ESC 2021 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice
European Society of Cardiology｜循環器 / 予防｜111 ページ｜チャンク 1150｜推奨 212 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.16 | I | C | Systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor (i.e. family history of premature CVD, FH, CVD risk factors such as smoking, arterial hypertension, DM, raised lipid level, obesity, or comorbidities increasing CVD risk). | |
| p.16 | IIb | C | Systematic or opportunistic CV risk assessment in the general population in men >40 years of age and in women >50 years of age or postme- nopausal with no known ASCVD risk factors may be considered.9 | |
| p.16 | IIb | C | In those individuals who have undergone CVD risk assessment in the context of opportunistic screening, a repetition of screening after 5 years (or sooner if risk was close to treatment thresh- olds) may be considered. | |
| p.16 | IIa | B | Opportunistic screening of BP in adults at risk for the development of hypertension, such as those who are overweight or with a known fam- ily history of hypertension, should be considered.19 | |
| p.16 | III | C | Systematic CVD risk assessment in men <40 years of age and women <50 years of age with no known CV risk factors is not recommended.9 | |
| p.30 | I | B | Recommendations for CVD risk estimation In apparently healthy people <70 years without established ASCVD, DM, CKD, genetic/rarer lipid or BP disorders, estimation of 10-year fatal and non-fatal CVD risk with SCORE2 is recommended.68 | |
| p.30 | I | B | In apparently healthy people >_70 years without established ASCVD, DM, CKD, genetic/rarer lipid or BP disorders, estimation of 10-year fatal and non-fatal CVD risk with SCORE2-OP is recommended.72 | |
| p.30 | IIa | C | In apparently healthy people, after estimation of 10-year fatal and non-fatal CVD risk, lifetime risk and treatment benefit, risk modifiers, frailty, polypharmacy, and patient preferences should be considered. | |
| p.30 | I | A | Patients with established ASCVD and/or DM and/or moderate-to-severe renal disease and/or genetic/rarer lipid or BP disorders are to be considered at high or very high CVD risk.75,77,81,8890 | |
| p.30 | I | B | ............................................................................................................................................................................ A stepwise treatment-intensification approach aiming at intensive risk factor treatment is rec- ommended for apparently healthy people at high or very high CVD risk, as well as patients with established ASCVD and/or DM, with con- sideration of CVD risk, treatment benefit of risk factors, risk modifiers, comorbidities, and patient preferences.66,67 | |
| p.30 | I | C | Treatment of ASCVD risk factors is recom- mended in apparently healthy people without DM, CKD, genetic/rarer lipid, or BP disorders who are at very high CVD risk (SCORE2 >_7.5% for age under 50; SCORE2 >_10% for age 5069; SCORE2-OP >_15% for age >_70 years).68,72 Treatment of ASCVD risk factors should | |
| p.30 | IIa | C | be considered in apparently healthy people without DM, CKD, genetic/rarer lipid, or BP disorders who are at high CVD risk (SCORE2 2.5 to <7.5% for age under 50; SCORE2 5 to <10% for age 5069; SCORE2-OP 7.5 to <15% for age >_70 years), taking CVD risk modifiers, lifetime risk and treatment benefit, and patient preferences into account. | |
| p.31 | IIa | B | ethnic subgroups should be considered.105 | |
| p.31 | I | C | An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended.96 CVD = cardiovascular disease. aClass of recommendation. bLevel of evidence. | |
| p.31 | IIa | B | Recommendations for CVD risk modifiers Stress symptoms and psychosocial stressors modify CVD risk. Assessment of these stressors should be considered.100102 | |
| p.31 | IIb | B | CAC scoring may be considered to improve risk classification around treatment decision thresh- olds. Plaque detection by carotid ultrasound is an alternative when CAC scoring is unavailable or not feasible.103,104 Multiplication of calculated risk by RR for specific | |
| p.31 | III | B | ............................................................................................................................................................................ The routine collection of other potential modifiers, such as genetic risk scores, circulating or urinary biomarkers, or vascular tests or imaging methods (other than CAC scoring or carotid ultrasound for plaque determination), is not recommended. | |
| p.34 | IIb | C | Patients at (very) high risk for CVD may be encouraged to try to avoid long-term exposure to regions with high air pollution. | |
| p.34 | IIb | C | ........................................................................................................................................ In regions where people have long-term exposure to high levels of air pollution, (opportunistic) CVD risk screening programmes may be considered. CVD = cardiovascular disease. aClass of recommendation. bLevel of evidence. | |
