Introduction: The major causes of atherosclerotic cardiovascular disease (CVD) are known. There has been some progress with regards to control of tobacco smoking, hypertension and hyperlipidaemia in recent decades. Despite the fact that control of these unequivocally reduces risk, clinical audits such as EuroAspire and SURF1,2 continue to show inadequate risk factor recording and control. Levels of overweight and consequent diabetes continue to increase.
The great Geoffrey Rose taught us that a small reduction in risk at population level will have a larger impact on population health than a more intense intervention applied to a small number of very high-risk persons, even though such individuals should be identified as they may gain much as individual people.3 This has led to a widespread realisation that population and high-risk strategies are complementary and not competitive. Rose also stated that “The primary determinants of disease are mainly economic and social, and therefore its remedies must be economic and social. Medicine and politics cannot and should not be kept apart”.3
These considerations have informed World Health Organisation (WHO),4 the American Heart Association5 and the European Alliance for Cardiovascular Health (EACH) report “A European Cardiovascular Health Plan: The need and the ambition”.6 This far-reaching report provides a comprehensive road map for prevention and clearly calls for the European Commission to take more responsibility.
In this paper we look at advances in cardiovascular risk estimation, comment on some issues with guidelines and their implementation, consider the lack of commitment at societal and political level and address the issue of over-medicalisation and the need to facilitate personal responsibility for health. We also comment on the striking inequalities in CVD risk and mortality between and within countries.
It is not the purpose of this review to examine drug treatments which are amply dealt with elsewhere except to note the more widespread availability of generic statins, the fact that newer therapies can achieve LDL goals in most persons7 albeit at high cost. Newer therapies to reduce Lp(a) hold promise but with, to date, no evidence of an impact on CVD endpoints.
Although this paper focusses on Europe, it is hoped that the principles may have universal applicability.
“The primary determinants of disease are mainly economic and social, and therefore its remedies must be economic and social. Medicine and politics cannot and should not be kept apart” (Geoffrey Rose)
Disclaimer: This paper is based on an invited review that has been submitted to the journal ‘Cardiology’
This topic was reviewed recently in a paper describing the European Society of Cardiology’s (ESC) Cardiovascular Risk Collaboration.8 Guidelines on CVD prevention recommend the use some form of risk calculator because the occurrence of CVD is usually the result of several interacting risk factors, and the clinical estimation of these effects is uncertain. The current ESC prevention Guidelines9 use SCORE210 and SCORE2-OP11 as their recommended risk estimation systems for people below and above 70 years of age. Like other systems, these are limited by the facts that they start at the age of inception of the cohorts from which they are derived (usually age 40- therefore after many years of exposure to risk) and, strictly speaking, apply to populations rather than individuals.
A thoughtful editorial by Navar and colleagues,12 based on a paper by Mortensen et al,13 notes some of the limitations of SCORE as used in the 2021 ESC Guidelines on prevention , including the impact of regional variations in risk factors, risk and statin usage. Although SCORE is indeed re-calibrated for different risk regions, this may not have fully adjusted for these issues. More importantly, the intervention thresholds for recommending statins may have a profound impact on statin usage. Using these new recommendations, Mortensen and colleagues13 estimated the proportion of people free of diabetes or kidney disease in Denmark now eligible for statin therapy for primary prevention. As Navar notes, “the results are alarming: under the 2019 ESC guideline, 20% of the population received a class 1 recommendation for a statin, and under the 2021 guideline, this decreased to 4%. Including class II recommendations, the proportion of individuals recommended for a statin dropped from 56% to 19%”. The thresholds used for recommending statins in the 2021 Guidelines need review.
As noted by Brian Ference in his contribution to,8 current risk estimation systems are dominated by age which is likely not a risk factor as such but rather a measure of exposure time. The future may lie in developing an exposure-time lifetime risk model based on years of exposure to risk factors. Mendelian randomisation studies may suggest that the rate of rise in LDL cholesterol and blood pressure from birth on may be causally determined by polymorphisms. Using causal estimates of the cumulative effect of lipids, systolic blood pressure and other factors that cause atherosclerosis may have the potential to permit individualised true lifetime risk at a much earlier age than is currently possible. In this approach, risk would be expressed not as 10-year risk but in terms of the combined effects of years of exposure to individual risk factors, with adjustment later lifestyle factors such as diet and smoking. It will likely require judicious use of artificial intelligence in its application. Much work needs to be done to see if the potential of this approach can be realised. These concepts have been outlined in a paper reporting the individual and combined effects of genetically determined levels of blood pressure and LDLcholesterol on lifetime risk.14
Polygenic scores have to date shown only a modest effect on risk estimation. This may be in part because, as above, the rate of rise in LDL-cholesterol and blood pressure is determined by polymorphisms and these effects may be greater than the independent effects of polygenic scores (B. Ference, personal communication). Guidelines and their implementation
Many Guidelines for the prevention of CVD exist, and yet risk factor control remains poor, even in the highest risk subjects.1,2 Perhaps Konrad Lorenz (1903-1969) understood the reasons”Said is not heard, heard is not understood, understood is not agreed upon, agreed is not applied, applied is not at all maintained”
(Brought to our attention by Prof Ulrich Keil)
The European Association of Preventive Cardiology has devoted considerable time to this issue.15
Their work re-emphasises the findings of earlier studies such as one published by the ESC:16
Barriers to guideline usage include:
• Insufficient training in both prevention and behaviour change
• Lack of remuneration (physicians are generally re-imbursed for treating the sick, not promoting health).
