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Cardiology · ESC

Cardiovascular disease prevention

ESC

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Source:2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice (with 2024 ESC HTN and 2025 ESC/EAS Dyslipidaemia focused updates)

Verified Apr 2026

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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)