| p.35 | I | C | Clinical condition CKD In all CKD patients, with or without DM, appropriate screening for ASCVD and kidney disease pro- gression, including monitoring changes in albuminuria is recommended.172 | |
| p.35 | I | B | Cancer It is recommended to monitor cardiac dysfunction using imaging techniques and circulating bio- markers before, periodically during, and after cancer treatment.173 | |
| p.35 | IIb | B | Cardioprotection in high-risk patients (those receiving high cumulative doses or combined radiotherapy) receiving anthracy- cline chemotherapy may be con- sidered for prevention of LV dysfunction.174,175 | |
| p.35 | I | C | Screening for ASCVD risk factors and optimization of the CVD risk profile is recommended in patients on treatment for cancer. | |
| p.35 | I | C | COPD It is recommended that all COPD patients be investigated for ASCVD and ASCVD risk factors. | |
| p.35 | IIb | B | Inflammatory conditions Assessment of total CVD risk may be considered in adults with chronic inflammatory conditions.176 | |
| p.35 | IIa | B | Multiplication of calculated total CVD risk by a factor of 1.5 should be considered in adults with rheu- matoid arthritis.177,178 | |
| p.35 | IIa | B | Migraine Presence of migraine with aura should be considered in CVD risk assessment.179181 | |
| p.35 | IIb | B | Avoidance of combined hormonal contraceptives may be considered in women with migraine with aura.182,183 Sleep In patients with ASCVD, obesity, | |
| p.35 | I | C | disorders and hypertension, regular screen- and OSA ing for non-restorative sleep is indicated (e.g. by the question: ‘how often have you been both- ered by trouble falling or staying asleep, or sleeping too much?’). | |
| p.35 | I | C | ............................................................................................................................................................................ If there are significant sleep prob- lems, which are not responding within 4 weeks to sleep hygiene, referral to a specialist is recommended. | |
| p.35 | I | C | Mental disorders It is recommended that mental disorders with either significant func- tional impairment or decreased use of healthcare systems be considered as influencing total CVD risk. | |
| p.35 | IIa | B | Sex-specific In women with a history of pree- conditions clampsia and/or pregnancy- induced hypertension, periodic screening for hypertension and DM should be considered.184187 | |
| p.35 | IIa | B | In women with a history of polycystic ovary syndrome or gesta- tional DM, periodic screening for DM should be considered.188191 | |
| p.35 | IIb | B | In women with a history of premature or stillbirth, periodic screening for hypertension and DM may be considered.192,193 | |
| p.35 | IIa | C | Assessment of CVD risk should be considered in men with ED. Continued | |
| p.42 | I | A | 4.3.Optimizing lifestyle 4.3.1. Physical activity and exercise Recommendations for physical activity It is recommended for adults of all ages to strive for at least 150 - 300 min a week of moderate- intensity or 75 - 150 min a week of vigorous- intensity aerobic PA, or an equivalent combination thereof, to reduce all-cause mortality, CV mortality, and morbidity.371,372 | |
| p.42 | I | B | It is recommended that adults who cannot perform 150 min of moderate-intensity PA a week should stay as active as their abilities and health condition allow.373,374 | |
| p.42 | I | B | .......................................................................................................... It is recommended to reduce sedentary time to engage in at least light activity throughout the day to reduce all-cause and CV mortality and morbidity.375377 | |
| p.42 | I | B | Performing resistance exercise, in addition to aerobic activity, is recommended on 2 or more days per week to reduce all-cause mortality.378,379 | |
| p.42 | IIa | B | Lifestyle interventions, such as group or individ- ual education, behaviour-change techniques, tel- ephone counselling, and use of consumer-based wearable activity trackers, should be considered to increase PA participation.380382 CV = cardiovascular; PA = physical activity. aClass of recommendation. bLevel of evidence. | |
| p.43 | I | A | A healthy diet is recommended as a cornerstone of CVD prevention in all individuals.401,402 | |
| p.44 | I | A | similar diet to lower risk of CVD.403,404 | |
| p.44 | I | A | BP and risk of CVD.410 | |
| p.44 | I | B | tion to a maximum of 100 g per week.413415 | |
| p.44 | I | A | It is recommended to adopt a Mediterranean or It is recommended to replace saturated with unsaturated fats to lower the risk of CVD.405409 It is recommended to reduce salt intake to lower | |
| p.44 | I | B | It is recommended to choose a more plantbased food pattern, rich in fibre, that includes whole grains, fruits, vegetables, pulses, and nuts.411,412 It is recommended to restrict alcohol consump- | |
| p.44 | I | B | It is recommended to eat fish, preferably fatty, at least once a week and restrict (processed) meat.406,416418 | |