• Lack of clarity (guidelines too detailed, too complicated).
• Unhelpful health policies, including a lack of a focussed health strategy and remuneration issues as above.
• Patient difficulties with adhering to advice- more a comment on our communication skills than a criticism.
Of these, the length and complexity of current guidelines may be a major factor impeding their widespread use. The 2021 ESC Guidelines on CVD prevention9 run to no less than 111 pages and 837 references. Fortunately, pocket guidelines, Apps and slide sets are available through www.escardio.org. Simple communication tools such as the American Heart Association
‘Life’s Essential 8’5 may simplify messages both for health professionals and the public. Factors which may increase guideline usage include:
• Simple, clear, credible national guidelines.
• Appropriate use of Apps and social media.
• An effective multidisciplinary implementation strategy.
• Facilitatory government policy
– Defined prevention strategy-
– Reimbursement for health professionals
– Public awareness and education from school on.
Societal and political commitment
The factors that impact on Guideline usage may also inform more effective preventive efforts. Additional factors that may militate against prevention are the overmedicalisation of prevention and the lack of a pan-European legal framework for health.
Do we, as healthcare workers, try to over-control prevention rather than fostering knowledge and skills in the public? The basic facts regarding cardiovascular risk and how to make choices about its components should surely be integrated into school curricula. “Integrated’ implies more than an add on module – it might include, for example, the relationships between the tobacco and food industries and health as well as knowledge of risk factors and the principles of behaviour change.
In 2011, Morgan, Burke and McGee17 undertook a benchmarking survey regarding the implementation of prevention in 13 European countries. In general, it was impossible to find any one person with responsibility for coordinated national policy with regards to prevention.
The same pertains at EU level – no one person with responsibility for prevention exists. Furthermore, there is no pan-European legal framework for health promotion. The EU may offer advice but, unlike food safety, has no legal basis for enforcing action. Attempts by bodies such as the ESC and European Heart network (EHN) to lobby the EU and European Parliament tend to be met with well-meaning words but little effective action- what has been termed ‘Implementation Deficiency Disorder’.
As long ago as 2007, the ESC, in partnership with the World Health Organisation (WHO) and EHN published the European Heart Health Charter  to address some of these issues. This was presented to the EU and virtually all countries in Europe signed up to the Charter, but little seemed to change. There was a lack of a follow-up strategy to ask each country to be accountable for implementation efforts. The Charter has now been updated and the implementation strategy is under discussion.
In the meantime, the EACH report6 makes widespread and logical recommendations that are essentially complementary to the European Heart Health Charter, including the following:
“Proposed Key components of a future CVH Plan”
Horizontal, cross-cutting actions:
• A European Cardiovascular Health Data Knowledge Centre
• A European Cardiovascular Health Observatory
• The Co-Creation of National CVH Action Plans
• Creating an incubator and progressive policy environment for digital transformation in CVH
• Primary prevention to decrease premature mortality and morbidity at population level
• Secondary prevention through screening for early detection and precision diagnosis – A European Cardiovascular Health Check
• Early intervention, access to care and optimal treatment
• Quality of life and other psychosocial outcomes across the spectrum of cardiovascular diseases
A CVH Mission – comprising a new research and innovation
agenda in the framework of HORIZON Europe”
Regarding implementation, detailed proposals are made for the consideration of the European Commission. But, as defined above, until such time as Europe can approach a cohesive, integrated approach to prevention with defined responsibilities, implementation will prove very challenging. It behoves us, as health professionals to lobby for this, individually and through our professional bodies.
The principles defined thus far may be reasonable, but there is another dimension. There is a West-East gradient in CVD mortality, with a higher mortality in Eastern countries that may lack the resources to combat the problem. And inequalities exist within countries- the socially deprived have higher levels of risk factors and the cliche that ‘the poor die young’ is true. These issues are clearly defined in the EACH report . Women in particular are less likely to have risk assessments or to be offered appropriate help. Any national or European strategy needs a specific plan to address these issues.
In conclusion, we know the causes of CVD and the interventions that reduce risk. Current information and monitoring systems are insufficient for the needs of a coordinated prevention strategy. Above all, integrated and accountable plans at National and European level are required and it is time for both individual countries and the European Union to commit to responding to their responsibilities if Europe’s major cause of death is to be addressed.
Written by Professor Ian M Graham MD, Professor of Cardiovascular Medicine, Trinity College Dublin
I am grateful to Cardiology for inviting this review.
Conflict of interest statement: None
Author contributions: Sole author