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European Society of Cardiology

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New guidelines for CVD prevention

New cardiovascular disease (CVD) prevention guidelines,1 emphasising the importance of evidence from clinical trials and observational population studies, were presented recently at the EuroPRevent2012 meeting in Dublin, Ireland.

“In the past, implementation of prevention guidelines could undoubtedly have been better.  So in a radical departure we’ve designed the guidelines in a new format that makes them much more accessible,” explained Professor Joep Perk, the chairperson of the Guidelines Task Force. “The change is to help disseminate the information from the guidelines out to where it’s needed – health professionals working in the field, politicians and the general public”.

The guidelines, developed by the Fifth Joint Task Force (JTF) of societies of Cardiovascular Disease Prevention in Clinical Practice, which includes the European Society of cardiology (ESC) and seven other societies, are around one third shorter than the 2007 fourth edition.  “We’ve gone back to the first principles of teaching by introducing the what, why, whom, how and where of preventive cardiology,” said Perk, from Linnaeus University, Kalmar, Sweden.

The guidelines stress that CVD prevention should be a “life long effort” that starts in the womb and lasts to the end of life.  Greater emphasis has been placed on the behavioural aspects of prevention, with discussion of ways to make it easier for patients to change their life styles.

The guidelines were launched at the EuroPRevent2012 meeting, and published simultaneously in the European Heart Journal and European Journal of Preventive Cardiology. “This was deliberate.  It’s meant that we could structure the meeting around the guidelines with plenty of opportunities for wide ranging discussions that allow everyone to get up to speed,” explained Professor Ian Graham, Chairperson of the EACPR Prevention Implementation Committee, and co-chairperson of the EuroPRevent2012 Programme Committee.

Guideline sessions have been organised for  GPs and practice nurses, with additional training  sessions to teach the national coordinators, who have been appointed from the different European countries to implement the guidelines, on how to engage with politicians, the profession and the public.

An electronic, interactive Guideline Learning Tool will also be launched at EuroPrevent2012.  “We’re really excited about this because it will allow doctors, students and other health care professionals to engage interactively with the guidelines through case histories and other new learning techniques,” commented Graham.

Additionally, pocket guidelines, an A 4 page with all the essential information and a slide-set for teaching purposes are in development. “Our ultimate aim is to get an A4 summary of the guidelines on the desk of every single family doctor in Europe. It will be the bible of health prevention,” said Perk.

“The INTERHEART study results suggest that 90% of heart attacks worldwide may be prevented, and that the majority of heart attacks are a direct result of the personal lifestyle choices made by individuals,” said Professor Guy De Backer, a member of the Guideline Task Force.  “But the good news is that it’s never too late for people to make modifications to lifestyle, even after they’ve suffered an event.”

The Task Force have for the first time introduced the Grading of Recommendations Assessment Development and Evaluation (GRADE) system for assessing medical evidence that gives increased weight to population studies. This is in addition to the traditional approach, applied by the ESC in all its guidelines, that awards recommendations different classes (I, IIa, IIb, or III) according to the type of trial the evidence has been obtained from.

“The traditional approach for grading the quality of the evidence gives predominance to randomised controlled trials (RCTs). This is good science but carries a problem in that drug trials will always outscore lifestyle measures because it’s easy to do RCTs  of cholesterol and blood pressure drugs, but hard to do RCTs of smoking cessation or other lifestyle changes,” said  Graham, from Trinity College, Dublin.

The GRADE system only uses two categories of recommendation – strong or weak. This encompasses strong recommendations to do something, strong recommendations not to do something, and weak recommendations. The implications of a strong recommendation are that most informed patients would choose the recommended intervention; whereas for weak recommendations some patients would want the intervention, but many would not. “It’s hoped that the GRADE system will allow much clearer interpretation of guidelines by clinicians, patients and policy makers,” said Graham.

The final chapter focuses on the “new era” of political engagement in preventive cardiology, showing how in addition to clinical prevention activities, health care professionals  should extend their remit to include political lobbying activities that may influence healthy behaviours in the wider population.

“Although we’ve already made gains at the clinical level to have a really big impact on CVD we need to engage politicians. Changing human behaviour is a political issue,” said Perk. “We need to create a healthier environment and this requires changes in the law, such as reducing the amount of salt and trans fatty acids in food, providing more cycle lanes and getting school curriculums to include more movement”.


1. The Fifth Joint Task Force. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (version 2012). EHJ 2012. doi:10.1093/eurheartj/ehs092

Published on: May 24, 2012

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