| p.44 | I | B | It is recommended to restrict free sugar con- sumption, in particular sugar-sweetened beverages, to a maximum of 10% of energy intake.419,420 CVD = cardiovascular disease; BP = blood pressure. aClass of recommendation. bLevel of evidence. | |
| p.46 | I | A | 4.3.3 Body weight and composition Recommendations for body weight It is recommended that overweight and obese people aim for a reduction in weight to reduce BP, dyslipidaemia, and risk of type 2 DM, and thus improve their CVD risk profile.450,451 | |
| p.46 | I | A | While a range of diets are effective for weight loss, it is recommended that a healthy diet in regard to CVD risk is maintained over time.452454 | |
| p.46 | IIa | B | ..................... Bariatric surgery for obese high-risk individuals should be considered when lifestyle change does not result in maintained weight loss.455 | |
| p.47 | I | C | Patients with mental disorders need intensified attention and support to improve adherence to lifestyle changes and drug treatment.3,465 | |
| p.47 | I | B | In ASCVD patients with mental disorders, evi- dence-based mental healthcare and interdisciplinary cooperation are recommended.100,113,466 | |
| p.47 | IIa | B | ASCVD patients with stress should be consid- ered for referral to psychotherapeutic stress management to improve CV outcomes and reduce stress symptoms.467469 | |
| p.47 | IIa | B | Patients with CHD and moderate-to-severe major depression should be considered for antidepressive treatment with an SSRI.470,471 | |
| p.47 | III | B | In patients with HF and major depression, SSRIs, SNRIs, and tricyclic antidepressants are not rec- ommended.472,473 c | |
| p.47 | I | A | 4.5 Smoking intervention ESC 2021 All smoking of tobacco should be stopped, as tobacco use is strongly and independently causal of ASCVD.487,488 | |
| p.47 | IIa | A | In smokers, offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered.489494 | |
| p.47 | I | B | ............................................................................................................. Smoking cessation is recommended regardless of weight gain, as weight gain does not lessen the ASCVD benefits of cessation.495 ASCVD = atherosclerotic cardiovascular disease. aClass of recommendation. bLevel of evidence. | |
| p.50 | I | C | 4.6.2 Defining lipid goals 4.6.2.1 Low-density lipoprotein cholesterol goals A stepwise treatment-intensification approach is recommended for apparently healthy people at high or very high CVD risk, as well as patients with established ASCVD and/or DM with con- sideration of CVD risk, treatment benefit, risk modifiers, comorbidities, and patient preferences. | |
| p.52 | I | A | It is recommended that a high-intensity statin is prescribed up to the highest tolerated dose to reach the LDL-C goals set for the specific risk group.21,520,521 | |
| p.52 | IIa | C | An ultimatec LDL-C goal of <1.4 mmol/L (55 mg/ dL) and LDL-C reduction of >_50% from baseline should be considered in apparently healthy persons <70 years at very high risk.21,22,522 | |
| p.52 | IIa | C | An ultimatec LDL-C goal of <1.8 mmol/L (70 mg/dL) and LDL-C reduction of >_50% from baseline should be considered in apparently healthy persons <70 years at high risk.21,22,522 | |
| p.52 | I | A | In patients with established ASCVD, lipid-lowering treatment with an ultimatec LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >_50% reduction in LDL- C vs. baseline is recommended.21,508,515517,522 | |
| p.52 | I | B | If the goals are not achieved with the maximum tolerated dose of a statin, combination with eze- timibe is recommended.515 | |
| p.52 | IIb | C | For primary prevention patients at very high risk, but without FH, if the LDL-C goal is not achieved on a maximum tolerated dose of a statin and ezetimibe, combination therapy including a PCSK9 inhibitor may be considered. | |
| p.53 | I | A | For secondary prevention patients not achieving their goals on a maximum tolerated dose of a statin and ezetimibe, combination therapy including a PCSK9 inhibitor is recommended.516,517 | |
| p.53 | I | C | For very-high-risk FH patients (that is, with ASCVD or with another major risk factor) who do not achieve their goals on a maximum toler- ated dose of a statin and ezetimibe, combination therapy including a PCSK9 inhibitor is | |
| p.53 | IIa | B | recommended. If a statin-based regimen is not tolerated at any dosage (even after rechallenge), ezetimibe should be considered.515,523525 | |
| p.53 | IIb | C | If a statin-based regimen is not tolerated at any dosage (even after rechallenge), a PCSK9 inhibitor added to ezetimibe may be considered.523,524,526 | |
| p.53 | IIb | C | If the goal is not achieved, statin combination with a bile acid sequestrant may be considered. | |
| p.53 | III | C | Statin therapy is not recommended in premenopausal female patients who are consid- ering pregnancy or are not using adequate contraception. | |
| p.54 | I | A | 4.6.4 Important groups Statin treatment is recommended as the first drug of choice for reducing CVD risk in high-risk individuals with hypertriglyceridaemia [triglycerides >2.3 mmol/L (200 mg/dL)].533 | |
