Systematic genetic studies are not recommended. A family history of premature CVD increases the individual's risk, though it may be difficult to determine if this is due to a genetic component or a common environment. Either way, information on family history is easy to obtain, although the guidelines acknowledge that the application of such information is complex.

The new guidelines discourage the generalized use of biomarkers and imaging and adhere to the SCORE system to identify CVR. Routine use of biomarkers is not recommended due to their lack of added value; no distinction is made between the different types of biomarker. There is a short section on imaging techniques and their role in further quantifying CVR; the information on their predictive capacity for cardiovascular events is inconsistent, and the economic implications of their use require assessment. Specifically, coronary artery calcium scoring with computed tomography has a class IIb recommendation in these guidelines (compared with IIa in previous guidelines). Such recommendations are in line with the latest American guidelines,7 which reserve imaging for intermediate-risk situations, with some limitations.

Moderate chronic kidney disease (CKD) confers a high CVR classification, and severe CKD (glomerular filtration rate < 30mL/min/1.73 m2) confers a very high CVR.

There is call for increased recognition of chemotherapy-induced cardiotoxicity, and cardioprotective measures are proposed. Patients with heart disease or existing increased CVR are the most likely to develop cardiotoxicity. The guidelines propose early diagnosis using a combination of longitudinal strain techniques on echocardiography and biomarkers such as troponin. Gaps in knowledge include the most suitable type of cardioprotective therapy and the timing of cardiotoxicity screening, given the possibility of late onset complications. In Spain, we must look at how to apply these recommendations. The SEC has already voiced its opinion and considers cardiotoxicity detection to be a quality criterion with added value.8

Within the risk assessment section, there is a new section aimed at addressing the persistent gaps in evidence.

The evidence is unchanged for cognitive-behavioral strategies and multimodal interventions with a class I level A recommendation for involving patients in their disease management. The recommendation that health care professionals be involved has increased from class IIa to class I, with level A evidence. As with previous guidelines, the question arises of how best to apply such guidelines given the lack of adequate specific training and the current pressures in the health care setting.

There is new evidence (class IIa level A) on the treatment of psychosocial risk factors, and it is recommended to refer for treatment if the psychosocial risk factor is a diagnosable disorder (eg, depression) or if risk factors could worsen the classic CVRFs. There is still no evidence on the effect of anxiety on CVD.

There are some small changes in the evidence and new concepts on physical exercise. The guidelines focus less on the known beneficial effects and pathophysiology, with a more practical focus on exercise training.

The guidelines continue to recommend aerobic exercise, whether with specific types of exercise (eg, swimming, running) or with everyday activities. To define exercise levels, intensity is expressed in terms of absolute intensity (MET) or relative intensity (effort level). Relative intensity refers to the percentage of maximum heart rate, the perceived exertion (Borg scale), or frequency of breathing (level of exercise that does not impede speaking).

Exercise duration recommendations (class I level A) are unchanged from previous guidelines, although the units have changed from hours per week to minutes per week. Recommendations are for 150minutes per week of moderate-intensity (activities such as golf, tennis doubles, cycling, gardening, and brisk walking) or 75minutes of high-intensity exercise (activities such as race-walking, running, tennis singles, higher-speed cycling, heavy gardening, and swimming).

For additional benefits, a longer duration is suggested, of 300minutes per week of moderate intensity or 150minutes per week of high-intensity or a combination of the two (class I level A). Sessions are recommended to last at least 10minutes, particularly for those unable to exercise for prolonged periods (class IIa level B). Exercise should be taken every day, and at least 3 to 5 times per week.

The guidelines place new importance on muscular strength physical activity and neuromotor activity (eg, agility, balance, coordination). However, they contain no evidence on the recommended quantity or the long-term prognostic effects on CVD. Interval training and high-intensity training are not yet recommended, until further studies are conducted.

There are new recommendations on medical evaluation prior to the start of physical activity. For the healthy low-CVR population, only a basic clinical evaluation is required (class I level C). Exercise testing should be considered for sedentary individuals with risk factors who want to start a vigorous physical activity or sport (class IIa level C).

A class I level B recommendation suggests regular assessment and counselling by medical professionals to encourage patient engagement.

The most cost-effective measure for CVD prevention is stopping smoking. Cardiovascular risk increases even with low levels of smoking, passive smoking, and other forms of tobacco consumption (pipe, water pipe, “light” cigarettes, etc), therefore such situations should not be a reason for the patient or physician to ignore or avoid smoking cessation advice. After myocardial infarction, early and ongoing intervention is important to avoid relapse.

