Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organizations-European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific Task Force. The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements. The rationale for an active approach to the prevention of cardiovascular diseases (CVD) is firmly based on five observations: CVD is the major cause of premature death in most European populations; it is an important source of disability and contributes in large part to theescalating costs of health care the underlying pathology is usually atherosclerosis, which develops insidiously over many years and is usually advanced by the time symptoms occur death, myocardial infarction and stroke nevertheless frequently occur suddenly and before medical care is available, and many therapeutic interventions are therefore inapplicable or palliative the mass occurrence of CVD relates strongly to lifestyles and modifiable physiological factors risk factor modifications have been unequivocally shown to reduce mortality and morbidity, especially in people with either unrecognised or recognisedCVD. Cardiovascular disease is generally due to a combination of several risk factors, and, in recognition of the multifactorial nature of this group of diseases, the European Atherosclerosis Society, the European Society of Cardiology, and the European Society of Hypertension agreed in the early 1990s to collaborate to suggest guidelines for prevention of coronary heart disease in clinical practice. The result was a set of recommendations published in 1994. A revision of these early guidelines was published in 1998 by the Second Joint Task Force, which set lifestyle, risk factor and therapeutic goals for coronary prevention. In this 2nd report the original three societies were joined by the European Society of General Practice/Family Medicine, the European Heart Network and by the International Society of Behavioural Medicine. Since completion of this report, important new data have been published. Therefore the Third Joint Task Force provides a second revision of the joint European guidelines. The Task Force has been joined by the European Association for the Study of Diabetes and by the International Diabetes Federation Europe. These new guidelines differ from the previous ones in several important aspects: (1) From coronary heart disease (CHD) to CVD prevention.The aetiology of myocardial infarction, ischaemic stroke and peripheral arterial disease is similar, and, indeed, recent intervention trials have shown that several forms of therapy prevent not only coronary events and revascularisations but also ischaemic stroke and peripheral artery disease. Hence, decisions about whether to initiate specific preventive action can be guided by estimation of risk of suffering any such vascular event, not just a coronary event, and preventive actions can be expected to reduce risk, not only of coronary heart disease, but also of stroke and peripheral arterial disease. (2) In order to assess the risk for development of CVD different multifactorial risk models have been developed. The Task Force recommends using the SCORE Model and Risk Charts as recently developed. The risk assessment using the SCORE database can be easily adapted to national conditions, resources and priorities and takes into account the heterogeneity in CVD mortality across European populations. A core element of the model is that risk is now defined in terms of the absolute 10 year probability of developing a fatal cardiovascular event. (3) Explicit clinical priorities. As in the 1994 and 1998 recommendations, the first priority of practitioners is patients with established cardiovascular disease and subjects who are at high risk of developing CVD. Subjects at high risk may also be recognised by new imaging techniques which allow visualisation of subclinical atherosclerosis. (4) All new and published knowledge from the field of preventive cardiology was considered, particularly results from recent clinical trials showing clinical benefit of dietary changes, of good management of risk factors and of the prophylactic use of certain drugs. This includes data on usage of certain drugs in elderly subjects and in subjects at high risk with a relatively low total cholesterol level. These guidelines are specifically intended to encourage the development of national guidance on cardiovascular disease prevention. Implementation of these guidelines is possible only through collaboration between very different professional groups at thenational level. The guidelines should be considered as the framework in which all necessary adaptations can be made in order to reflect different political, economic, social and medical circumstances. The Third Joint Task Force recognises that these guidelines which are targeted at those at highest CVD risk should be complemented by strategies aimed at whole populations at the national and European level as a contribution to a public health policy to reduce the enormous burden of cardiovascular disease in European populations. Preventive efforts are most efficient when they are directed at those at highest risk. The present recommendations therefore define the following priorities for CVD prevention in clinical practice: patients with established coronary heart disease, peripheral artery disease and cerebrovascular atherosclerotic disease asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular diseases because of: multiple risk factors resulting in a 10 year risk of ≥5% now (or if extrapolated to age 60) for developing a fatal CVD event markedly raised levels of single risk factors: cholesterol ≥8mmol/l (320mg/dl), LDL cholesterol ≥6mmol/l (240mg/dl), blood pressure ≥180/110mmHg diabetes type 2 and diabetes type 1 with microalbuminuria close relatives of: patients with early onset atherosclerotic cardiovascular disease asymptomatic individuals at particularly high risk other individuals encountered in routine clinicalpractice The objectives of these guidelines are to reduce the incidence of first or recurrent clinical events due to coronary heart disease, ischaemic stroke and peripheral artery disease. The focus is prevention of disability and early deaths. To this end, the current guidelines address the role of lifestyle changes, the management of major cardiovascular risk factors and the use of different prophylactic drug therapies in the prevention of clinical CVD. Intermediate end-points such as left ventricular hypertrophy, carotid artery plaques and to a lesser extent endothelial dysfunction as well as alteration in the electrical stability of the myocardium have been shown to increase the risk of cardiovascular morbidity, indicating that subclinical organ damage has clinical relevance. Accordingly such measurements may be incorporated in more sophisticated models to assess the risk for future CVD events. Patients with established cardiovascular disease have declared themselves to be at high total risk of a further vascular event. Therefore, they require the most intensive lifestyle intervention, and where appropriate drug therapies. In asymptomatic, apparently healthy subjects, preventive actions should be guided in accordance with the total CVD risk level. Those at highest total risk should be identified and targeted for intensive lifestyle interventions and when appropriate drug therapies. Several models have been developed to assess the risk for CVD in asymptomatic subjects. Using different combinations of risk factors these models are all based on a multifactorial risk analysis in populations which have been followed for several years. These guidelines recommend a new model for total risk estimation based on the SCORE (Systematic Coronary Risk Evaluation) system. The new risk chart based on the SCORE study represents several advantages compared to the previous chart. The SCORE risk assessment system is derived from a large dataset of prospective European studies and predicts any kind of fatal atherosclerotic end-point i.e. fatal CVD events over a ten-year period. In SCORE the following risk factors are integrated: gender, age, smoking, systolic blood pressure and either total cholesterol or the cholesterol/HDL ratio. Since this chart predicts fatal events the threshold for being at high risk is defined as ≥5%, instead of the previous ≥20% in charts using a composite coronary endpoint. Using SCORE it is now possible to produce risk charts tailored for individual countries provided reliable national mortality information is available. Practitioners should use total CVD risk estimates when decisions are taken to intensify preventive actions i.e. when dietary advice should be more specified, when the physical activity prescription should be more individualized, when drugs should be prescribed, dosages adapted or combinations started to control risk factors; these decisions should usually not be based on the level of any one risk factor alone; neither should they be linked to only one arbitrary cut point from the continuous total CVD risk distribution. Total CVD risk can easily be derived from printed charts (see illustrations in Figs. 1 and 2) or from the web where in addition the SCORECARD system will provide physicians and patients with information on how total risk can be reduced by interventions (both lifestyles and drugs) that have been proven to be efficacious and safe in descriptive cohort studies and/or in randomized controlled trials. Ten year risk of fatal CVD in high risk regions of Europe by gender, age, systolic blood pressure, total cholesterol and smoking status. Ten year risk of fatal CVD in low risk regions of Europe by gender, age, systolic blood pressure, total cholesterol and smoking status. Both the SCORE and the SCORECARD system also allows the estimation of total CVD risk to be projected to age 60 which may be of particular importance for guiding young adults at low absolute risk at the age of 20 or 30 but already with an unhealthy risk profile which will put them at much higher risk when they grow older. Furthermore, both systems allow the use of relative risk estimates which, in addition to total absolute risk, may be of interest in particular cases. Definition of high total risk for developing a fatal cardiovascular event Patients with established cardiovascular disease Asymptomatic subjects who have: Multiple risk factors resulting in a 10 year risk ≥5% now or if extrapolated to age 60 (see also box with qualifiers) Markedly raised levels of single risk factors: total cholesterol ≥8mmol/l (320mg/dl), LDL cholesterol ≥6mmol/l (240mg/dl), blood pressure ≥180/110mmHg Diabetes type 2 and diabetes type 1 with microalbuminuria Instructions on how to use the chart The low risk chart should be used in Belgium, France, Greece, Italy, Luxembourg, Spain, Switzerland