| p.54 | IIb | B | In patients taking statins who are at LDL-C goal with triglycerides >2.3 mmol/L (200 mg/dL), fenofi- brate or bezafibrate may be considered.534536 | |
| p.54 | IIb | B | In high-risk (or above) patients with triglycerides >1.5 mmol/L (135 mg/dL) despite statin treat- ment and lifestyle measures, n-3 PUFAs (icosapent ethyl 2 2 g/day) may be considered in combination with a statin.84 | |
| p.54 | I | A | Treatment with statins is recommended for ESC 2021 older people with ASCVD in the same way as for younger patients.538,539 | |
| p.54 | IIb | B | Initiation of statin treatment for primary preven- tion in older people aged >_70 may be considered, if at high risk or above.538,539 | |
| p.54 | I | C | ............................................................................................................ It is recommended that the statin is started at a low dose if there is significant renal impairment and/or the potential for drug interactions. ASCVD = atherosclerotic cardiovascular disease. aClass of recommendation. bLevel of evidence. Adapted from 3 | |
| p.54 | I | A | In patients with type 2 DM at very high risk (e.g. with established ASCVD and/or severe TODc), intensive lipid-lowering therapy, ultimatelyd aim- ing at >_50% LDL-C reduction and an LDL-C of <1.4 mmol/L (55 mg/dL) is recommended.21,22,522,540,541 | |
| p.55 | I | A | In patients with type 2 DM >40 years at high risk, lipid-lowering treatment with an ultimate LDL-C goal of >_50% LDL-C reduction and an LDL-C of <1.8 mmol/L (70 mg/dL) is recommended.540,541 | |
| p.55 | IIb | C | Statin therapy may be considered in persons aged <_40 years with type 1 or type 2 DM with evidence of TOD and/or an LDL-C level >2.6 mmol/L (100 mg/dL), as long as pregnancy is not being planned. | |
| p.55 | IIa | B | If the LDL-C goal is not reached, statin combination with ezetimibe should be considered.515,542 | |
| p.55 | I | A | The use of statins or statin/ezetimibe combina- tion is recommended in patients with non-dialysis-dependent, stage 35 CKD.525,544,545 | |
| p.55 | IIa | C | In patients already on statins, ezetimibe, or a sta- tin/ezetimibe combination at the time of dialysis initiation, continuation of these drugs should be considered, particularly in patients with ASCVD. | |
| p.55 | III | A | In patients with dialysis-dependent CKD who are free of ASCVD, commencing statin therapy is not recommended.546,547 | |
| p.56 | I | A | drug treatment is recommended.4,552 | |
| p.56 | I | A | be lowered to <80 mmHg.555,558,559 | |
| p.56 | I | A | people with high-normal BP or higher.c | |
| p.56 | III | A | The combination of two RAS blockers is not recommended.575,576 | |
| p.56 | I | C | Classification of BP It is recommended that BP should be classified as optimal, normal, high-normal, or grades 1 - 3 hypertension, according to office BP. Diagnosis of hypertension It is recommended to base the diagnosis of hypertension on: Repeated office BP measurements, on more than one visit, except when hypertension is severe (e.g. grade 3 and especially in high-risk I patients) | |
| p.56 | I | B | or Out-of-office BP measurement with ABPM and/ I or HBPM when feasible. Assessment of HMOD To evaluate for the presence of HMOD, measurement of serum creatinine, eGFR, electrolytes, and ACR is recommended for all patients. A 12- lead ECG is recommended for all patients, and echocardiography is recommended for those with ECG abnormalities or signs/symptoms of LV dysfunction. Fundoscopy or retinal imaging is recommended for patients with grades 2 or 3 hypertension and all hypertensive patients with | |
| p.56 | I | C | DM.548551 For grade 1 hypertension, treatment initiation based on absolute CVD risk, estimated lifetime benefit, and the presence of HMOD is recommended.552,553 For patients with grade 2 hypertension or higher, | |
| p.56 | I | A | Office BP treatment targets It is recommended that the first objective of treatment is to lower BP to <140/90 mmHg in all patients, and that subsequent BP targets are tailored to age and specific comorbidities.552,554 | |
| p.56 | I | A | In treated patients aged 1869 years, it is rec- ommended that SBP should ultimately be low- ered to a target range of 120 - 130 mmHg in most patients.552,554556 | |
| p.56 | I | A | In treated patients aged >_70 years, it is recom- mended that SBP should generally be targeted to <140 and down to 130 mmHg if tolerated.552,554,557 In all treated patients, DBP is recommended to Treatment of hypertension: lifestyle interventions Lifestyle interventions are recommended for | |
| p.56 | I | B | Treatment of hypertension: drug treatment It is recommended to initiate antihypertensive treatment with a two-drug combination in most patients, preferably as a single-pill combination. Exceptions are frail older patients and those with low-risk, grade 1 hypertension (particularly if SBP <150 mmHg).560565 | |
| p.56 | I | A | It is recommended that the preferred combina- tions include a RAS blocker (i.e. an ACE inhibitor or ARB) with a CCB or diuretic, but other combinations of the five major classes can be used (ACE inhibitor, ARB, beta-blocker, CCB, thia- zide/thiazide-like diuretic).566569 C | |