Despite a small decrease in smoking in Europe, mainly in adult men, smoking rates have increased in women and socially disadvantaged individuals, including adolescents.

The evidence has been updated on the efficacy and safety of drugs such as bupropion and varenicline, and these drugs are recommended alone or in combination (class I level A). Varenicline appears to be more effective than bupropion or nicotine replacement therapy.

Electronic cigarettes are a new addition to the guidelines: evidence on their effectiveness in smoking cessation is limited, and moderate at best, although they may be considered as a risk reduction strategy in some individuals while more robust results are awaited.

The guidelines contain is a specific section on population strategies. Adolescence is the most vulnerable period for starting smoking, and applying high levels of tax to all tobacco products is the most effective method to reduce the numbers of new young smokers. Tobacco smoke must be restricted due to the solid evidence on its damaging effects, as should electronic cigarettes due to the uncertainty over their effects and safety. Neutral packaging is effective, and advertising, promotions, and sponsorship restrictions are recommended. The goal of such common European measures would be to achieve a smoke-free Europe by 2030.

The recommendations on diet type prevail. The Spanish PREDIMED trial9 has helped strengthen the evidence that the Mediterranean diet is the most heart-healthy, and the DASH diet is advocated for hypertensive patients. There is still no evidence on the use of vitamin supplements. In addition, the lower limit of healthy body mass index (BMI) is set at 20kg/m2; the upper limit remains at 25.

A daily fiber intake of more than 7g and 10g is shown to be associated with a 9% and 16% lower risk of stroke and coronary artery disease, respectively. There is evidence (from meta-analyses) that a regular intake of fruit and vegetables (5 pieces per day) and walnuts or mixed nuts (30g/d) reduces CVR, although there are no data from randomized control trials. There is also evidence from prospective studies on CVR reduction with a weekly intake of fish, attributed to the omega-3 fatty acid content, although 3 randomized trials have shown negative results.

One of the most remarkable aspects of the guidelines is the doubt cast regarding alcohol consumption, contrary to the potential benefits in CVR reduction from red wine polyphenols. An analysis of 59 epidemiological studies showed that the lowest level of CVR is observed in those who abstain from alcohol, and that any quantity of alcohol consumption is associated with increased BP and BMI.10.

The guidelines highlight that in individuals younger than 60 years, all-cause mortality is lowest when BMI is between 20 and 25. A healthy weight in elderly people is higher than the healthy weight of younger patients and other adults.

The guidelines reflect on the growing interest around the concept of the metabolically healthy obese phenotype. They explain that there is a subgroup of obese individuals that are resistant to metabolic complications such as hypertension and insulin resistance; however, individuals with metabolically healthy obesity have a higher risk of all-cause mortality than those with a healthy weight.11 The long-term results suggest that metabolically healthy obesity is a transition phase toward glucometabolic abnormalities rather than a specific clinical state.

Diet, exercise, and lifestyle changes remain the cornerstone for weight control, despite a lack of long-term success. Orlistat and bariatric surgery are still recommended as alternatives.

In 2016, new guidelines will be published on dyslipidemia; these will be analyzed in a separate article. The most contentious new point in those guidelines is likely to be the advised 50% reduction in low-density lipoprotein cholesterol (LDL-C), going beyond the targets of < 70mg/dL in very high-risk patients or < 100mg/dL in high-risk patients: this could mean LDL-C concentrations of as low as 35 to 50mg/dL. For the rest of the population, LDL-C levels of < 115mg/dL are advised.

Although these levels have been shown to be safe in both the IMPROVE-IT trial and studies on PCSK9 inhibitors, physicians should be prudent until more information is available. For statins or ezetimibe, each 1 mmol reduction in LDL-C lowers the relative risk of a CV event by approximately 20% to 22%. Also, as shown in the meta-analysis by Boekhold et al.,12 there may be an even greater risk reduction with values below 50mg/dL. It is still unknown whether PCSK9 inhibitors will have similar effects.

A multifactorial approach is essential. The widespread claim that all diabetic patients have a CVR similar to that of coronary patients has been withdrawn, as the initial phases of type 2 diabetes mellitus cannot be considered a coronary disease risk equivalent.

The guidelines reaffirm the need for early glycemic control; the general aim is for glycosylated hemoglobin (HbA1c) of < 7%. Strict control is not advised for frail or elderly patients, or those with established CVD but otherwise (and provided there are no hypoglycemic episodes) a target of HbA1c < 6.5% may be considered. Regarding drug therapy, the guidelines echo the study results of noninferior cardiovascular safety of various dipeptidyl peptidase 4 (DPP4) inhibitors and glucagon-like peptide 1 (GLP1) receptor agonists. However, saxagliptin increased the rate of hospitalization for heart failure, and the lack of additional cardiovascular benefits from such agents is stressed. Metformin is considered the first-line therapy. An important update is the recommendation (IIa) of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with type 2 diabetes mellitus and associated CVD. These are the first guidelines to recommend SGLT2 inhibitors for diabetic patients with CVD, suggesting a class effect, though this could be debated.