and Portugal; the high risk chart should be used in all other countries of Europe. To estimate a person’s total ten year risk of CVD death, find the table for their gender, smoking status and age. Within the table find the cell nearest to the person’s systolic blood pressure (mmHg) and total cholesterol (mmol/l or mg/dl). The effect of lifetime exposure to risk factors can be seen by following the table upwards. This can be used when advising younger people. Low risk individuals should be offered advice to maintain their low risk status. Those who are at 5% risk or higher or will reach this level in middle age should be given maximal attention. To define a person’s relative risk, compare their risk category with that of a non-smoking person of the same age and gender, blood pressure <140/90 mmHg and total cholesterol < 5mmol/l(190mg/dl). The chart can be used to give some indications of the effect of changes from one risk catagory to another, for example when the subject stops smoking or reduces other risk factors. Qualifiers: Note that total CVD risk may be higher than indicated in the chart: as the person approaches the next age category. in asymptomatic subjects with pre-clinical evidence of atherosclerosis (e.g. CT scan, ultrasonography) in subjects with a strong family history of premature CVD in subjects with low HDL cholesterol levels, with raised triglyceride levels, with impaired glucose tolerance, and with raised levels of C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lp(a) in obese and sedentary subjects Magnetic Resonance Imaging (MRI) allows in vivo imaging of the arterial wall and differentiation of plaque components. Coronary calcifications can be detected and quantified by computed tomography (EB-CT or MS-CT). The resulting calcium score is an important parameter to detect asymptomatic individuals at high risk for future CVD events, independent of the risk factors. Furthermore, carotid by is a risk factor for events and ventricular hypertrophy, either detected by or by has also been shown to be an independent risk factor for CVD mortality and in subjects. of these measurements has they may be in sophisticated models for risk which may be more than current models based on in many of individual are necessary in a large majority of patients with established CVD or at high risk of but recent surveys suggest a between recommendations for and the advice provided by physicians in routine clinical practice. The management of risk factors is for patients with CVD and but risk smoking, sedentary which have for many a professional many people it can be to lifestyle to a This especially to people and patients who are and who control over a and who are in a family or who and social and may to preventive both in patients and in people. The can these by using a set of is helpful and in some and can require expert and or As risk factors are independent of risk factors, efforts to and social should be that may be used to the of a therapeutic with the that patients the between health and disease help patients to the to from patients to patients in and the risk factors to use a combination of strategies of for a lifestyle through other health care possible All should be to smoking all forms of that may help can be into the following A all at determine the of and to strongly all to on a smoking therapy and/or a of healthy is an part of total risk All individuals should professional advice on and to a with the risk of cardiovascular disease. A reduces risk by several of blood pressure, on control of glucose and of the to General recommendations be to should be and must be to maintain the of the following should be and whole and low and and have particular total should account for more than of and of should not a of total The of cholesterol should be than in an can be by by and from and Patients with arterial and or other should dietary activity should be in all age to the all patients and high risk people should be and to increase their physical activity to the level with the risk of CVD. the is at an of physical activity on most of the more activity is also with health people should be to which into their 30 to to at of the heart patients with established advice must be based on a clinical the results of an recommendations for CVD patients have been given by other expert or is important in patients with established CVD as well as in high risk people. is strongly for obese people or and and for those with as indicated by in and in in is more if it but it also strong by the The risk of cardiovascular diseases as blood pressure from levels that are considered to be the The to not only on the level of blood pressure, but also on an assessment of total cardiovascular risk and the or of organ In patients with established CVD the of drugs on the underlying cardiovascular disease. A to blood pressure management in asymptomatic people is given in The to blood pressure with drugs not only on the total cardiovascular risk but also on of organ therapy should be in individuals with a systolic blood pressure and/or a blood pressure of their total cardiovascular risk to blood pressure at high risk of developing CVD with of and/or also require drug such drugs should be used to blood pressure to of blood pressure in low risk people organ damage should be followed and lifestyle advice should be be considered the individuals with and/or