| p.56 | I | A | It is recommended, if BP remains uncontrolled with a two-drug combination, that treatment be increased to a three-drug combination, usually a RAS blocker with a CCB and a diuretic, prefera- C bly as a single-pill combination.563,570,571 | |
| p.56 | I | B | ............................................................................................................................................................................ It is recommended, if BP is not controlled by a three-drug combination, that treatment should be increased by the addition of spironolactone, or if not tolerated, other diuretics such as ami- loride or higher doses of other diuretics, an alpha-blocker or beta-blocker, or clonidine.555,572574 Management of CVD risk in hypertensive patients Statin therapy is recommended for many patients with hypertension.d Antiplatelet therapy is indicated for secondary prevention in patients with hypertension.e | |
| p.62 | IIa | A | 4.8 Diabetes mellitus Screening When screening for DM in individuals with or without ASCVD, assessment of HbA1c (which can be done non-fasting) or fasting blood glu- cose should be considered.583 | |
| p.62 | I | A | Lifestyle Lifestyle changes including smoking cessation, a low saturated fat, high-fibre diet, aerobic PA, and strength training are recommended.584 | |
| p.62 | I | B | Reduction in energy intake is recommended to patients, to help achieve lower body weight or prevent or slow weight gain.584 | |
| p.62 | IIa | A | For those motivated to try, considerable weight loss with use of low-calorie diets followed by food reintroduction and weight-maintenance phases early after diagnosis can lead to DM remission and should be considered.585,586 | |
| p.63 | IIa | B | weight gain should be considered.559,588,593 | |
| p.63 | I | A | Glycaemia targets A target HbA1c for the reduction of CVD risk and microvascular complications of DM of <7.0% (53 mmol/mol) is recommended for the majority of adults with either type 1 or type 2 DM.587,588 | |
| p.63 | IIa | B | For patients with a long duration of DM and in old or frail adults, a relaxing of the HbA1c tar- gets (i.e. less stringent) should be considered.588 | |
| p.63 | IIa | B | A target HbA1c of <_6.5% (48 mmol/mol) should be considered at diagnosis or early in the course of type 2 DM in persons who are not frail and do not have ASCVD.587,588 | |
| p.63 | I | B | Metformin is recommended as first-line therapy, following evaluation of renal function, in the majority of patients without previous ASCVD, CKD, or HF.589 | |
| p.63 | IIa | B | In persons with type 2 DM with ASCVD, metfor- min should be considered, unless contraindica- tions are present.5,590592 Avoidance of hypoglycaemia and excessive | |
| p.63 | I | A | In persons with type 2 DM and ASCVD, the use of a GLP-1RA or SGLT2 inhibitor with proven outcome benefits is recommended to reduce CV and/or cardiorenal outcomes.590592 | |
| p.63 | IIb | B | In patients with type 2 DM and TOD,c the use of an SGLT2 inhibitor or GLP-1RA with proven outcome benefits may be considered to reduce future CV and total mortality.594597 | |
| p.63 | I | A | In patients with type 2 DM and CKD, the use of an SGLT2 inhibitor is recommended to improve ASCVD and/or cardiorenal outcomes.598,599 | |
| p.63 | I | A | In patients with type 2 DM and HFrEF, use of an SGLT2 inhibitor with proven outcome benefits is recommended to lessen HF hospitalizations and CV death.600,601 | |
| p.63 | IIa | B | In patients with type 2 DM but without ASCVD, HF, or CKD, use of an SGLT2 inhibitor or GLP- 1RA should be considered based on estimated future risks (e.g. with the ADVANCE risk score or DIAL model) for adverse CVD or cardiorenal outcomes from risk factor profiles.602 | |
| p.64 | I | A | Aspirin 75 - 100 mg daily is recommended for secondary prevention of CVD.619 | |
| p.64 | I | B | 4.9 Antithrombotic therapy Clopidogrel 75 mg daily is recommended as an alternative to aspirin in secondary prevention in case of aspirin intolerance.620 | |
| p.64 | IIb | A | Clopidogrel 75 mg daily may be considered in preference to aspirin in patients with established ASCVD.620,621 | |
| p.64 | I | A | Concomitant use of a proton pump inhibitor is recommended in patients receiving antiplatelet therapy who are at high risk of gastrointestinal bleeding.622,623 | |
| p.65 | IIb | A | In patients with DM at high or very high CVD risk, low-dose aspirin may be considered for pri- mary prevention in the absence of clear contraindications.5,624,625 | |
| p.65 | III | A | Antiplatelet therapy is not recommended in indi- viduals with low/moderate CV risk due to the increased risk of major bleeding.624,626630 | |
| p.65 | IIb | A | ............................................................................................................ Low-dose colchicine (0.5 mg o.d.) may be consid- ered in secondary prevention of CVD, particularly if other risk factors are insufficiently controlled or if recurrent CVD events occur under optimal therapy.85,86 CVD = cardiovascular; o.d. = omni die (once a day). aClass of recommendation. bLevel of evidence. | |
