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Table 3 Continued

New or revised Recommendations in 2013 version Class Recommendations in 2021 version Class Policy interventions at the population level  section 5 New Putting in place measures to reduce air pollution, including reduc-

ing PM emission and gaseous pollutants, reducing the use of fossil fuels, and limiting carbon dioxide emissions, are recommended to reduce CVD mortality and morbidity. I

Risk management of disease-specific cardiovascular disease  section 6 New It is recommended that patients with HF are enrolled in a com-

prehensive CR programme to reduce the risk of HF hospitalization and death. I

New 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. I

New In patients with a cerebrovascular event, improvement of lifestyle

factors in addition to appropriate pharmacological management is recommended. I

New Identification and management of risk factors and concomitant

diseases are recommended to be an integral part of treatment in patients with AF. I

New Adding a second antithrombotic drug (a P2Y12 inhibitor or low-

dose rivaroxaban) to aspirin for long-term secondary prevention should be considered in patients with a high risk of ischaemic events and without high bleeding risk. IIa

New 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. IIb Adding a second antithrombotic drug to aspirin for long-term secondary prevention may be considered in patients with a moderate risk of ischaemic events and without a high bleeding risk. IIb

Risk factors and clinical conditions  section 3 Revised ABI may be considered as a risk modifier in

CVD risk assessment. IIb 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. III

Risk factors and interventions at the individual level  section 4 Revised Drug treatment should be considered in

patients with grade 1 or 2 hypertension who are at high CVD risk. IIa For grade 1 hypertension, treatment initiation based on absolute

CVD risk, estimated lifetime benefit, and the presence of HMOD is recommended. I

Revised In patients with type 2 DM and CVD, use

of an SGLT2 inhibitor should be considered early in the course of the disease to reduce CVD and total mortality. IIa 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. I

ABI = ankle brachial index; AF = atrial fibrillation; ASCVD = atherosclerotic cardiovascular disease; b.i.d. = bis in die (twice a day); BP = blood pressure; CAC = coronary artery calcium; CHD = coronary heart disease; CKD = chronic kidney disease; CR = cardiac rehabilitation; CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; EBCR = exercise-based cardiac rehabilitation; ED = erectile dysfunction; FH = familial hypercholesterolaemia; GLP-1RA = glucagon-like peptide-1 receptor agonist; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HMOD = hypertension-mediated organ damage; LDL-C = low-density lipoprotein cholesterol; LEAD = lower extremity artery disease; mHealth = mobile device-based healthcare; o.d. = omni die (once a day); PA = physical activity; PCSK9 = proprotein convertase subtilisin/kexin type 9; PM = particulate matter; PUFA = polyunsaturated fatty acid; SBP = systolic blood pressure; SCORE2 = Systematic Coronary Risk Estimation 2; SCORE2-OP = Systematic Coronary Risk Estimation 2-Older Persons; SGLT2 = sodium-glucose cotransporter 2; SNRI = serotonin-noradrenaline reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; TOD = target organ damage. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026