Primary prevention

Use a systematic approach among people aged 40 years and above to identify those at high risk of cardiovascular disease (CVD) and most likely to benefit from preventive actions.[54][55]

  • National Institute for Health and Care Excellence (NICE) guidance recommends the use of the QRISK3 tool to assess 10-year CVD risk for primary prevention in individuals aged between 25 and 84 years.[54] QRISK3 Opens in new window

  • The European Society of Cardiology (ESC) guideline on CVD prevention recommends use of country-specific SCORE2 risk charts.[55]

Most guidelines recommend initial risk assessment using 10-year CVD risk calculators.[54][55][56] Consider use of a lifetime risk estimation tool to inform subsequent discussion and shared decision-making; NICE suggests considering this in people with a 10-year QRISK3 score less than 10%, and in people younger than age 40 years who have CVD risk factors.[54][55] QRISK3-lifetime Opens in new window

CVD risk tools may underestimate risk in certain groups of people (e.g., people with severe mental illness; those with autoimmune disorders and other systemic inflammatory disorders; people who have recently stopped smoking; people taking medications for HIV, immunosuppressants, or treatments for CVD risk factors).[54] Some groups of patients are unsuitable for calculator-based risk assessment so check the guidance for each tool carefully. For example, NICE recommends that all patients with type 1 diabetes, patients with an estimated glomerular filtration rate of <60 mL/minute/1.73 m², and patients with familial hypercholesterolaemia should be considered at high risk of CVD without using a risk assessment tool.[54]

Risk assessment becomes more challenging with advancing age. Coronary artery calcification increases every decade over the age of 40, and increases rapidly in women post menopause.[57] However, CVD-free survival dissociates from overall survival with increasing age, and there is evidence that the QRISK3 tool overstates CVD risk in older people.[55][58] In view of this ongoing uncertainty, guideline organisations differ in their approach to age-specific recommendations:

  • NICE recommends that any person aged 85 years or older should be considered high risk based on age alone (especially if they smoke and/or have high blood pressure).[54]

  • The ESC recommends progressively higher thresholds for treatment of risk factors with advancing age.[55]

Encourage individuals of all ages to adopt a healthy lifestyle and take steps to modify any major risk factors for CVD regardless of their 10-year or lifetime risk score, and before offering medicines to treat risk factors.[54][55]

  • Advise smokers to stop and offer support to help them do so.

    • For a smoker, cessation is the single most important step that can be taken to reduce heart-related and all-cause death.

    • Even low levels of smoking increase risk of CVD; this includes exposure to secondhand smoke.[9][16]

    • Various support programmes, medicines, and alternative therapies are available.

  • Encourage a cardioprotective diet, for example replacing consumption of saturated fats (e.g., meat, dairy products) with unsaturated fats (e.g., fish, fruits, vegetables, and nuts).

  • Offer advice on ways of increasing activity levels to the recommended minimum (150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic physical activity each week).[59]

  • Advise weight loss if the person is living with obesity or overweight.

  • Advise avoidance of excess alcohol consumption.

  • Advise on further dietary and lifestyle measures and/or treatment to control other modifiable risk factors (e.g., low salt diet for control of high blood pressure, with addition of antihypertensive medication if indicated).

Offer a statin to any individual whose CVD risk score puts them at increased risk of CVD.

  • NICE recommends to offer atorvastatin for primary prevention to anyone whose 10-year CVD risk is estimated to be 10% or higher, using the QRISK3 tool (after modification of lifestyle and management of risk factors).[54]

  • The ESC recommendations for lipid-lowering treatment follow age-band-specific 10-year risk thresholds, with higher treatment thresholds recommended for older people.[55]

  • Check local and national guidelines; treatment recommendations differ depending on underlying population risk and practical considerations. For example, the Scottish Intercollegiate Guidelines Network (SIGN) concluded that a 10-year CVD risk of 20% or higher is a more appropriate threshold for offering statin treatment for primary prevention in the Scottish population, after their analysis found 95% of all individuals aged 60 to 64 in Scotland to be eligible for treatment under a 10% or higher 10-year risk threshold.[60]

Aspirin is not recommended for the primary prevention of CVD because the increased risk of major bleeding is considered to outweigh any potential benefits.[54][55]

Secondary prevention

Recommended pharmacotherapy for secondary prevention is covered in  Management recommendations. 

Offer cardiac rehabilitation to all patients. This should include an exercise component, health education, stress management, and psychological and social support. Advise all patients on lifestyle changes such as:[7][61]

  • Changes to diet

  • Reduction of alcohol consumption

  • Smoking cessation

  • Weight management

  • Physical exercise

  • Reduced sedentary time.

The most important preventive actions involve combined dietary and lifestyle changes, as outlined in the Primary prevention section.

Patients should switch to a heart-healthy diet. If overweight, patients should lose weight and maintain a healthy body weight. Patients should consume a diet rich in vegetables and fruits. Patients should be advised to choose wholegrain, high-fibre foods and to eat fish, especially oily fish, at least twice a week. Excess sugars, trans-fats, salt, and foods with excess cholesterol should be limited.

For a smoker, cessation is the single most crucial step that can be taken to reduce heart-related and all-cause death. This includes avoiding second-hand smoke. Many different types of support are available, and smoking cessation service referrals can be made via a cardiac rehabilitation programme. Data from the EVITA (Evaluation of Varenicline in Smoking Cessation for patients post Acute Coronary Syndrome) trial suggest that pharmacotherapy with varenicline started in hospital at the time of an acute coronary syndrome may be efficacious for smoking cessation; however, further studies to assess safety end points are needed.[142]

Improving physical fitness through aerobic exercise is extremely important. Advice about exercise should be offered as part of a cardiac rehabilitation programme.[61] It is recommended that patients engage in ≥30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week. Likewise, patients should engage in multiple short bouts of physical activity daily, such as walking the dog or taking the stairs instead of the lift.

Sedentary behaviour is an independent risk factor for all-cause mortality and the European Society of Cardiology recommends advising reduced sedentary time.[7]

Family members can be very helpful and should become involved along with other support systems to help remind patients of, and to reinforce, lifestyle changes. Patients should use the resources that are available (e.g., written materials, the Internet, educational classes, regular counselling) and be in close communication with healthcare providers.

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