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............................................................................................................................................................................. 5.1. Population-level approaches to the prevention of cardiovascular disease Population level approaches to CVD prevention centre around upstream measures requiring broad public-health interventions targeting lifestyle and promoting monitoring of CVD. These measures are designed to address populations and are intended to shift the population attributable risk. This is based on a prevention paradox described by Geoffrey Rose in 1981.665 The population attributable risk depends on the RR and on the prevalence of a risk factor in the general population. If the prevalence of a significant RR factor is low, then the population attributable risk may be modest. Conversely, if a low-impact RR factor is common, the population attributable risk may be high. This prevention approach following the Geoffrey Rose paradigm665,666 states that small shifts in the risk of disease across a whole population consistently lead to greater reductions in disease burden than does a large shift in high-risk individuals only.667,668 In other words, many people exposed to a small risk may generate more disease than a few exposed to a conspicuous risk. This population-wide approach—as opposed to strategies targeting highrisk individuals—has major advantages at the population level whilst sometimes having only a modest benefit at the individual level, because it addresses the CV health of a large number of individuals over the entire life course. It should be noted that high-risk and population-level prevention strategies are not mutually exclusive and must therefore coexist.

Prevalence of high-risk conditions and incidence rates of CVD vary across countries. Many of their underlying causes are known, and they are closely related to dietary habits, PA, smoking, alcohol, employment, social deprivation, and the environment. The objective of population approaches to prevention of CVD is to control the underlying determinants of CV health and, in this way, reduce population incidence rates. The population approach may bring numerous benefits, such as narrowing the gap in health inequalities, preventing other conditions such as cancer, pulmonary diseases, and type 2 DM, and saving costs from the avoided CV events and early retirement due to health problems. Individual behaviour is enacted in an environment with hierarchical levels, which encompass individual choice, family influence, cultural and ethnic grouping, workplace, healthcare, and policy at the regional, state and global levels (e.g. EU policies and international trade agreements). The aim of this section of the guidelines is to provide evidence-based suggestions for the most effective interventions to reduce CVD risk at the population level, improve CVD health, and promote healthy choices at the community, regional, and global level. Health challenges cannot be solved by the healthcare systems alone and require political support. To advance this cause, the WHO has been organizing Global Conferences on Health promotion since 1990.

5.2 Specific risk factor interventions at

the population level Population-level interventions aim to alter the societal environment, modify certain social determinants of health, and provide incentives to encourage changes in individual behaviour and exposure to risk factors. Social determinants of health include socioeconomic status (education, occupation, and income), wealth inequalities, neighbourhood and urban design, and social networks, to name but a few. Healthcare professionals play an important role in advocating evidence-based population-level interventions. By modifying the general context, one can induce healthy decisions as a default in entire populations (all age groups and particularly vulnerable ones). The task for both national and local authorities is to create social environments that provide healthier defaults, taking health literacy into account.669,670 The evidence presented here builds on recent comprehensive reviews and individual studies, noting that it is rarely feasible to use an RCT to evaluate population-level interventions (in contrast to individual-level interventions).671,672 The importance of heart disease in women has become apparent and sex differences in CVD prevention have prompted sex-specific awareness campaigns with the aim of reducing sex disparities in research and clinical care. While interpreting this section, it is important to recognize that there are often vested interests, which may influence policy decisions on health promotion.

The supplementary material for this section presents evidence for population-level strategies dealing with specific risk factor interventions for PA (section 5.2.1), diet (section 5.2.2), smoking and tobacco use (section 5.2.3), and alcohol consumption (section 5.2.4). Lifestyle changes at the population level take time, may be expensive, and need to be sustained over time. Furthermore, the benefits may be slow to manifest; however, they persist over the long term and improve health-related quality of life and well-being.

5.2.1. Physical activity Please see the supplementary material section 3.1.

5.2.2. Diet Please see the supplementary material section 3.2.

5.2.3. Smoking and tobacco use Please see the supplementary material section 3.3.

5.2.4. Alcohol Please see the supplementary material section 3.4.

5.3 Environment, air pollution, and

climate change Air pollution contributes to mortality and morbidity. It specifically increases the risk of respiratory and CV diseases, notably CAD, HF, cardiac arrhythmias and arrest, cerebrovascular disease, and venous thromboembolism.158,673,674 Loss of life-expectancy due to ambient air pollution has been estimated at 2.9 years, accounting for an estimated global excess mortality of 8.8 million/year.159 Plausible mechanisms by which air pollution is linked to CVD include promoting atherosclerosis, inflammation, thrombosis, systemic vascular dysfunction, myocardial fibrosis, epigenetic changes, and interactions with traditional risk factors.158 Important sources of fine particles are road traffic, power plants, and industrial and residential heating using oil, coal, and wood. Main components of outdoor air pollution include airborne PM (ranging in size from coarse particles 2.510 mm, fine particles <2.5 mm (PM2.5), and ultrafine particles <0.1 mm in diameter) and gaseous pollutants such as ozone, nitrogen dioxide, volatile organic compounds, carbon monoxide, and sulphur dioxide, produced primarily by fossil fuel combustion.158,675 Up to one-third of Europeans living in urban areas Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026