Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

Figures & data

Table 1. Recommendations for cardiovascular risk assessment.

Recommendations	Class of recommendation	Level of evidence
Systematic CV risk assessment is recommended in individuals at increased CV risk, i.e. with family history of premature CVD, familial hyperlipidaemia, major CV risk factors (such as smoking, high BP, DM or raised lipid levels) or comorbidities increasing CV risk.	I	C
It is recommended to repeat CV risk assessment every five years, and more often for individuals with risks close to thresholds mandating treatment.	I	C
Systematic CV risk assessment may be considered in men >40 years of age and in women >50 years of age or post-menopausal with no known CV risk factors	IIb	C
Systematic CV risk assessment in men <40 of age and women <50 years of age with no known CV risk factors is not recommended.	III	C

BP: blood pressure; CV: cardiovascular; CVD: cardiovascular disease; DM: diabetes mellitus.

Table 2. Recommendation for how to estimate cardiovascular risk.

Recommendations	Class of recommendation	Level of evidence
Total CV risk estimation, using a risk estimation system such as SCORE, is recommended for adults >40 years of age, unless they are automatically categorized as being at high-risk or very high-risk based on documented CVD, DM (>40 years of age), kidney disease or highly elevated single risk factor	I	C

CV: cardiovascular; CVD: cardiovascular disease; DM: diabetes mellitus; SCORE: systematic coronary risk estimation.

Table 3. Risk categories.

Very high-risk Subjects with any conditions in the right column.	•Documented CVD, clinical or unequivocal on imaging. Documented clinical CVD includes previous AMI, ACS, coronary revascularization and other arterial revascularization procedures, stroke and TIA, aortic aneurysm and PAD. Unequivocally documented CVD on imaging includes plaque on coronary angiography or carotid ultrasound. •DM with target organ damage such as proteinuria or with a major risk factor such as smoking or marked hypercholesterolaemia or marked hypertension. •Severe CKD (GFR <30 ml/min/1.73 m^2). •A calculated SCORE ≥10%.
High-risk Subjects with any conditions in the right column.	•Markedly elevated single risk factors, in particular cholesterol >8 mmol/l (>310 mg/dl) (e.g. in familial hypercholesterolaemia) or BP ≥180/110 mmHg. •Most other people with DM (with the exception of young people with type 1 DM and without major risk factors that may be at low or moderate risk). •Moderate CKD (GFR 30–59 ml/min/1.73m^2). •A calculated SCORE ≥5% and <10%
Moderate risk	SCORE is ≥1% and <5% at 10 years.
Low risk	SCORE <1%

BP: blood pressure; CVD: cardiovascular disease; DM: diabetes mellitus; SCORE: systematic coronary risk estimation; ACS: acute coronary syndrome; AMI: acute myocardial infarction; CKD: chronic kidney disease; GFR: glomerular filtration rate; PAD: peripheral artery disease; TIA: transient ischaemic attack.

Table 4. Examples of risk modifiers that are likely to have reclassification potential.

Socio-economic status, social isolation, or lack of social support.

Family history of premature CVD.

BMI and central obesity.

CT coronary calcium score.

Atherosclerotic plaques determined by carotid artery scanning.

ABI

CVD: cardiovascular disease; BMI: body mass index; CT: computed tomography; ABI: ankle–brachial blood pressure index.

Table 5. Drugs to be preferred in specific conditions.

Condition	Drug
Asymptomatic organ damage
LVH	ACE-I, calcium antagonist, ARB.
Asymptomatic atherosclerosis	ACE-I, calcium antagonist.
Microalbuminuria	ACE-I, ARB.
Renal dysfunction	ACE-I, ARB.
Clinical CV event
Previous stroke	Any agent effectively lowering BP.
Previous MI	β-blockers, ACE-I, ARB.
Angina pectoris	β-blockers, calcium antagonist.
Heart failure	Diuretic, β-blockers, ACE-I, ARB, mineralocorticoid receptor antagonist.
Aortic aneurism	β-blockers.
AF: prevention	Consider ARB, ACE-I, β-blockers or mineralocorticoid receptor antagonist.
AF: rate control	β-blockers and no-dydropyridine calcium antagonist.
ESRD/proteinuria	ACE-I, ARB.
PAD	ACE-I, calcium antagonist.
Other condition
ISH (elderly)	Diuretic, calcium antagonist.
DM	ACE-I, ARB.
Pregnancy	Methyldopa, β-blockers, calcium antagonist.
Black people	Diuretic, calcium antagonist.

BP: blood pressure; CV: cardiovascular; DM: diabetes mellitus; PAD: peripheral artery disease; ACE-I: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; AF: atrial fibrillation; ISH: isolated systolic hypertension; LVH: left ventricular hypertrophy; MI: myocardial infarction.