Significant advances in the prevention and treatment of cardiovascular disease (CVD) have been achieved in recent years. However, CVD remains the leading cause of death and a major cause of morbidity in Europe and many other regions.1 Worse cardiovascular health,2,3 along with cardiovascular risk factors4,5 and CVD, leads to substantial health care costs and imposes a significant burden for patients, families and society in Spain and worldwide.6 This situation poses a major challenge for health care systems. Despite this, there are few national plans specifically designed to enhance cardiovascular health and mitigate the burden of CVD through a comprehensive approach. Unlike cancer,7 there is no specific European plan to combat CVD.

In response to these challenges, and with the aim of reducing the burden of CVD in Spanish society while promoting equity in cardiovascular health promotion, prevention, and care among its 17 regions, the Spanish Ministry of Health developed its first national Strategy on Cardiovascular Health of the National Health System (ESCAV, Estrategia en Salud Cardiovascular del Sistema Nacional de Salud), which was released in 2022. This manuscript aims to summarize the methodology for the development of the ESCAV, outline its main content, and describe the initial steps for its implementation. It is intended as a potential model for other countries or as a reference for the development of a European plan.

CVD is the leading cause of death globally and a major contributor to morbidity, health care costs, and societal burden in all European countries.17,18 Despite its significant impact, CVD does not receive proportional priority in political planning or research funding. For instance, the European Union recently launched Europe's Beating Cancer Plan to address cancer prevention, treatment, and care, recognizing the growing challenges and opportunities in cancer care advancements.7 However, there is no equivalent European plan aimed at reducing the burden of CVD or enhancing cardiovascular health. This gap has been highlighted as an urgent priority by the European Society of Cardiology (ESC) in partnership with the European Alliance for Cardiovascular Health (EACH).19 To date, Spain appears to be the only country with a comprehensive plan to prevent and improve CVD care. A recent review of cardiovascular health plans in Europe identifies the Spanish Strategy as a leading example, alongside a funded CVD plan in Poland and initial efforts in Bulgaria (focused on a future CVD plan) and France (working on a White Paper).20 Given the major disparities in epidemiology, resources, care, and outcomes,21 there is an urgent need to invest in CVD prevention, care, and research at levels comparable to those dedicated to cancer prevention and care.22

After decades of positive epidemiological trends in CVD mortality, characterized by a steady decrease in CVD incidence and mortality, new societal changes are posing significant challenges to further progress. These include accelerated population aging, the growing prevalence of obesity5 and diabetes, social inequalities in cardiovascular risk factors, a rising number of patients living with chronic CVD due to better acute CVD care, and increasing rates of multimorbidity and dependence. Consequently, an increasing proportion of the population is living with disability and chronic CVD,23 resulting in a huge economic burden.24 This paradox stems from societal and health care advancements that have led to increased longevity and improved survival among individuals with CVD. As a result, there is a growing need for new actions to reduce the burden of CVD and enhance cardiovascular health across the population. These efforts must extend beyond the traditional focus on disease management and patient care to include a broader public health approach. Such an approach should address not only individuals with CVD but also the healthy population and the environmental factors that influence cardiovascular health.

Spain has released its first Cardiovascular Health Strategy, the most ambitious proposal ever developed to enhance the overall health of the Spanish population. This comprehensive strategy encompasses the promotion of cardiovascular health, primary prevention, early diagnosis, and the acute and chronic care of various cardiovascular syndromes (figure 1). Although Spain operates under a unified NHS, health care is delivered by 17 regional health care systems and 2 autonomous cities. This decentralized structure often results in regional differences that contribute to inequities in care. To address these disparities, the Spanish NHS Strategies were designed to promote equity and coherence in health care delivery across regions, aiming to minimize variations while allowing regional autonomy in planning, implementation, and service provision. The Ministry of Health has previously introduced several general strategies related to cardiovascular health in the NHS, including the Strategies on Diabetes,25 Stroke,26 Health Promotion and Prevention,27 Management of Chronicity,28 and the Strategy for Nutrition, Physical Activity and Obesity Prevention.29 These initiatives have served as a foundation for the Cardiovascular Health Strategy, which integrates and builds upon their principles.

Only one previous strategy had specifically focused on CVD: the Strategy on Ischemic Heart Disease, approved in 2006.30 Since then, no other dedicated strategy for CVD had been proposed. The new Cardiovascular Health Strategy represents a paradigm shift, moving from a focus on specific cardiovascular diseases to a broader emphasis on cardiovascular health. This expanded perspective includes the four most prevalent groups of CVDs and shifts attention beyond disease management to encompass the entire process of potential health loss. The strategy adopts a holistic approach, extending its scope from the health care system to society, from patients to citizens, and from health care professionals to all actors involved in health promotion and care.

