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................................................................................... sometimes at the expense of side-effects. Meta-analysis of medication-assisted weight loss found favourable effects on BP, glycaemic control, and ASCVD mortality.464

A very effective treatment option for extreme obesity or obesity with comorbidities is bariatric surgery. A meta-analysis indicated that patients undergoing bariatric surgery had over 50% lower risks of total, ASCVD, and cancer mortality compared with people of similar weight who did not have surgery.455

4.4 Mental healthcare and psychosocial

interventions

Treatment of an unhealthy lifestyle will reduce CVD risk as well as improve mental health. Smoking cessation, for instance, has a positive effect on depression outcomes,474,475 as do exercise therapy113,476 and healthy dietary practices.477 Evidence-based interventions for smoking cessation, and improving PA and diet, are considered useful and applicable for persons with mental disorders.465,478480 Mental disorders are associated with an increased risk of CVD and a worse prognosis in patients with ASCVD, due to CVD events or other death causes, including suicide.100,113,305 Mental-health treatments effectively reduce stress symptoms and improve quality of life. Several observational studies indicate that treatment or remission of depression reduces CVD risk.113,481484 Psychological interventions in patients with CHD may reduce cardiac mortality (RR 0.79) and alleviate psychological symptoms.466 Psychotherapy focusing on stress management in ASCVD patients improves CVD outcomes. In SUPRIM (Secondary Prevention in Uppsala Primary Health Care project), patients in the intervention group had a 41% lower rate of fatal and non-fatal first recurrent ASCVD events [hazard ratio (HR 0.59)] and fewer recurrent AMIs (HR 0.55).467 In SWITCHD (Stockholm Women’s Intervention Trial for Coronary Heart Disease), the intervention yielded a substantial reduction in all-cause mortality (OR 0.33).468 A recent RCT reported that cardiac rehabilitation (CR) enhanced by stress management produced significant reductions in ASCVD events compared with standard CR alone (HR 0.49).469 Concerning psychopharmacotherapy of patients with CHD and depression, selective serotonin reuptake inhibitor (SSRI) treatment lowers rates of CHD readmission (risk ratio 0.63) and all-cause mortality (risk ratio 0.56).470 A recent RCT reported that, in patients with ACS and depression, treatment with the SSRI, escitalopram, resulted in a lower rate of the composite endpoint of all-cause mortality, myocardial infarction, or percutaneous coronary intervention (PCI) (HR 0.69).471 Collaborative care for patients with CHD and depression has small beneficial effects on depression, but significantly reduces short-term major cardiac events.485

Concerning side-effects of psychopharmacological treatments, many psychiatric drugs are associated with an increased risk of sudden cardiac death.486 In patients with HF, antidepressants are associated with increased risk of cardiac and all-cause mortality (HR 1.27; for details see supplementary material for section 4.4).472 Therefore, ASCVD patients with complex mental disorders, and particularly those needing psychiatric drug treatment, require interdisciplinary cooperation.

4.5 Smoking intervention

4.5.1. Smoking cessation Stopping smoking is potentially the most effective of all preventive measures, with substantial reductions in (repeat) myocardial infarctions or death.487,488 Lifetime gains in CVD-free years are substantial at all ages, and benefits are obviously even more substantial if other complications from smoking would be accounted for. From age 45 years, gains of 3 - 5 years persist in men to age 65 and in women to age 75 years (Figure 11). Even in heavy smokers (>_20 cigarettes/day), cessation lowers CVD risk within 5 years, although it remains elevated beyond 5 years. Total health benefits will be even larger because of gain in non-CVD health.

Recommendations for mental healthcare and psychosocial interventions at the individual level

Recommendations Classa Levelb

Patients with mental disorders need intensified attention and support to improve adherence to lifestyle changes and drug treatment.3,465 I C In ASCVD patients with mental disorders, evidence-based mental healthcare and interdisciplinary cooperation are recommended.100,113,466 I B ASCVD patients with stress should be considered for referral to psychotherapeutic stress management to improve CV outcomes and reduce stress symptoms.467469 IIa B Patients with CHD and moderate-to-severe major depression should be considered for antidepressive treatment with an SSRI.470,471 IIa B In patients with HF and major depression, SSRIs, SNRIs, and tricyclic antidepressants are not recommended.472,473 c III B

ASCVD = atherosclerotic cardiovascular disease; CHD = coronary heart disease; CV = cardiovascular; HF = heart failure; SNRI = serotonin-noradrenaline reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. aClass of recommendation. bLevel of evidence. cDetails explaining this recommendation are provided in the supplementary material section 2.1. ESC 2021 Recommendations for smoking intervention strategies

Recommendations Classa Levelb

All smoking of tobacco should be stopped, as tobacco use is strongly and independently causal of ASCVD.487,488 I A In smokers, offering follow-up support, nicotine replacement therapy, varenicline, and bupropion individually or in combination should be considered.489494 IIa A Smoking cessation is recommended regardless of weight gain, as weight gain does not lessen the ASCVD benefits of cessation.495 I B

ASCVD = atherosclerotic cardiovascular disease. aClass of recommendation. bLevel of evidence. ESC 2021

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