Immediate implementation of three 2019 European Society of Cardiology guidelines in daily practice
Authors: Sarnighausen H , Gaertner L S , Willner-Sarnighausen C 
Published: October 2021

Abstract

Background
The prognosis of patients depends on their cardiovascular risk. In the 2019 ESC guidelines [I, II, III] new health targets were defined. The manifestation of cardiovascular disease, diabetes mellitus and its complications and renal function had to be considered. This is a real challenge in daily practice.

Purpose
Could the five modifiable health targets blood pressure, hbA1c, LDL, weight loss and smoking cessation be changed in primary and secondary prevention immediately after the release of the 2019 ESC guidelines in a prospective observational trial in primary care?

Methods
Patients from 40 to 75 years of age were identified from 03 SEP to 02 DEC 2019 and followed up three to six months later, until 02 JUN 2020. The CV-risk was calculated. For the informed patient, the best evident therapy was recommended and best support, including lifestyle and diabetes counselling and sport programs provided, as needed. With diabetics, achievements were discussed with the German diabetes pass.

Results
303 patients were identified as 63.7% males, 74.9% diabetics, 69.3% impaired renal function, 64.7% in primary prevention. The calculated CV-risk was higher in the elderly (74.2% were ≥60 years of age). 78.2% had a high or very high CV risk. Renal function declined with ageing (Table 1).
Blood pressure and HbA1c values remain stable. LDL values, below 100 mg/dl at start, were reduced in all CV-risk groups after 3–6 months. One third (33.6% of n=217) reached their LDL target. In secondary prophylaxis the LDL value was reduced above 10 mg/dl and 29% of n=72 reduced LDL value below 55 mg/dl. In the highest CV-risk group 22.6% dropped LDL &lt;55 mg/dl. The number of reached health targets raised from 2.1 to 2.5 during the observation. At least 36% of patients reached more health targets (Table 2).

Conclusions
It is difficult to reach LDL targets in Europe documented in an ESC/EAS Survey [IV]. In the START Registry [V] only 3.2% of the very high-risk patients reached LDL values below 55 mg/dl. The proportion of patients with very high-risk that reached an LDL value below 55 mg/dl could nearly be doubled in this observation. But many patients do still not reach at least three of five health targets and nearly two thirds should lower their LDL value further especially in secondary prophylaxis. Disease management programs should be empowered to ask for reached health goals. New therapeutic options are available as PCSK-9 inhibitors, small interfering RNA molecules (inclisiran), ATP-Citrat-Lyase inhibitors (bempedoinic acid) to reduce LDL values in addition to statins or without. Antisense oligonucleotides (pelacarsen) can change prognosis for patients with very high liporotein(a) values.
Abbreviations: CV, cardiovascular; CKD, chronic kidney disease; CHD, coronary heart disease; PAD, peripheral artery disease; TIA, transient ischemic attack; ICA, internal carotid artery; UNK, unknown.

Funding Acknowledgement
Type of funding sources: None. Table 1. Observed populationTable 2. Reached health targets