| p.66 | I | A | Participation in a medically supervised, structured, comprehensive, multidisciplinary EBCR and prevention programme for patients after ASCVD events and/or revascularization, and for patients with HF (mainly HFrEF), is recom- mended to improve patient outcomes.638642 | |
| p.66 | IIa | B | Methods to increase CR and prevention referral and uptake should be considered (i.e. electronic prompts or automatic referrals, referral and liai- son visits, structured follow-up by nurses or health professionals, and early programme initia- tion after discharge).643646 | |
| p.66 | IIb | B | Home-based CR, telehealth, and mHealth inter- ventions may be considered to increase patient participation and long-term adherence to healthy behaviours.647,648 | |
| p.66 | I | C | .................................................................. Policies and population approaches to PA, diet, smoking and tobacco use, and alcohol in governmental restrictions and mandates, media and education, labelling and information, economic incentives, schools, worksites, and community settings follow different levels of recommenda- tions (see specific tables in the supplementary material for section 5). Putting in place measures to reduce air pollution, including reducing PM emission and gaseous pol- lutants, reducing the use of fossil fuels, and limiting carbon dioxide emissions, are recommended, to reduce CVD mortality and morbidity. | |
| p.68 | I | A | Aspirin 75 - 100 mg daily is recommended for patients with a previous myocardial infarction or revascularization.619 | |
| p.68 | IIb | C | Aspirin 75 - 100 mg daily may be considered in patients without a history of myocardial infarction or revascularization, but with definitive evi- dence of CAD on imaging.622 | |
| p.68 | I | A | In ACS, DAPT with a P2Y12 inhibitor in addition to aspirin is recommended for 12 months, unless there are contraindications such as excessive risk of bleeding.681683 | |
| p.68 | I | A | In patients with CCS, clopidogrel 75 mg daily is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type, unless a shorter duration (1 - 3 months) is indicated due to risk or occurrence of life-threatening bleeding.622 | |
| p.68 | IIa | A | Adding a second antithrombotic drug (a P2Y12 inhibitor or low-dose rivaroxaban) to aspirin for long-term secondary prevention should be con- sidered in patients with a high risk of ischaemic events and without high bleeding risk.83,622,687689 | |
| p.69 | I | A | LV dysfunction or systolic HF.622 | |
| p.69 | IIb | A | Adding a second antithrombotic drug to aspirin for long-term secondary prevention may be con- sidered in patients with a moderate risk of ischaemic events and without a high bleeding risk.83,622,687689 | |
| p.69 | I | A | ACE inhibitors (or ARB) are recommended if a patient has other conditions (e.g. HF, hyperten- sion, or DM).622 Beta-blockers are recommended in patients with | |
| p.69 | I | A | In patients with established ASCVD, oral lipid- lowering treatment with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >_50% reduction in LDL-C vs. baseline is recommended. | |
| p.69 | I | A | It is recommended that patients with HF are enrolled in a comprehensive CR programme to reduce the risk of HF hospitalization and death.c 691-694 | |
| p.69 | I | A | EBCR is recommended in stable symptomatic patients with HFrEF to reduce the risk of HF hospitalization.700,701 | |
| p.69 | I | A | It is recommended to screen patients with HF for both CV and non-CV comorbidities which, if present, should be treated, provided safe and effective interventions exist, not only to alleviate symptoms but also to improve prognosis.c | |
| p.69 | I | A | An ACE inhibitor is recommended, in addition to a beta-blocker and an MRA, for patients with symptomatic HFrEF to reduce the risk of HF hospitalization and death.702705 | |
| p.69 | I | A | A beta-blocker is recommended, in addition to an ACE inhibitor (or an ARNI) and an MRA, for patients with stable, symptomatic HFrEF to reduce the risk of HF hospitalization and death.711717 | |
| p.70 | I | A | An MRA is recommended for patients with HFrEF already treated with an ACE inhibitor (or an ARNI) and a beta-blocker, to reduce the risk of HF hospitalization and death.718,719 | |
| p.70 | I | B | Sacubitril/valsartan is recommended as a replacement for an ACE inhibitor to reduce the risk of HF hospitalization and death in patients with HFrEF.707,730 | |
| p.70 | I | B | An ARB is recommended to reduce the risk of HF hospitalization or CV death in symptomatic patients with HFrEF who are unable to tolerate an ACE inhibitor and/or ARNI (patients should also receive a beta-blocker and an MRA).706 | |
| p.70 | I | A | Dapagliflozin or empagliflozin are recom- mended, in addition to optimal treatment of an ACE inhibitor (or ARNI), a beta-blocker, and an MRA, for patients with HFrEF to reduce the risk of HF hospitalization and death.600,601,730 | |
