Impact of the 2021 ESC Prevention Guideline's stepwise approach for cardiovascular risk factor treatment in patients with established ASCVD.

BACKGROUND AND AIMS

To evaluate the stepwise-approach for cardiovascular (CV) risk factor treatment as outlined by the ESC 2021 Guidelines on CV Disease (CVD) Prevention in patients with established atherosclerotic CVD (ASCVD).

METHODS

In patients with ASCVD, included in UCC-SMART (n = 8,730) and European parts of the REACH registry (n = 18,364), the 10-year CV risk was estimated using SMART2. Treatment effects were derived from meta-analyses and trials. Step 1 recommendations were LDL-cholesterol (LDLc) < 1.8 mmol/L, systolic blood pressure (SBP) < 140 mmHg, using any antithrombotic medication, sodium glucose co-transporter 2 (SGLT2) inhibition, and smoking cessation. Step 2 recommendations were LDLc <1.4 mmol/L, SBP <130 mmHg, dual pathway inhibition (DPI, aspirin plus low-dose rivaroxaban), colchicine, glucagon-like peptide (GLP)-1 receptor agonists, and eicosapentaenoic acid. Step 2 was modelled accounting for Step 1 non-attainment.

RESULTS

With current treatment residual CV risk was 22%, 32%, and 60% in the low, moderate, and pooled (very) high European risk regions, respectively. Step 2 could prevent up to 198, 223, 245 events per 1000 patients treated, respectively. Intensified LDLc-reduction, colchicine, and DPI could be applied to most patients, preventing up to 57, 74, and 59 events per 1000 patients treated, respectively. Following Step 2 the number of patients with a CV risk of <10% could increase from 20%, 6.4%, and 0.5%, following Step 1, to 63%, 48%, and 12%, in the respective risk regions.

CONCLUSIONS

With current treatment residual CV risk in patients with ASCVD remains high across all European risk regions. The intensified Step 2 treatment options result in marked further reduction of residual CV risk in patients with established ASCVD.

Patients with established cardiovascular disease are at high risk for new cardiovascular events. The European Society of Cardiology guideline for the prevention of cardiovascular disease introduced a stepwise treatment approach. Step 1 in this approach are treatments that apply to all patients and Step 2 are intensive treatments that can be prescribed to patients who are still at high risk of new events even with Step 1 treatments. The current study investigates the effect of Step 1 and Step 2 on the risk of cardiovascular disease in 27,094 patients all across Europe. With the conventional treatments of Step 1 the risk of cardiovascular disease remains high, with a 10-year risk of new events higher than 10% in 80-99% of patients. The intensive treatment options from Step 2 could prevent an additional 198-245 new cardiovascular events for every 1000 patients that are treated. With intensive treatment up to 63% of patients could achieve a 10-year risk of new cardiovascular disease below 10%.

Informations de copyright

© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.