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4.1.2.1 Smoking and substance abuse

Smoking cessation in CCS patients improves prognosis, with a reported 36% risk reduction of premature death in those who quit compared with those who continue to smoke.447 Measures to promote smoking cessation include brief advice, counselling and behavioural interventions, and pharmacological therapy.448,449 Patients should also avoid passive smoking. Drug support to assist in smoking cessation should be considered in all smokers who are ready to undertake this action. Nicotinereplacement therapy, bupropion, or varenicline are effective,450,451 and are not linked to an increase in MACE.452 The use of electronic cigarettes (e-cigarettes), as an alternative to conventional cigarettes, should be discouraged because they are not harmfree.453 Newer devices deliver higher nicotine contents, and e-cigarettes emit other constituents, such as carbonyls, and fine and ultrafine particulates.454 Evidence from several studies indicates that acute inhalation of e-cigarettes leads to negative changes in vascular endothelial function.453,454 E-cigarettes should only be considered to aid tobacco cessation alongside a formal tobacco cessation programme.453,455,456 Various substances, including cocaine, opioids, and marihuana can have adverse effects on the cardiovascular system and have a potential for drug–drug interactions with cardiovascular medication.457–459 Single-question screening for unhealthy drug use has been validated in primary care and can identify individuals requiring counselling on adverse cardiovascular effects.460

4.1.2.2 Weight management

In a population-based study, lifetime risk of incident CVD, and cardiovascular morbidity and mortality, were higher in those who were overweight or obese compared with those with a normal BMI (18.5–24.9 kg/m2).461 Compared with normal BMI, among middle-aged men and women, competing hazard ratios (HR) for incident CVD were 1.21 [95% confidence interval (CI), 1.14–1.28] and 1.32 (95% CI, 1.24–1.40), respectively, for overweight (BMI of 25.0–29.9 kg/m2), 1.67 (95% CI, 1.55–1.79) and 1.85 (95% CI, 1.72–1.99) for obesity (BMI of 30.0–39.9 kg/m2), and 3.14 (95% CI, 2.48–3.97) and 2.53 (95% CI, 2.20–2.91) for morbid obesity (BMI of ≥40.0 kg/m2). Obesity was associated with a shorter overall lifespan, and being overweight was associated with developing CVD at an earlier age.461 In subjects with CAD, intentional weight loss is associated with a significantly lower risk of adverse clinical outcomes,462 and has beneficial effects on risk-factor control and QoL.463 Healthy diets with energy intake limited to the amount needed to obtain and maintain a healthy weight (BMI of 18.5–25 kg/m2), and combined with increasing physical activity, are recommended for weight management.16 If weight targets are not reached, pharmacological treatment with glucagon-like peptide-1 (GLP-1) receptor agonists may be considered for further weight reduction (Section 4.3.4). In patients without diabetes, the STEP8 trial showed a significant reduction in weight after 68 weeks with either semaglutide (mean weight change of −15.8%; 95% CI, −17.6% to −13.9%) or liraglutide (mean weight change of −6.4%; 95% CI, −8.2% to −4.6%) compared with placebo (−1.9%; 95% CI, −4.0% to 0.2%).464 The double-blind, placebocontrolled Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity (SELECT) trial showed a significant reduction in the incidence of cardiovascular death, MI, or stroke (HR 0.80; 95% CI, 0.72–0.90) in patients with pre-existing CVD who were overweight or obese, but without diabetes, treated with weekly subcutaneous semaglutide.465 The SURMOUNT-1 (Efficacy and Safety of Tirzepatide Once Weekly in Participants Without Type 2 Diabetes Who Have Obesity or Are Overweight With Weight- Related Comorbidities: A Randomized, Double-Blind, Placebo-Controlled Trial) trial showed a dose-dependent weight-loss benefit (mean weight change of up to −20.9%; 95% CI, −21.8% to −19.9%) with tirzepatide, a combined glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonist, compared with placebo in obese adults without diabetes over 72 weeks,466 a dose effect that was confirmed in the SURMOUNT-2 trial.467 Bariatric surgery in severe obesity appears to be a safe and effective intervention for further weight loss in CCS patients.468

Cardiac rehabilitation programmes should include weight-loss interventions to reach a healthy weight as a specific component. The incremental value of telehealth interventions and pharmacological interventions need full consideration in secondary prevention.469

4.1.2.3 Diet and alcohol

Dietary habits influence cardiovascular risk, mainly through risk factors such as lipids, BP, body weight, and DM. It is recommended to adopt a Mediterranean or similar diet to lower the risk of CVD, as described in the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.16 If alcohol is consumed, it should be limited to <100 g/week or 15 g/day, since alcohol intake of >100 g/week is associated with higher all-cause and other CVD mortality in large individual-data meta-analyses.470 A recent genetic analysis showed that the causal association between light-to-moderate levels of alcohol intake and lower cardiovascular risk is possibly mediated by confounding lifestyle factors, therefore questioning the previously observed cardioprotective role of light alcohol use.471

4.1.2.4 Mental health

Psychosocial stress, depression, and anxiety are associated with worse cardiovascular outcomes, and make it difficult for patients to make positive changes to their lifestyles or adhere to a therapeutic regimen. Therefore, assessment for psychosocial risk factors is recommended in secondary prevention.16 Clinical trials have shown that psychological (e.g. counselling and/or cognitive behavioural therapy) and pharmacological interventions have a beneficial effect on depression, anxiety, and stress, with some evidence of a reduction in cardiac mortality and events compared with placebo (see Section 6.1.2).472

4.1.2.5 Physical activity and sedentary behaviour

Physical activity reduces the risk of many adverse health outcomes and risk factors in all ages and both sexes. There is an inverse relationship between moderate-to-vigorous physical activity and all-cause mortality, cardiovascular mortality, and atherosclerotic cardiovascular disease (ASCVD).473 The reduction in risk continues across the full range of physical activity volumes, and the slope of risk decline is steepest for the least active individuals.474 Adults are recommended to perform at least 150–300 min per week of moderate-intensity physical activity, or 75–150 min of vigorous-intensity physical activity, or an equivalent combination of both, spread throughout the week.473 Additional benefits are gained with even more physical activity.475 Practising physical activity should still be encouraged in individuals unable to meet the minimum. In sedentary individuals, a gradual increase in activity level is recommended.476 Physical activity can be incorporated flexibly, either daily or limited to specific days. Activity patterns limited to 1–2 sessions per week but meeting recommended levels of physical activity have been shown to reduce all-cause mortality (HR 0.66; 95% CI, 0.62– 0.72), CVD mortality (HR 0.60; 95% CI, 0.52–0.69), and cancer mortality (HR 0.83; 95% CI, 0.73–0.94) when compared with inactive participants.477 Physical activity accumulated in bouts of even <10 min is associated with favourable outcomes, including mortality.478 High levels of time spent sedentary is associated with an increased risk for several major chronic diseases and mortality.479 For physically Downloaded from academic.oup.com/eurheartj/article/45/36/3415/7743115 by guest on 07 October 2026