not drug Patients with a high or very high cardiovascular risk profile and patients with diabetes can benefit from blood pressure the of and/or drugs should not only blood pressure They should have a profile and be to reduce and of drugs these and In many clinical blood pressure control has been by the combination of or three and drug combination therapy is also necessary in routine clinical practice. In patients with several diseases drug can a major and good clinical management is to In all blood pressure should be most the of therapy is blood pressure than but for patients with diabetes and individuals at high total CVD risk, the blood pressure should be In total cholesterol should be and LDL cholesterol should be patients established CVD and patients with diabetes the goals should be total cholesterol and LDL cholesterol specific goals are defined for HDL cholesterol and but of HDL cholesterol and are used as of risk. HDL cholesterol in and in and as of cardiovascular risk. of HDL cholesterol and should also be used to the of drug Asymptomatic people at high multifactorial risk of developing cardiovascular disease, of total and LDL cholesterol are already close to and to benefit from further of total cholesterol to and from further of LDL cholesterol to with of drugs. these are not goals of therapy for patients with higher because the of which have not been be to reach such In asymptomatic individuals (see the first is to assess total cardiovascular risk and to these of risk that are to be the 10 year risk of cardiovascular death is and will not 5% if the risk factor combination is projected to age professional advice a physical activity and smoking should be given to the cardiovascular risk Risk assessment should be at Note that assessment of total risk not to patients with total cholesterol and LDL cholesterol by a at high total risk of CVD. to management in asymptomatic subjects. the 10 year risk of cardiovascular death is ≥5%, or will ≥5% if the risk factor combination is projected to age a analysis of should be and intensive lifestyle particularly dietary should be of total and LDL cholesterol and and the total CVD risk estimate has these should be followed at to that cardiovascular risk low drugs. In if total CVD risk ≥5%, drug therapy should be considered to total and LDL cholesterol The goals in such individuals are to total cholesterol to and to LDL cholesterol to As these are not goals of therapy for patients with higher The first clinical trials which the clinical benefits of therapy with were to individuals years and total cholesterol published trials that such can also be in the elderly and in subjects with individuals require combination In patients with several diseases drug can a major and good clinical management is to In some goals be on maximal but they will benefit from to the extent to which cholesterol has been It has been that to diabetes can be or by lifestyle intervention in individuals with impaired glucose In patients with type 1 and type 2 is evidence from controlled trials that good control the prevention of cardiovascular events, are also good reasons to aim for good glucose control in both of In type 1 glucose control appropriate therapy and professional dietary In type 2 professional dietary of and physical activity should be the first at good glucose therapy must be if these not to a of for type 2 diabetes are given in the goals for blood pressure and are generally more in patients with diabetes (see goals in patients with type 2 In clinical the given by the National can be used for the of individuals with the The of the is when three or more of the following are in in or in blood pressure glucose with the are usually at high risk of cardiovascular disease. has a strong on all the of the and therefore the in the management of the should be in lifestyle changes, particularly efforts to reduce and increase physical blood pressure, the drug as in the present guidelines. In addition to drugs to blood pressure, and the following drug should also be considered in the prevention of CVD in clinical practice: or other drugs in all patients with established CVD in patients following myocardial infarction or with left ventricular dysfunction due to in patients with symptoms or of left ventricular dysfunction due to and/or arterial in those patients with who are at risk of events. In asymptomatic high risk people is evidence that low can reduce the risk of cardiovascular events in people with in people with well controlled and in at high multifactorial CVD risk. relatives of patients with premature coronary heart disease years and and who to with or other should be for cardiovascular risk factors, because all of these are at risk of developing cardiovascular disease. from this In patients with established relevant lifestyle smoking, healthy and increase physical activity and a for and In people at high CVD use the SCORE system to define level of total CVD risk relevant lifestyle smoking, healthy and increase physical activity for blood pressure cholesterol and control European Association for the Study of Diabetes International Diabetes Federation Europe European Atherosclerosis Society European Heart Network European Society of Cardiology European Society of Hypertension International Society of Behavioural European Society of General Practice/Family from the of the Preventive Task Force. The the of