies is encour-
aged; as examples, reference is made to the ESH/ESC guide- All causes Men 4519403
4lines on the management of arterial hypertension and to Women 4336346
the guidelines on diabetes, pre-diabetes and CVD by the All circulatory Men 1963644
5ESC/EASD. Implicit in this partnership process is that these Women 2307945
CHD Men 967258will be compatible with the generic Joint Guidelines.
Women 983229The development of national guidance on CVD prevention
Stroke Men 504307is also specifically encouraged. The Joint Guidelines should
Women 775571be regarded as a framework from which national guidelines
Other Men 492079
can be developed to suit local political, economic, social,
Women 637405
and medical circumstances. The production of guidelines is
only one step in the process of prevention, and the develop-
ment of national multidisciplinary implementation partner- of these, 695 per 100000 were caused by CHD and 375 per
ships is recommended; the section on implementation 100 000 by stroke, but more than half were due to other
addresses some of the issues involved. forms of chronic heart disease. The estimated total cost of
It should be appreciated that the Fourth Joint Task Force 8CVDs in the EU countries wasE168 757 million in 2003.
Guidelinesarefortheuseofphysiciansandotherhealthpro- CVD mortality rates vary with age, gender, socio-economic
fessionals engaged in clinical practice. Therefore, they give status, ethnicity, and geographical region. Mortality rates
the highest priority to those individuals at highest CVD risk increase with age, and are higher in men, in people of low
becausesuchpersonsgainmostbyactiveriskfactormanage- socio-economic status, in Central and Eastern Europe, and in
ment. However, they should be complemented by national immigrants of South Asian origins. There are marked socio-
and European public health strategies aimed at whole popu- economic gradients in CVD morbidity and mortality within
lations in a co-ordinated and comprehensive effort to European countries, which are partially explained by socio-
reduce the enormous burden of CVD that afflicts European economic differences in conventional risk factors, such as
populations. In this way, we hope that the guidelines will smoking,bloodpressure(BP),bloodcholesterol,andglucose.
promote higher quality of care to help reduce this burden Total CVD mortality has been falling consistently, both in
andCVDinEurope.Theseissuesinformamajornewinitiative, middle life and at older ages, since 1970 in Western
the publication of the European Health Charter, available 9Europe. In Central and Eastern Europe, they started to
through www.heartcharter.eu. The Charter was produced by decline only in recent years, and they remain very high in
the ESC, European Union (EU), and the European Heart such countries. There is still nearly a 10-fold gradient in
Network, in partnership with the World Health Organization male CHD mortality between Eastern Europe and France at
(WHO). The relationship between the Charter and the ages35–74,anduptoa6-folddifferenceinstrokemortality.
presentGuidelinesmaybesummarized: Declines in CHD mortality are related to population-wide
behavioural changes in nutrition and smoking in both
10The European Heart Health Charter and the Western and Eastern Europe. The incidences of CHD and
Guidelines on cardiovascular disease stroke have also been declining in Western Europe, but
prevention increasing in other countries, principally in Eastern Europe
and Spain.
(1) The European Heart Health Charter advocates the
development and implementation of comprehensive
health strategies, measures and policies at European, Practical aspects: coronary artery disease
national, regional and local level that promote
cardiovascular health and prevent cardiovascular Changes in CHD mortality at the end of the 20th century
disease. were mostly explained by changes in incidence rather than
(2) These guidelines aim to assist physicians and other changes in short-term case fatality of acute myocardial
11health professionals to fulfill their role in this infarction (AMI). Major emphasis is needed in the control
endeavour, particularly with regard to achieving
of risk factors and of the determinants of incident CHD.effective preventive measures in day-to-day clinical
The reduction in blood pressure noted at population level ispractice.
only partly attributable to an increase in the proportion of(3) They reflect the consensus arising from a multi-
hypertensive subjects receiving treatment, suggesting thatdisciplinary partnership between the major European
professional bodies represented. despite the importance of medication to individuals, other
determinants of BP lowering are more powerful in whole
populations. Risk factor control in high risk patients and in
The scope of the problem: past and future patients with established CHD remains poor, especially
regarding obesity, smoking, and BP, and mostly so in diabetic
Scientific background
patients, in spite of issued guidelines indicating the need for
CVDs were the direct cause of .4 million deaths in Europe reinforcing dissemination and implementation of cost-
12around the year 2000 (1.9 million in the EU), accounting for effective prevention actions in an organized way.
43% of all deaths of all ages in men and for 55% in women As survival after acute events improves, prevalent CHD
6 7(Table 1 from www.ehnheart.org ). CVDs were also the increases, especially in older women. It is known that dia-
major cause of hospital discharges, with an average rate of betes is a more powerful risk factor for women, and, thus,
2557 per 100 000 population around the year 2002. Out control of risk factors among diabetic patients becomes aE6 European Journal of Cardiovascular Prevention and Rehabilitation 2007, Vool 14 (suppl 2)l 14 (suppl 2)
special priority. As theprevalence of overweight and obesity Stroke
increasesworldwide,anincrease intheprevalenceoftype2
The incidence of stroke increases exponentially with age,
diabetesandhenceallitscomplicationsmaybeanticipated.
affecting about 25 per 100000 in the age group 35–44
Consequently, control of the growing epidemic of obesity
years and 1500 per 100000 in age group 75–84 years
should be a priority.
annually. Stroke is the third leading cause of death in
The clinical manifestations of CVD may be very different.
many countries. Intracerebral haemorrhage and subarach-
Hospital statistics reveal only the tip of the iceberg, since
noid haemorrhage contribute 10 and 5% of strokes, respect-
sudden cardiac death occurring outside the hospital still
ively. Ischaemic stroke may be due to large vessel disease,
represents a large proportion of all cardiovascular deaths.
small vessel disease, emboli from the heart or from the
aortic arch, or other rarer identified causes, while a large
22Heart failure proportion still remains undetermined.
