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............................................................................................................................................................................. estimated after initial lifestyle changes and risk factor treatment, and is mostly used in patients with established ASCVD. For younger apparently healthy subjects, lifetime CVD risk estimates are available to support treatment decisions, replacing 10-year risk algorithms that consistently estimate low 10-year risk even in the presence of high risk factor levels. In an ageing population, treatment decisions require a specific CVD risk score that takes competing non-CVD risk into account, as well as specific low-density lipoprotein cholesterol (LDL- C) and blood pressure (BP) treatment considerations. Estimating lifetime benefit in individual patients of smoking cessation, LDL-C lowering, and BP lowering provides opportunities to communicate benefit of treatment in an easy-to-understand way. Personalized treatment decisions using CVD risk estimations and a stepwise approach to treatment is more complex than a more general onesize-fits-all prevention strategy, but reflects the diversity in patients and patient characteristics in clinical practice.

Regarding LDL-C, BP, and glycaemic control in patients with DM, goals and targets remain as recommended in recent European Society of Cardiology (ESC) Guidelines.35 These prevention guidelines propose a new, stepwise approach to treatment intensification as a tool to help physicians and patients pursue these targets in a way that fits patient profile and preferences. Of note, however, new evidence and/or new consensus may have resulted in some differences with these recent domain-specific ESC Guidelines. New evidence on antithrombotic treatment regimens for ASCVD prevention is also presented. Sex-specific aspects are included. ASCVD prevention needs an integrated, interdisciplinary approach including input from several disciplines and areas of expertise. We must work together in a patient- and family-centred way to address each of the core components of prevention and rehabilitation, including lifestyle modification, psychosocial factors, risk factor treatment, and social determinants (Central Illustration).

2.2 Development

The Task Force chairs and members were appointed by the ESC Clinical Practice Guidelines Committee (CPG). Each member of the Task Force was assigned specific writing tasks, which were reviewed by other (sub)section writers, the section coordinators, and the chairs. The text was developed over 11 months, during which the Task Force members met collectively on three occasions and corresponded intensively between meetings. The review panel consisted of experts selected by all the scientific societies that were involved in the development of these guidelines, not only the ESC.

2.3 Cost-effectiveness

The Task Force acknowledge the fact that healthcare budgets are, in many circumstances, limited and thus that certain recommendations and goals may not always be attainable. However, the current guidelines do not provide cost-effectiveness analyses. Large national and regional differences in budgets and costs associated with both interventions and diseases/events preclude valid universal costeffectiveness analyses. However, some recommendations clearly have financial implications, either in terms of costs for individual patients and/or in terms of budget impact. Some of these recommendations pertain to diagnosis (e.g. large-scale use of expensive imaging tests such as computed tomography), others to interventions (e.g. expensive drugs, such as novel lipid-lowering or anti-diabetic drugs). For such recommendations, it is inappropriate to ‘unconditionally’ implement them without first considering cost-effectiveness in a national or regional context or, ideally, to perform formal costeffectiveness analyses with country-specific input parameters and cost-effectiveness thresholds.

2.4 What is new?

New recommendations, and new and revised concepts, are presented in Table 3.

3 Risk factors and clinical

conditions

3.1 Target population for assessing

cardiovascular disease risk CVD risk assessment or screening can be done opportunistically or systematically. Opportunistic screening, which means screening without a predefined strategy, is done when a person presents for some other reason. Systematic screening can be done in the general population as part of a formal screening programme, with call and recall of patients, or in targeted subpopulations such as subjects with type 2 DM, or family history of premature CVD. Systematic screening results in improvements in risk factors, but has no effect on CVD outcomes.69 Opportunistic screening for ASCVD risk factors, such as BP or lipids, is effective at increasing detection rates and is recommended, although a beneficial effect on clinical outcome is uncertain.10 Structured national programmes aiming to identify undocumented ASCVD risk factors in adults over 40 years of age without DM or ASCVD and treat them have shown better risk factor control, but there are conflicting results as to clinical outcomes.11,12 A high-risk strategy of inviting the population predicted to be at the highest risk according to an integrated risk score would be equally effective at preventing new cases of CVD and have potential cost savings.13 One large trial of mobile ultrasound screening for aortic aneurysm, peripheral artery disease (PAD), and hypertension in males aged 6574 years showed a 7% mortality reduction at 5 years.14 A common criticism of screening in general is the potential that false positive and false negative results may cause harm. However, evidence on CVD screening shows that those who participate do not report mental distress.1518 Systematic CVD risk assessment assessment in the general population (adult men >40 and women >50 years of age) with no known CV risk factors appears not cost-effective in reducing subsequent vascular events and premature death, at least in short-term follow-up, but does increase detection of CV risk factors. Risk assessment is not a one-time event; it should be repeated, for example, every 5 years, although there are no empirical data to guide intervals.

3.2 Risk factors and risk classification

3.2.1. Risk factors The main causal and modifiable ASCVD risk factors are blood apolipoprotein-B-containing lipoproteins [of which low-density lipoprotein (LDL) is most abundant], high BP, cigarette smoking, and DM. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026