Professional Documents
Culture Documents
Prevention
Fourth Joint European
Societies Task Force on
cardiovascular disease
prevention in clinical
practice
September 2007
1
1994
1995-96
EUROASPIRE I
1998
1999-2000
EUROASPIRE II
2000
2003
2007
The partners
ESC
EAS
ESH
ESGP/FM
ISBM
Risk evaluation
SCORE
EHN
Report to
Third Joint Task Force
on CVD Prevention
Advice
from
Audit
EUROASPIRE
EASD
IDFEurope
ESC
Committee on
practical guidelines
and policy
conference
Joint Cardiovascular
Prevention Committee
MEMBERS
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ESC STAFF
Marie-Therese Cooney
Alexandra Dudina
Tony Fitzgerald
Edmond Walma
Keith McGregor
Veronica Dean
Catherine Despres
Sophie Squarta
CONTENTS
1. Introduction
2. Scope of the problem;
past and future
3. Prevention strategies
and policy issues
4. How to evaluate
scientific evidence
5. Priorities total risk
estimation and
objectives
6. Behaviour change and
behavioural risk factors
7. Smoking
8. Nutrition, overweight
and obesity
9. Physical activity
10. Blood pressure
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CVD Prevention:
CHALLENGES
z Inactivity
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Obesity
Stroke
Heart failure
Renal failure
Implementation
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3. PREVENTION
STRATEGIES AND
POLICY ISSUES
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Fig. 1 - The expected number of CVD deaths at increasing levels of predicted risk.
Illustration of the fact that most events occur in low risk subjects with few deaths
among high risk subjects.
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60
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9 10 11 12 13 14 15 16 17 18 19
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4. HOW TO EVALUATE
SCIENTIFIC EVIDENCE
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Validity
Reproducibility
Reliability
Representative development
Clinical applicability
Clinical flexibility
Clarity
Meticulous documentation
Scheduled review
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ESC classification of
evidence. Is it appropriate?
Classes of recommendations:
I
II
IIa
IIb
III
Levels of evidence:
A
B
C
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0 3 5 140 5 3 0
moderate activity
2.
2.
No smoking;
Healthy food choices;
Physical activity: 30 min of moderate activity a day;
BMI <25 kg/m2 and avoidance of central obesity;
BP <140/90 mmHg;
Total cholesterol <5 mmol/L (~190 mg/dL);
LDL cholesterol <3 mmol/L (~115 mg/dL);
Blood glucose <6mmo/L (~110 mg/dL).
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4.
When do I assess
cardiovascular risk?
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Fig 2
The relationship of total cholesterol / HDL cholesterol ratio to 10 year fatal
CVD events in men and women aged 60 yrs with and without risk factors,
based on a risk function derived from the SCORE project.
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Men, smoking,
SBP=160 mmHg
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Men, non-smoking,
SBP=120 mmHg
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15
Women, smoking,
SBP=160 mmHg
10
TC/HDL ratio
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Table 1
AGE
60
60
60
60
CHOL
BP
SMOKE RISK %
120
NO
140
YES
160
NO
180
YES
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35
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Established
CVD
Markedly
elevated single
risk factor
SCORE risk 5%
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Lifestyle recommendations
No smoking
Healthy diet
Lifestyle advice
to maintain low risk
status
Re-assess total
risk at regular
intervals
Drug treatment
More likely as SCORE risk exceeds 5% and especially as it approaches 10%, or
if there is end-organ damage. In the elderly, drug treatment is generally not
recommended below 10% risk unless a specific indication exists
Consider BP-lowering drugs when BP 140/90
Consider statins when total cholesterol 5 or LDL 3
In patients with CVD: Aspirin. Statins for most
In patients with diabetes: consider glucose-lowering drugs
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7. SMOKING
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Normal
<130/85
High Normal
130139/
8589
Grade 1
140159/
9099
Grade 2
160179/
100109
Grade 3
Low
<1%
Lifestyle
advice
Lifestyle
advice
Lifestyle
advice
Drug Rx
if persists
Drug Rx
Moderate
14%
Lifestyle
advice
Lifestyle
advice
+consider
drug Rx
Drug Rx
if persists
Drug Rx
Increased
5-9%
Lifestyle
advice
+consider
drug Rx
Drug Rx
Drug Rx
Drug Rx
Markedly
increased
10%
Lifestyle
advice
+consider
drug Rx
Drug Rx
Drug Rx
Drug Rx
180/110
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JTF4 Lipids
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In ALL cases, look for and manage all risk factors. Those with established CVD, diabetes
type 2 or type 1 with microalbuminuria, or with severe hyperlipidaemia are already at high
risk. For all other people, the SCORE charts can be used to estimate total risk
Established
CVD
Diabetes as
above
Markedly
raised lipid
levels
SCORE risk 5%
SCORE risk
still 5%
TC <5 mmol/l
and LDL-C <3
mmol/l and
SCORE now
<5%
Treatment goals are not defined for HDL cholesterol and triglycerides, but
HDL-C <1.0 mmol/L (~40 mg/dL) for men and <1.2 mmol/L (~45 mg/dL)
for women and fasting triglycerides of >1.7 mmol/L (~150 mg/dL) are
markers of increased cardiovascular risk
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Lifestyle
advice to
reduce
total chol
<5
mmol/L
(~190
mg/dL)
and LDL-C
<3
mmol/L
(~115
mg/dL)
Regular
follow-up
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Target
HbA1c (DCCTaligned)
HbA1c (%)
6.5 if feasible
Plasma glucose
Fasting/pre-prandial
mmol/L (mg/dL)
Post-prandial
mmol/L (mg/dL)
Blood pressure
mmHg
130/80
Total cholesterol
mmol/L (mg/dL)
mmol/L (mg/dL)
<4.5 (175)
<4.0 (155) if feasible
LDL cholesterol
mmol/L (mg/dL)
mmol/L (mg/dL)
<2.5 (100)
<2.0 (80) if feasible
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Genetic factors
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CVD in women:
Management implications I
1.
CVD in women:
Management implications II
3. The principles of total risk estimation
and management are the same for
both sexes. In women, emphasise the
evaluation of smoking, weight,
glucose tolerance and oral
contraceptive use.
4. A low absolute risk in a younger
woman may conceal a very high
relative risk. Detailed lifestyle advice
may prevent this from changing into a
high absolute risk in later life.
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19. CARDIOPROTECTIVE
DRUG THERAPY
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Sufficient time.
Implementation strategies:
European level
1.
2. Presentations at international
conferences of the participating
societies.
3. Directly influencing EU health policy
- for example through the
Luxembourg Declaration and the
European Health Charter.
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Implementation strategies:
National level
z Veronica
Dean
z Catherine Despres
z Marie-Therese Cooney
z Alexandra Dudina
z Sophie Squarta
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