Joint societies CVD Prevention Guidelines launched in May 2012 The latest CVD Prevention Guidelines emphasize changing behaviour and give more weight to population studies

The joint European Societies Guidelines on cardiovascular prevention in clinical practice were launched at EuroPRevent 2012 in May in Dublin, Ireland. Nine societies have joined forces in a task force to produce this fifth edition of CVD Prevention Guidelines. The last document was published in 2007, and the 2012 version differs in numerous ways. First, it takes the bold step of stating that 80–90% of all cardiovascular disease (CVD) is preventable. The Guidelines then place greater emphasis on the behavioural aspects of prevention and discuss ways of making it easier for patients to change their lifestyles. In a controversial move, taskforce chair Professor Joep Perk (Kalmar, Sweden) introduced the GRADE system for the grading of evidence in order to increase the weight given to population studies. Traditional grading systems gave studies with a doubleblind cross-over design (often industry sponsored drug studies) a strong rating, but this rigorous methodology could not be used in population studies of smoking, physical activity, etc. It was believed that there was so much information in large population studies that they had to be upgraded in scientific value. The 2007 CVD Prevention Guidelines did not contain any strict evidence-based recommendations because of conflict around not taking population studies on board. ‘It made those guidelines rather weak’, says Perk. ‘I decided to fight for taking GRADE on board’. Using GRADE, the 2012 guidelines now have three types of recommendations: strong recommendations to do something, strong recommendations not to do something, and weak recommendations. The latter is a kind of wish list of things that could be done if the time and money are available, but they should not be top priority. Perk says: ‘It’s a more practical, pragmatic way of thinking and that’s because the document is in the first place for people working in the field’. Another change Perk argued for was asking all parties to deliver a more concise message. This produced its own diplomatic challenges, with people asking why their particular field was now less important. He also fought for a new format based on the what, why, whom, how, and where of preventive cardiology, in an effort to make the Guidelines more accessible to readers and for the first time refers to implementation. The chapter on the ‘where’ of prevention, for example, explores implementation at different levels of health care, from nurse coordinated programmes to specialized rehabilitation and prevention centres. Each chapter kicks off with key messages and recommendations, which are useful for all readers. The chapters conclude with the most important new information (for the knowledgeable clinician) and the remaining gaps in evidence. It’s hoped that the latter will inspire scientists to investigate these areas. For the first time the 2012 CVD Prevention Guidelines provide recommendations for four classes of CVD risk: very high, high, moderate, and low risk. The 2007 document discussed just two levels of risk. The 2012 Guidelines highlight the fact that the number of low-risk countries in Western Europe has increased considerably over the past 2–3 decades. Three quarters of this change can be attributed to lifestyle alterations in populations (primarily less smoking, although increasing physical activity has also played a role). Just onequarter is due to better medical treatment. At the same time, the risk of CVD is increasing in several Eastern European countries. A number of tools are being produced to aid implementation. These will be launched at the ESC Congress in Munich, Germany, in August. The whole document will be boiled down to the essentials on one A4 sheet of paper. This could be put on the desk of every general practitioner in Europe with an interest in CVD prevention. Pocket guidelines will focus on the what, why, whom, how, and where of preventive cardiology. Slide sets will be available on the ESC website for teaching purposes at medical schools, hospital meetings, and so on. Continuing medical education (CME) questions on the field of prevention will be created to enable cardiologists to earn CME points. Finally, an implementation group will create a European toolkit. The final chapter of the 2012 CVD Prevention Guidelines is devoted to a discussion of political activities at national and EU levels. It recognizes the fact that changing human behaviour is a political issue. ‘If we want to change behaviour we also need the political decisions’, says Perk. ‘We talk about building cities, creating surroundings where people can move around, promoting healthy food. All these things are at the level of the politicians’. The smoking ban is an excellent example of how political decisions can help people make lifestyle changes, with resulting benefits on heart health. Doctors need to become engaged at the political level, talking to politicians and pressing them to make population decisions that create a healthier environment. It goes back to the evidence that 75% of the gains in the western world have been at the population level. The guidelines assert that doctors should continue their clinical activities but extend that to promoting healthy behaviour in populations.