This shift necessitates addressing the determinants of health, both individual and social, and implementing public health initiatives such as promoting sustainable living environments, population education campaigns, taxing unhealthy foods, and implementing measures to reduce tobacco and alcohol consumption. Additionally, the strategy emphasizes addressing factors contributing to worse health outcomes and inequities, such as socioeconomic conditions and access to education. While the central focus is on cardiovascular health, the strategy also identifies specific clinical areas requiring improvement, including: early diagnosis of heart failure and atrial fibrillation, optimization of regional networks for managing acute myocardial infarction,31 expansion to non–ST-segment elevation myocardial infarctions,32 cardiogenic shock,33 multidisciplinary management of chronic heart failure or aortic stenosis,34 increased cardiac rehabilitation and the development of a national plan for out-of hospital cardiac arrest.

The previous Strategy on Ischemic Heart Disease of Spain's NHS recommended the establishment of STEMI networks to achieve earlier and higher reperfusion rates in each Spanish region. The implementation of these networks progressed at varying speeds across regions, initially resulting in a regional disparity in STEMI mortality—higher in regions without established networks. However, this gap narrowed significantly after all regions implemented their respective STEMI networks.35 Other initiatives include the approval of the Spanish smoke-free law, regulations to reduce the availability of unhealthy foods in schools, and the more recent National Plan for Tobacco Prevention and Control 2024-2027. Given these precedents, it is reasonable to anticipate similarly positive outcomes from the new Cardiovascular Health Strategy. These results are expected to be particularly evident in terms of effectiveness and efficiency, especially when concrete actions with specific monitoring indicators are proposed.

Reducing regional inequalities is a fundamental objective of the ESCAV. Special emphasis has been placed on addressing gender inequities, as cardiovascular care has long been identified as a significant source of gender inequity in health care.36,37 Evidence of such inequities continues to be observed in Spain38,39 and other countries.40 Consequently, gender equity has been established as a cross-cutting theme throughout the ESCAV.

While the content of the strategy may apply to other countries or health care systems, the selection and prioritization of critical points, strategic aims, and actions need to be adapted to each context. The methods employed in the development of the strategy and the prioritization of its objectives may serve as a valuable resource for others seeking to create similar strategies or expand existing ones to address additional CVDs.

Although conceptually robust, implementing the ESCAV presents significant challenges. A wide range of indicators was selected to monitor its progress and assess the achievement of established objectives. However, the collection and measurement of these indicators remain far from routine practice and are often viewed as burdensome and complex. One major obstacle is the lack of automatic recording systems, which hinders efficient data collection. To address these challenges, improving registration and information systems is essential to enhance knowledge about cardiovascular health at the population level and CVD care within the health care system. This requires a framework to manage critical information: CVD care structures, processes, results, and quality indicators; standardizing data definitions; harmonizing data collection, integration, and sharing; considering all potential sources of information; and developing a systematic analysis plan for identifying needs and gaps while prioritizing improvement initiatives. These efforts are particularly critical given the ongoing transformations in data use regulations and artificial intelligence (AI) in Europe. Key regulatory frameworks, such as the General Data Protection Regulation (GDPR),41 European Data Space for Health (EEDS),42 and the proposed Artificial Intelligence Act (AIA),43 must be considered to ensure compliance and facilitate progress in cardiovascular health data management and analysis.

Despite potential skepticism regarding the ambition of the ESCAV to transform the national status of cardiovascular health—perceived by some as a naïve effort driven by voluntarism due to the lack of specific central funding—the success of the strategy will largely depend on its dissemination and the active involvement of key stakeholders. These include public institutions, scientific societies, and civil society. Encouragingly, early indicators of alignment with the ESCAV are evident in the growing number of activities and publications that reflect its principles and goals. Furthermore, the success of previous health strategies provides additional optimism, demonstrating the potential for meaningful impact through coordinated and sustained efforts.

The ESCAV represents one of the most ambitious initiatives ever undertaken to enhance cardiovascular health at the national level. The steps taken and the methodologies employed in the development of this strategy could serve as a reference for other countries and act as a catalyst for the creation of a comprehensive European plan for cardiovascular health.

All expenses related to the development of ESCAV were covered by public funding from the Ministry of Health, Spain.

During the preparation of this work, generative artificial intelligence was used exclusively to improve English language. The output was supervised and approved by the corresponding author.

H. Bueno, G. Seara, M. R. Azcutia, and M. J. Rodríguez-García were the scientific coordinators; S. Peláez and Y. Agra were the technical coordinators; and P. Aparicio Azcárraga was the technical leader during the drafting of the document of the ESCAV. C. A. Dueñas is the current technical coordinator of the rollout and development of the ESCAV and P. Gullón is the current technical leader of the rollout and development of the ESCAV. H. Bueno conceived the manuscript. H. Bueno and G. Seara drafted the manuscript, and all other authors critically reviewed its content contributing significantly to the final version.

None of the authors have conflicts of interest directly related to this work. Outside of this work, H. Bueno receives research funding from the European Union (EU4H-2022-JA-03), Instituto de Salud Carlos III, Spain (FORTALECE program, PI21/01572), the Spanish Society of Cardiology, AstraZeneca, Boehringer Ingelheim, Janssen, and Novartis; and has previously received consulting and speaking fees from AstraZeneca, Novartis, Novo Nordisk and Organon. All other authors have nothing to declare.