Recommendations on blood pressure control are similar to previous recommendations, with a general target of < 140/85mmHg. A recent meta-analysis identified a group of young patients in whom a target of < 130/80 reduced morbidity but not mortality.

In line with the American societies, the guidelines on lipid control suggest a cutoff of 40 years after which taking statins is beneficial. Although this is a new recommendation since the 2012 guidelines, the evidence that it is based on is unchanged, making the current class I recommendation surprising.

Primary prevention with aspirin is not recommended. Microalbumin measurement is advised to identify which patients should be started on renin-angiotensin inhibitors. The guidelines do not discuss the role of coronary artery disease screening in individuals with type 2 diabetes mellitus.

There is a specific section on type 1 diabetes mellitus, describing the different pathophysiology to type 2 diabetes mellitus. However, the targets and general focus are very similar. The only difference is a target BP of < 130/80mmHg.

There are no substantial changes in the field of hypertension. In the general recommendations, some evidence levels have been reviewed and changed and there are slight modifications to some aspects.

Regarding office BP measurement, BP values should be verified with “at least 2 BP measurements per visit and on at least 2 visits” (the 2012 guidelines stated “several times, on several separate occasions”). If BP is only mildly elevated, this should be followed up over several months. Blood pressure should preferably be measured at the arm. A new point specifies that automatic methods are invalid for patients in atrial fibrillation. The diagnostic roles of ambulatory blood pressure measurement (ABPM) and home blood pressure measurement (HBPM) are described as complementary, not competitive, and the value of night-time BP measurements in predicting events is noted. Devices should be calibrated periodically, ideally every 6 months. Carotid Doppler, ankle-brachial index, and pulse wave velocity measurement are not recommended as additional investigations.

The decision to treat must be based on both BP levels and total CVR measured using SCORE (as in 2012). We are reminded that assessment of target organ damage, including subclinical damage, is highly useful, particularly with intermediate SCORE values (1%-4%).

Treatment recommendations are similar to previous guidelines. In the decision to start early pharmacological treatment, the guidelines stress the importance of risk stratification, although in grade 3 hypertension, early pharmacological treatment is essential independently of risk level. For patients older than 60 with a systolic BP ≥ 160mmHg, the target BP should be 140 to 150mmHg.

This section is practically unchanged, other than the statement on role of the polypill, which may be considered (IIb B) as a means to increase treatment adherence and improve control of CVRFs.13

In the section on the cost-effectiveness of prevention, the guidelines highlight the limitations of current studies, which are mostly based on simulations rather than clinical trials or real life.

This new section reflects the aim that the guidelines should provide stakeholders with evidence-based suggestions to create a social environment that promotes healthy lifestyle choices as the default. Such modification of the social environment is wide-ranging, from local interventions to national and international policies. The guidelines highlight the responsibility of health professionals to take an active role in advocating such evidence-based interventions at the population level.

The recommendations center on promoting a healthy lifestyle and are divided into 5 main groups: diet, physical activity, smoking, alcohol abuse protection, and healthy environment (environmental pollution). Although the recommendation levels follow the same format as the rest of the ESC guidelines, their basis differs (the highest recommendation level corresponds to “consistent findings from several high-quality studies”, and not necessarily robust randomized clinical trials).

The dietary measures proposed include promoting production of and access to healthy products, legislative regulation of potentially harmful contents and advertising aimed at vulnerable populations, economic incentives using pricing policies, and the creation of healthy environments (school, work).

New importance is given to physical exercise. The guidelines assert that physical activity should be promoted at a population level with specific policies starting in childhood. The main messages are that regular exercise is recommended for men and women throughout life for at least 150minutes per week if moderate-intensity and 75minutes if vigorous-intensity. In childhood, a minimum of 30minutes and preferably 60minutes per day of exercise should be encouraged in schools, and availability of spaces and equipment for this should be increased (class I recommendation). Breaks between academic classes should be considered, integrating exercise into the everyday timetable, for example with supervised walking routes to get to school (class IIa recommendation). Similar measures are recommended in the workplace for the adult population.

The recommendations work on the idea that small changes in population CVRFs lead to a greater reduction in the disease burden than large changes in high risk individuals only.14