The most important risk factor is hypertension, followedPump failure of the heart is a common cause of death in the
by smoking and diabetes. Others are sedentary lifestyle,elderly, although this not always reflected in mortality stat-
overuse of alcohol, and illicit drugs, elevated cholesterol,istics because of the limitations of coding rules. Hospital
use of oral contraceptives or postmenopausal hormones,admission rates for heart failure have been increasing in
overweight, low socio-economic status (SES), and athero-the USA and in Europe. Hypertension, obesity, and diabetes
sclerotic stenosis of extracranial vessels.are major risk factors. Although a small proportion of clini-
cal cases are due to valve disease (often linked with CHD),
or to cardiomyopathy, epidemiological studies suggest Practical aspects: prevention and management
that, in well developed countries, the majority of cases of stroke
13are due to ischaemia.
Antihypertensive treatment reduces risk of both ischaemic
and haemorrhagic stroke, and stroke prevention is the
Aortic aneurysm and dissection most important effect of antihypertensive treatment.
Smoking should be discouraged and physical activityAortic aneurysm is also atherosclerotic in nature, and
encouraged. Alcohol intake in low amounts may not beincreasing mortality trends have been shown in some Euro-
14 harmful. With regard to statin therapy, stroke survivorspean countries. It is a potentially preventable cause of
should be treated in the same way as those with otherdeath, particularly when confined to the abdominal aorta.
manifestations of CVD. Carotid endarterectomy in sympto-The prevalence is 5% in men aged 60 years or more, and
matic patients with stenosis of the internal carotid artery1–2% in women. Screening for this condition has been
reducing the lumen .70% reduces the risk of recurrentsuggested since elective surgical repair carries a 5–8%
stroke.30-day mortality in comparison with 50% mortality for rup-
Prophylactic antithrombotic treatment: Within the thera-tured aneurysm; a trial of screening conducted in the UK
15 peutic range of international normalized ratio (INR) 2–3,has shown encouraging results.
anticoagulation reduces stroke risk in patients with atrial
fibrillation. Antiplatelet therapy is indicated in patientsPeripheral arterial disease
with non-cardioembolic ischaemic stroke. Aspirin is the
Itis knownthatcoronaryandperipheralvesselsareaffected mostwidelyuseddrugindosesof75–150mgaday.Thecom-
by the same disease process, requiring the same treatment bination of aspirin and dipyridamole gives an additional risk
modalities. Peripheral arterial disease (PAD) occurs almost reduction. Clopidogrel has an effect similar to aspirin in
16as frequently in women as in men. The correlation of patients with ischaemic cerebrovascular disease. Combi-
PADwithCHD,myocardialinfarction(MI),andstrokereflects nation of clopidogrel and aspirin is not recommended for
the widespread nature of atherosclerosis. However, some stroke survivors. For a more comprehensive review,
23minor differences have emerged from epidemiological readers are referred to the European Stroke Initiative.
studies regarding the risk factors for these diseases.
Smoking appears to be more important in the aetiology of
17PAD than in CHD. A positive family history, hypertension, Prevention strategies and policy issues
diabetes, dyslipidaemia including increased total and low-
Scientific background
density lipoprotein (LDL) cholesterol and decreased HDL
cholesterol, increased fibrinogen and C-reactive protein Three strategies for the prevention of CVD can be distin-
(CRP), advanced age, and physical inactivity seem to be guished: population, high-risk and secondary prevention.
common risk factors. The three strategies are necessary and complement
AsinCHD,effectiveriskfactormanagementisessential.Risk each other. The population strategy in particular is critical
reductioncanbeachievedthroughlifestylemodification,par- to reducing the overall incidence of CVD since it aims to
ticularlyphysicalactivityandexercise,smokingcessation,and reduce risk factors at population level through lifestyle
therapiessuchasuseofstatins,antiplatelettherapies,antith- andenvironmentalchangesthataffectthewholepopulation
rombotic strategies, angiotensin-converting enzyme (ACE) without requiring the medical examination of individuals.
16,18,19inhibitors, and b-blockers. The beneficial effects of This type of strategy is mostly achieved by establishing ad
20statins in these patients have been shown in large trials. hoc policies and community interventions.
StatinsnotonlylowertheriskofPADandvascularevents,but The strategies aimed to diminish the total cardiovascular
they also improve the symptoms associated with PAD. There risk of individuals are the high risk primary prevention and
is also evidence that statins reduce surgical mortality and the secondary prevention strategies. The former deals
21improvegraftpatencyandlimbsalvageinPADpatients. with healthy persons belonging to the upper part of the

)