| p.70 | IIb | B | Vericiguat may be considered in patients with symp- tomatic HFrEF who have experienced HF worsening despite treatment with an ACE inhibitor (or an ARNI), a beta-blocker, and an MRA, to reduce the risk of HF hospitalization or CV death.722 | |
| p.70 | I | C | Diuretics are recommended in patients with HFrEF with signs and/or symptoms of congestion to reduce the risk of HF hospitalization.723,724 | |
| p.70 | IIa | B | Ivabradine should be considered in symptomatic patients with LVEF <_35%, in sinus rhythm, and with a resting heart rate >_70 bpm despite treatment with an evidence-based dose of a beta-blocker (or maximum tolerated dose below that), an ACE inhibitor (or an ARNI), and an MRA, to reduce the risk of HF hospitalization or CV death.725 | |
| p.70 | IIa | C | Ivabradine should be considered in symptomatic patients with LVEF <_35%, in sinus rhythm, and with a resting heart rate >_70 b.p.m. who are unable to tolerate or have contraindications for a beta-blocker to reduce the risk of HF hospital- ization or CV death. Patients should also receive an ACE inhibitor (or ARNI) and an MRA.726 | |
| p.70 | IIa | B | Hydralazine and isosorbide dinitrate should be considered in self-identified black patients with LVEF <_35% or with LVEF <45% combined with a dilated LV in NYHA class IIIIV despite treat- ment with an ACE inhibitor (or ARNI), a beta- blocker, and an MRA, to reduce the risk of HF hospitalization and death.731 | |
| p.70 | IIb | B | Hydralazine and isosorbide dinitrate may be con- sidered in patients with symptomatic HFrEF who cannot tolerate ACE inhibitors, ARBs, or ARNIs (or if they are contraindicated), to reduce the risk of death.728 | |
| p.70 | IIb | B | ................................................ Digoxin may be considered in patients with symptomatic HFrEF in sinus rhythm despite treatment with an ACE inhibitor (or ARNI), a beta-blocker, and an MRA, to reduce the risk of hospitalizations (all-cause and HF).729 | |
| p.71 | I | B | patients with LEAD.29,781 | |
| p.71 | I | C | Antiplatelet therapy is recommended in patients with symptomatic LEAD.c | |
| p.71 | I | A | control is recommended.768 | |
| p.71 | I | A | In patients with a cerebrovascular event, improvement of lifestyle factors in addition to appropriate pharmacological management is recommended.732,733,741 | |
| p.71 | I | A | In patients with ischaemic stroke or TIA, prevention with antithrombotics is recommended; choice of antithrombotic depends on the mecha- nism of event. Use of an antiplatelet is recommended for patients with non-cardioembolic ischaemic stroke or TIA, and use of an anticoa- gulant is recommended in patients with cardioembolic ischaemic stroke or TIA.732,741 | |
| p.71 | I | A | In patients with non-cardioembolic ischaemic stroke or TIA, prevention with aspirin only, or dipyridamole plus aspirin, or clopidogrel alone is recommended.620,743745 | |
| p.71 | IIa | A | In patients with minor ischaemic strokec or TIA, DAPT with aspirin and clopidogrel or with aspirin and ticagrelor, for 3 weeks after the acute event should be considered.750,751,755 | |
| p.71 | I | A | In patients with stroke or TIA who have BP of 140/90 mmHg or higher, BP lowering is recommended.757,766 | |
| p.71 | I | C | Smoking cessation is recommended in all Healthy diet and PA are recommended for all patients with LEAD. | |
| p.71 | I | A | In patients with intermittent claudication: Supervised exercise training is recommended782784 | |
| p.71 | I | C | Non-supervised exercise training is recommended when supervised exercise training is not feasible or available. | |
| p.71 | I | A | .............................................................................................................. In patients with LEAD and hypertension, it is recommended to control BP at <140/90 mmHg.776,785,786 In patients with LEAD and DM, strict glycaemic | |
| p.71 | IIa | B | ACE inhibitors or ARBs should be considered as first-line therapy in patients with PAD and hypertension.d 575,787 | |
| p.71 | IIb | B | In patients with DM and chronic symptomatic LEAD without high bleeding risk, a combination of low-dose rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) may be considered.774 ESC 2021 | |
| p.72 | I | B | Treatment with an ACE inhibitor or an ARB is recommended in patients with DM, hypertension, and albuminuria. These medications should be titrated to the highest approved dose that is tolerated. | |
| p.72 | IIa | B | An SGLT2 inhibitor with proven outcome benefits should be considered for the prevention of renal deterioration and mortality in patients with CKD.599 | |
| p.72 | III | C | Combination treatment with ACE inhibitors and ARBs is not recommended. | |
| p.73 | I | B | Identification and management of risk factors and concomitant diseases are recommended to be an integral part of treatment.795 | |
| p.73 | I | B | Modification of unhealthy lifestyle and targeted therapy of intercurrent conditions is recom- mended to reduce AF burden and symptom severity.216,795802 | |
