1. EU Heart Group Brussels 2 October 2007 Fourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical practice Ian Graham, IRL Chairman JTF4 For the European Society of Cardiology

2. EU Heart Group Brussels 2 October 2007 Fourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical practice The product of a partnership between the major players in cardiovascular disease prevention in Europe that is fully compatible with the European Heart Health Charter

4. Recent developments in CVD prevention in Europe 1994First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention 1995-96 EUROASPIRE I 1998Second Joint Task Force Recommendations 1999-2000EUROASPIRE II 2000Joint European Societies CVD Prevention Committee 2003 Third Joint Task Force Recommendations 2007 Fourth JointTask Force Recommendations

5. 4 th Joint Task Force on Prevention: MEMBERS Dan Atar [ESC] Knut Borch-Johnson [EASD/IDF Europe] Gudrun Boysen [EUSI] Gunilla Burrell [ISBM] Renata Cifkova [ESH] Jean Dallongeville Guy de Backer [ESC] Shah Ebrahim [ESC] Bjorn Gjelsvik [ESGP/FM/Wonca] Christoff Hermann-Lingen [ISBM] Arno W Hoes [ESGP/FM/Wonca] Steve Humpries [ESC] Mike Knapton [EHN] Joep Perk [EACPR] Sylvia G Priori [ESC] Kalevi Pyorala [ESC] Zeljko Reiner [EAS] Luis Ruilope [ESC] Susana Sans-Mendes [ESC] Wilma Scholte Op Reimer [ESC council on CV Nursing] Peter Weissberg [EHN] David Wood [ESC] John Yarnell [EACPR] Jose Luis Zamorano [ESC/CPG]

6. JTF4 on CVD PREVENTION 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 11. Plasma lipids 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drug therapy 20. Implementation strategies

7. What’s new in the Fourth Joint Task Force Guidelines on the Prevention of CVD? Increased input from general practice and cardiovascular nursing Increased emphasis on exercise, weight, and lifestyle More detailed discussion on the limitations of present systems of grading evidence Re-defined priorities and objectives Revised approach to risk in the young More information from SCORE on total events, diabetes, HDL cholesterol, and body mass index (BMI) New sections on gender, heart rate, BMI/waist circumference, other manifestations of CVD including stroke and renal impairment

8. Why develop a preventive strategy in clinical practice? 1.Cardiovascular disease (CVD) is the major cause of premature death in Europe. It is an important cause of disability and contributes substantially to the escalating costs of health care 2.The underlying atherosclerosis develops insidiously over many years and is usually advanced by the time that symptoms occur 3.Death from CVD often occurs suddenly and before medical care is available, so that many therapeutic interventions are either inapplicable or palliative 4.The mass occurrence of CVD relates strongly to lifestyles and to modifiable physiological and biochemical factors 5.Risk factor modifications have been shown to reduce CVD mortality and morbidity, particularly in high risk subjects

9. JTF4 on CVD Prevention in Clinical Practice PRIORITIES, TOTAL RISK ESTIMATION AND OBJECTIVES Note that these guidelines are for health professionals. A complementary community strategy is also vital

10. 0 3 5 140 5 3 0 People who stay healthy tend to have certain characteristics: 0 No tobacco 3 Walk 3 km daily, or 30 mins any moderate activity 5 Portions of fruit and vegetables a day 140 Blood pressure less than 140 mm Hg systolic 5 Total blood cholesterol <5mmol/l 3 LDL cholesterol <3 mmol/l 0 Avoidance of overweight and diabetes

11. What are the PRIORITIES for CVD prevention in clinical practice? 1.Patients with established atherosclerotic CVD 2.Asymptomatic individuals who are at increased risk of CVD because of 2.1 Multiple risk factors resulting in raised total CVD risk (≥5% 10-year risk of CVD death) 2.2 Diabetes type 2 and type 1 with microalbuminuria 2.3 Markedly increased single risk factors especially if associated with end-organ damage 3Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk

12. What are the OBJECTIVES of CVD prevention? 1.To assist those at low risk of CVD to maintain this state lifelong, and to help those at increased total CVD risk to reduce it 2.To achieve the characteristics of people who tend to stay healthy: 2.1 No smoking 2.2 Healthy food choices 2.3 Physical activity: 30 min of moderate activity a day 2.4 BMI <25 kg/m 2 and avoidance of central obesity 2.5 BP <140/90 mmHg 2.6 Total cholesterol <5 mmol/L (~190 mg/dL) 2.7 LDL cholesterol <3 mmol/L (~115 mg/dL) 2.8 Blood glucose <6mmo/L (~110 mg/dL)

13. What are the OBJECTIVES of CVD prevention? 3.To achieve more rigorous risk factor control in high risk subjects, especially those with established CVD or diabetes: 3.1 Blood pressure under 130/80 mmHg if feasible 3.2 Total cholesterol <4.5 mmol/L (~175 mg/dL) with an option of <4 mmol/L (~155 mg/dL) if feasible 3.3 LDL cholesterol <2.5 mmol/L (~100 mg/dL) with an option of <2mmol/L (~80 mg/dL) if feasible 3.4 Fasting blood glucose <6 mmol/L (~110 mg/dL) and HbA1c <6.5% if feasible 4.To consider cardioprotective drug therapy in these high risk subjects especially those with established atherosclerotic CVD

14. Why stress assessment of total CVD risk ? Multiple risk factors usually contribute to the atherosclerosis that causes CVD These risk factors interact, sometimes multiplicatively Thus the aim should be to reduce total risk; if a target cannot be reached with one risk factor, total risk can still be reduced by trying harder with others.

15. How is CVD risk assessed quickly and easily? Those with- ~known CVD ~type 2 diabetes or type 1 diabetes with microalbuminuria, ~ very high levels of individual risk factors are already at INCREASED CVD RISK and need management of all risk factors For all other people, the SCORE risk charts can be used to estimate total risk—this is critically important because many people have mildly raised levels of several risk factors that, in combination, can result in unexpectedly high levels of total CVD risk

16. 10 year risk of fatal CVD in high risk regions of Europe

17. 10 year risk of fatal CVD in low risk regions of Europe

18. Relative Risk Chart This chart may used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication

19. Guidelines are a waste of time without an implementation strategy: What would make the practice of CVD prevention easier? Simple, clear, credible guidelines Sufficient time Positively helpful government policies (defined prevention strategy with resources, and incentives including remuneration for prevention as well as treatment) Educational policies that facilitate patient adherence to advice