Red Flags
- SCORE2 10-year fatal+non-fatal CVD risk ≥ 10% in adults <50, ≥ 10% in 50–69, or ≥ 15% in ≥ 70 — high CVD risk; aggressive lipid and BP targets[1]
- LDL-C ≥ 4.9 mmol/L (190 mg/dL) — likely familial hypercholesterolaemia regardless of risk score; high-intensity statin and family screening[1]
- Diabetes with target organ damage (CKD, retinopathy, established CVD) — automatic high or very-high CV risk regardless of calculated SCORE2[1]
- Cumulative tobacco use, severe obesity (BMI ≥35), and metabolic syndrome — risk-amplifying factors that warrant earlier intervention thresholds[1]
First-line treatment
Interventions
- Lifestyle counselling — stepwise approach[1]Mediterranean dietary pattern, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, alcohol ≤10 g/day, smoking cessation. First step for low-risk; foundation for all higher-risk tiers
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Atorvastatin[2] | HMG-CoA reductase inhibitor (statin) | Start 10–20 mg PO daily for high-risk (LDL-C goal <1.8 mmol/L); 40–80 mg for very-high-risk (goal <1.4 mmol/L) | — | Step 1 of stepwise lipid management. Add ezetimibe if not at goal at 4–6 weeks |
| Ezetimibe[2] | Cholesterol absorption inhibitor | 10 mg PO once daily | — | Step 2 — added when statin alone insufficient. ESC 2025 recommends earlier combination |
| Single-pill antihypertensive combination (ACE-i/ARB + CCB or thiazide)[3] | Combination antihypertensive | e.g. perindopril/amlodipine 4/5 mg PO once daily, up-titrate as needed | — | ESC 2024 recommends starting with single-pill combination when BP ≥160/100 or ≥20/10 above target |
| Empagliflozin[1] | SGLT2 inhibitor | 10–25 mg PO once daily | — | Add in T2DM with established CVD or high CV risk; cardio-renal protection independent of glycaemic effect |
Atorvastatin[2]
HMG-CoA reductase inhibitor (statin)
- Adult
- Start 10–20 mg PO daily for high-risk (LDL-C goal <1.8 mmol/L); 40–80 mg for very-high-risk (goal <1.4 mmol/L)
- Paediatric
- —
Step 1 of stepwise lipid management. Add ezetimibe if not at goal at 4–6 weeks
Ezetimibe[2]
Cholesterol absorption inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- —
Step 2 — added when statin alone insufficient. ESC 2025 recommends earlier combination
Single-pill antihypertensive combination (ACE-i/ARB + CCB or thiazide)[3]
Combination antihypertensive
- Adult
- e.g. perindopril/amlodipine 4/5 mg PO once daily, up-titrate as needed
- Paediatric
- —
ESC 2024 recommends starting with single-pill combination when BP ≥160/100 or ≥20/10 above target
Empagliflozin[1]
SGLT2 inhibitor
- Adult
- 10–25 mg PO once daily
- Paediatric
- —
Add in T2DM with established CVD or high CV risk; cardio-renal protection independent of glycaemic effect
Safety-net
- Cardiovascular risk is cumulative — small daily habits over years compound. Stay consistent with diet, activity, and any prescribed medications[1]
- Statins, blood pressure medications, and SGLT2 inhibitors are taken lifelong unless your clinician explicitly stops them[1]
- Reassess your cardiovascular risk every 5 years, or sooner if your weight, blood pressure, smoking status, or family history changes meaningfully[1]
Referral criteria
- LDL-C ≥ 4.9 mmol/L or strong family history of premature ASCVD or tendon xanthomasLipid clinic for familial hypercholesterolaemia evaluation and family cascade screening[2]
- SCORE2 ≥ 15% in age <60 OR uncertainty about treatment intensityCardiology / preventive cardiology for shared decision making and CAC scoring[1]
- Resistant hypertension or suspected secondary causeHypertension clinic[3]
- T2DM with established CVD, heart failure, or CKD not on SGLT2 inhibitor or GLP-1 receptor agonistDiabetes or cardiology clinic for cardio-renal-protective therapy[1]
Clinical summary
Risk-stratified primary prevention of atherosclerotic cardiovascular disease across lipid, blood pressure, glycaemic, and lifestyle interventions.
References
- 1.2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice (with 2024 ESC HTN and 2025 ESC/EAS Dyslipidaemia focused updates) (2021)
- 2.2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal / Atherosclerosis (2025)
- 3.2024 ESC Guidelines for the management of elevated blood pressure and hypertension. European Heart Journal (2024)