| p.73 | I | B | Attention to good BP control is recommended in AF patients with hypertension to reduce AF recurrences and risk of stroke and bleeding.800,801 | |
| p.73 | IIa | B | In obese patients with AF, weight loss together with management of other risk factors should be considered to reduce AF incidence, AF progression, AF recurrences, and symptoms.795797 | |
| p.73 | IIa | B | Advice and management to avoid alcohol excess should be considered for AF prevention and in AF patients considered for oral anticoagulant therapy.798,803,804 | |
| p.73 | IIa | C | PA should be considered to help prevent AF incidence or recurrence, with the exception of excessive endurance exercise, which may pro- mote AF.805812 | |
| p.73 | IIb | C | Optimal management of OSA may be considered to reduce AF incidence, AF progression, AF recurrences, and symptoms.813816 | |
| p.79 | I | C | An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended. | |
| p.80 | I | C | Screening for CV risk factors and optimization of the CV risk profile is recommended in patients on treatment for cancer. | |
| p.80 | I | C | It is recommended that all COPD patients be investigated for ASCVD and ASCVD risk factors. | |
| p.80 | I | A | A healthy diet is recommended as a cornerstone of CVD prevention in all individuals. | |
| p.80 | I | A | It is recommended to adopt a Mediterranean or similar diet to lower risk of CVD. | |
| p.80 | I | A | It is recommended to replace saturated with unsaturated fats to lower the risk of CVD. | |
| p.80 | I | A | It is recommended to reduce salt intake to lower BP and risk of CVD. | |
| p.80 | I | B | It is recommended to restrict alcohol consumption to a maximum of 100 g per week. | |
| p.80 | I | B | It is recommended to eat fish, preferably fatty, at least once a week and restrict (processed) meat. | |
| p.80 | III | B | In patients with HF and major depression, SSRIs, SNRIs, and tricyclic antidepressants are not recommended. | |
| p.80 | I | A | All smoking of tobacco should be stopped, as tobacco use is strongly and independently causal of ASCVD. | |
| p.80 | I | B | Smoking cessation is recommended regardless of weight gain, as weight gain does not lessen the ASCVD benefits of cessation. | |
| p.81 | I | B | If the goals are not achieved with the maximum tolerated dose of a statin, combination with ezetimibe is recommended. | |
| p.81 | I | A | Treatment with statins is recommended for older people with ASCVD in the same way as for younger patients. | |
| p.81 | I | A | The use of statins or statin/ezetimibe combination is recommended in patients with non-dialysis-dependent, stage 35 CKD. | |
| p.81 | III | A | In patients with dialysis-dependent CKD who are free of ASCVD, commencing statin therapy is not recommended. | |
| p.81 | I | C | • Out-of-office BP measurement with ABPM and/or HBPM when feasible. | |
| p.81 | I | A | For patients with grade 2 hypertension or higher, drug treatment is recommended. | |
| p.82 | I | A | In all treated patients, DBP is recommended to be lowered to <80 mmHg. | |
| p.82 | I | A | Lifestyle interventions are recommended for people with high-normal BP or higher. | |
| p.82 | III | A | The combination of two RAS blockers is not recommended. | |
| p.82 | I | A | Reduction in energy intake is recommended to patients, to help achieve lower body weight or prevent or slow weight gain. | |
| p.82 | I | A | Aspirin 75100 mg daily is recommended for secondary prevention of CVD. | |
| p.82 | I | B | Clopidogrel 75 mg daily is recommended as an alternative to aspirin in secondary prevention in case of aspirin intolerance. | |
| p.82 | III | A | Antiplatelet therapy is not recommended in individuals with low/moderate CV risk due to the increased risk of major bleeding. | |
| p.83 | I | A | Aspirin 75100 mg daily is recommended for patients with a previous myocardial infarction or revascularization. | |
| p.83 | I | A | ACE inhibitors (or ARB) are recommended if a patient has other conditions (e.g. HF, hypertension, or DM). | |
| p.83 | I | A | Beta-blockers are recommended in patients with LV dysfunction or systolic HF. | |
| p.83 | I | A | EBCR is recommended in stable symptomatic patients with HFrEF to reduce the risk of HF hospitalization. | |
| p.83 | I | A | In patients with stroke or TIA who have BP of 140/90 mmHg or higher, BP lowering is recommended. | |
| p.83 | I | B | Smoking cessation is recommended in all patients with LEAD. | |
| p.83 | I | C | Healthy diet and PA are recommended for all patients with LEAD. | |
| p.83 | I | A | In patients with intermittent claudication: • Supervised exercise training is recommended | |
| p.83 | I | C | • Non-supervised exercise training is recommended when supervised exercise training is not feasible or available. | |
| p.83 | I | C | Antiplatelet therapy is recommended in patients with symptomatic LEAD. | |
| p.83 | I | A | In patients with LEAD and hypertension, it is recommended to control BP at <140/90 mmHg. | |
| p.83 | I | A | In patients with LEAD and DM, strict glycaemic control is recommended. | |
| p.84 | III | C | Combination treatment with ACE inhibitors and ARBs is not recommended. |