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3.3.10.1 Which index of obesity is the best predictor of cardiovascular risk? BMI can be measured easily and is used extensively to define categories of body weight (see Supplementary Table 6). Body fat stored in visceral and other ectopic depots carries a higher risk than subcutaneous fat. Several measures of global and abdominal fat are available, of which waist circumference is the simplest to measure. The WHO thresholds for waist circumference are widely accepted in Europe. Two action levels are recommended:

• Waist circumference >_94 cm in men and >_80 cm in women: no further weight gain • Waist circumference >_102 cm in men and >_88 cm in women: weight reduction advised.

Different cut-offs for anthropometric measurements may be required in different ethnicities. The phenotype of ‘metabolically healthy obesity’, defined by the presence of obesity in the absence of metabolic risk factors, has gained interest. Long-term results support the notion that metabolically healthy obesity is a transient phase moving towards glucometabolic abnormalities rather than a specific ‘state’.170

3.3.10.2 Risk reclassification The associations between BMI, waist circumference, and waist-to-hip ratio and CVD are maintained after adjustment for conventional risk factors. However, these measures did not improve CVD risk prediction as assessed by reclassification.47

Recommendations for cardiovascular disease assessment in specific clinical conditions

Clinical condition Recommendations Classa Levelb

CKD In all CKD patients, with or without DM, appropriate screening for

ASCVD and kidney disease progression, including monitoring changes in albuminuria is recommended.172 I C

Cancer It is recommended to monitor cardiac dysfunction using imaging

techniques and circulating biomarkers before, periodically during, and after cancer treatment.173 I B Cardioprotection in high-risk patients (those receiving high cumulative doses or combined radiotherapy) receiving anthracycline chemotherapy may be considered for prevention of LV dysfunction.174,175 IIb B Screening for ASCVD risk factors and optimization of the CVD risk profile is recommended in patients on treatment for cancer. I C

Continued COPD It is recommended that all COPD

patients be investigated for ASCVD and ASCVD risk factors. I C

Inflammatory conditions Assessment of total CVD risk may be considered in adults with chronic

inflammatory conditions.176 IIb B Multiplication of calculated total CVD risk by a factor of 1.5 should be considered in adults with rheumatoid arthritis.177,178 IIa B

Migraine Presence of migraine with aura

should be considered in CVD risk assessment.179181 IIa B Avoidance of combined hormonal contraceptives may be considered in women with migraine with aura.182,183 IIb B

Sleep disorders and OSA In patients with ASCVD, obesity,

and hypertension, regular screening for non-restorative sleep is indicated (e.g. by the question: ‘how often have you been bothered by trouble falling or staying asleep, or sleeping too much?’). I C If there are significant sleep problems, which are not responding within 4 weeks to sleep hygiene, referral to a specialist is recommended. 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. I C

Sex-specific conditions In women with a history of pree-

clampsia and/or pregnancyinduced hypertension, periodic screening for hypertension and DM should be considered.184187 IIa B In women with a history of polycystic ovary syndrome or gestational DM, periodic screening for DM should be considered.188191 IIa B In women with a history of premature or stillbirth, periodic screening for hypertension and DM may be considered.192,193 IIb B Assessment of CVD risk should be considered in men with ED. IIa C

ASCVD = atherosclerotic cardiovascular disease; CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease; CV = cardiovascular; CVD = cardiovascular disease; DM = diabetes mellitus; ED = erectile dysfunction; LV = left ventricular; OSA = obstructive sleep apnoea. aClass of recommendation. bLevel of evidence. ESC 2021

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