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....................................................................................... are exposed to levels exceeding EU air-quality standards. The EU Commission released a policy package to be implemented by 2030, with measures to reduce harmful emissions from traffic, energy plants, and agriculture.

Indoor air pollution and exposure to noise must also be highlighted. Household air pollution, such as that produced from burning biomass, accounts for over 3 million deaths worldwide.38 It has been estimated by the WHO that 30% of the European population is exposed to nightly levels of noise exceeding 55 dB.161 These levels have been associated with hypertension, arteriosclerosis, CAD, CV mortality, and stroke. It should be noted that mitigating efforts to reduce noise exposure have not, as yet, proven to have a beneficial health effect.161 The extent to which environmental exposures in soil and water contribute to CVD has also been established.157 Interventions to reduce this pollution are required, including factory regulations and drinking water controls.157 Patient organizations and health professionals have an important role in supporting education and policy initiatives. Information on patients’ behaviour during smog peaks is needed. Economic incentives, such as reduced taxes on electric and hybrid cars, can contribute to the improvement of air quality as well as incentives encouraging the use of public transport. Urban design promoting the construction of new houses and schools in areas remote from highways and polluting industries needs to be urged. ‘Clean air’ legislation aimed at promoting decreased particle emissions, and promotion of public transport should also be encouraged. The urgency of accepting what might appear as ‘comfort sacrifices’ for distant health benefits, and the transitory high costs of reorganizing entire sections of industry, probably remain a major dilemma to the populationbased approach. An example of such legislation is the European Green Deal, by which the EU aims to be climate neutral by 2050.

5.3.1.Climate change Climate change resulting from the increasing use of fossil fuels, as a major source of both air pollution and ‘greenhouse’ gases, is becoming a major public health and environmental concern. Societal measures to reduce such fuels, and transfer towards renewable sources, are becoming urgent to reduce air pollution and climate change.676 The impact of diet, notably long-term non-sustainable meat-based food production chains, as well as the impact of sedentary lifestyles on climate-altering variables, will also need to be addressed by policy makers.

5.4 Implications for public health policy

and advocacy at the governmental and non-governmental level Please see the supplementary material section 3.5.

6 Risk management of disease-

specific cardiovascular disease

This section addresses CVD prevention in specific clinical contexts. A significant number of patients already have such comorbidities, which put them at additional risk. The general principles of lifestyle modification and treatment of major risk factors are outlined in section 4. In this section, only disease-specific aspects are added. 6.1.Coronary artery disease Disease-specific acute management of coronary syndromes is covered in detail in recent guidelines.677680

As for antithrombotic therapy, dual antiplatelet therapy (DAPT) for 12 months, preferably with prasugrel or ticagrelor, is the standard antithrombotic treatment after ACS.681683 There are conflicting data as to whether prasugrel is preferable to ticagrelor.684,685 A 6month duration of DAPT after ACS is generally too short,686 but may be considered in selected patients at high bleeding risk. In patients with chronic coronary syndromes (CCS) undergoing elective PCI, the standard duration of DAPT is 6 months, but shortening this to 1 - 3 months is an option when bleeding risk is very high.622 Clopidogrel is the P2Y12 inhibitor of choice, but prasugrel and ticagrelor may be considered after complex interventions.622 Prolonged DAPT (>12 months) following PCI for either ACS or CCS is an option for patients who tolerate DAPT well and have features of high ischaemic risk.687,688 In patients with stable CAD, dualpathway inhibition with low-dose rivaroxaban (2.5 mg b.i.d.) and aspirin improved CV outcomes at the price of more major bleeding events than aspirin alone.83 Based on the above, and in line with the CCS Guidelines,622 adding a second antithrombotic drug (P2Y12 inhibitor or low-dose rivaroxaban) to aspirin for long-term secondary prevention should be considered for patients who are at high ischaemic risk and do not have a high risk of bleeding. It may also be considered in patients who are at moderate ischaemic risk and without a high risk of bleeding, but the benefits are lower.622 More details on antithrombotic treatment options are found in the ESC Guidelines for CCS.622

Recommendations for patients with coronary artery disease

Recommendations Classa Levelb

Aspirin 75 - 100 mg daily is recommended for patients with a previous myocardial infarction or revascularization.619 I A Aspirin 75 - 100 mg daily may be considered in patients without a history of myocardial infarction or revascularization, but with definitive evidence of CAD on imaging.622 IIb C In ACS, DAPT with a P2Y12 inhibitor in addition to aspirin is recommended for 12 months, unless there are contraindications such as excessive risk of bleeding.681683 I A In patients with CCS, clopidogrel 75 mg daily is recommended, in addition to aspirin, for 6 months following coronary stenting, irrespective of stent type, unless a shorter duration (1 - 3 months) is indicated due to risk or occurrence of life-threatening bleeding.622 I A 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.83,622,687689 IIa A

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