What are the recommended management strategies for cardiovascular disease according to the World Health Organization (WHO)?

WHO-Endorsed Cardiovascular Disease Management Strategies

The WHO recommends a comprehensive three-tiered prevention strategy combining population-level interventions (tobacco control, dietary modifications, physical activity promotion), high-risk individual screening with total cardiovascular risk assessment, and evidence-based pharmacological treatment targeting blood pressure control, lipid management, and antiplatelet therapy for those with established disease. 1

Core Prevention Framework

The WHO endorses three complementary prevention strategies that must work in concert 1:

• Population-level prevention targets entire populations through lifestyle and environmental changes without requiring individual medical examination, achieved through policies and community interventions 1
• High-risk primary prevention identifies healthy individuals in the upper part of the cardiovascular risk distribution for targeted intervention 1
• Secondary prevention manages patients with established cardiovascular organ damage or disease 1

Population-Level Interventions (WHO Priority Actions)

The WHO Global Hearts initiative provides six technical packages (HEARTS) for cardiovascular disease prevention 1:

• Training health workers to counsel on behavioral risk factors and promote healthy lifestyles 1
• Implementing simple, standardized treatment protocols for hypertension and diabetes using evidence-based approaches 1
• Ensuring access to essential medicines (generic antihypertensives, statins, antiplatelet agents) and basic technology (blood pressure monitors) 1
• Adopting risk-based management using country-specific cardiovascular risk charts appropriate to local populations 1
• Implementing team-based care with task-shifting to trained community health workers 1
• Establishing monitoring systems with standardized indicators like hypertension control rates 1

Specific Policy Recommendations

The WHO strongly endorses population-wide interventions 1:

• Tobacco control through the WHO Framework Convention for Tobacco Control 1
• Dietary modifications: reducing saturated fat in national diets, reducing salt in processed foods, increasing fruit and vegetable consumption 1
• Physical activity promotion through urban planning and community programs 1
• Weight reduction programs at the population level 1

The European guidelines specifically recommend addressing external risk factors through urban planning—relocating housing away from highways and polluting industries, reducing fossil fuel consumption with tax incentives for hybrid/electric vehicles 1

Individual Risk Assessment and Stratification

Total Cardiovascular Risk Approach

Policy recommendations must emphasize a total risk approach rather than treating individual risk factors in isolation 1:

• Assessment of total CVD risk should be based on epidemiological data appropriate to the specific population 1
• The intensity of interventions should be proportional to total cardiovascular risk, with lower treatment thresholds for higher-risk patients 1
• Risk assessment can be based on age, sex, body mass index, blood pressure, smoking status, diabetes, and history of CVD 1

When to Initiate Risk Assessment

CVD risk assessment is most important for guiding treatment decisions in individuals with systolic blood pressure 130-139 mmHg 1. However, risk assessment should not delay treatment initiation—whenever it may impede timely hypertension treatment or patient follow-up, it should be postponed and included as a follow-up strategy 1.

Pharmacological Management Strategies

Hypertension Treatment (WHO 2022 Guidelines)

Initiate pharmacological treatment for confirmed hypertension with systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 1:

• First-line drug classes (any of the following): thiazide/thiazide-like diuretics, ACE inhibitors, angiotensin receptor blockers, or long-acting dihydropyridine calcium channel blockers 1
• Combination therapy is preferred, ideally as single-pill combinations to improve adherence, using drugs from the above classes 1
• Target blood pressure: <140/90 mmHg for patients without comorbidities; <130 mmHg systolic for patients with known CVD 1

For individuals with systolic BP 130-139 mmHg 1:

• Initiate treatment if existing cardiovascular disease is present 1
• Consider treatment if high cardiovascular risk, diabetes, or chronic kidney disease is present 1

Diabetes Management in CVD Prevention

First-line therapy should be metformin or SGLT2 inhibitors (particularly with chronic kidney disease or heart failure with reduced ejection fraction) 1:

• HbA1C targets: <7% overall, <6.5% in early diagnosis without established atherosclerotic CVD, less aggressive in older/frail adults 1
• Second-line agents: SGLT2 inhibitors or GLP-1 receptor agonists for patients with additional atherosclerotic CVD risk factors 1

Lipid Management

Statin therapy should be used for stroke survivors and patients with other manifestations of CVD 1. The European guidelines emphasize treating stroke survivors identically to those with other cardiovascular disease manifestations 1.

Antiplatelet and Anticoagulation Therapy

For stroke prevention 1:

• Anticoagulation (INR 2-3) for patients with atrial fibrillation 1
• Aspirin 75-150 mg daily for non-cardioembolic ischemic stroke 1
• Aspirin plus dipyridamole provides additional risk reduction 1
• Clopidogrel has similar efficacy to aspirin in ischemic cerebrovascular disease 1
• Avoid clopidogrel plus aspirin combination in stroke survivors 1

Implementation Requirements

National Healthcare System Integration

Governments, national societies, and foundations must collaborate to develop clinical and public health guidelines targeting risk factors 1:

• Evidence-based guidelines should incorporate professional judgment translating evidence into effective, culturally and financially appropriate care 1
• National professional societies must inform policymakers of risk factor targets and drug therapies appropriate to their nation 1
• Governments should incorporate CVD prevention into legislation at all levels 1

Healthcare Worker Training and Task-Shifting

National professional societies must facilitate CVD prevention through education and training programs for health professionals 1. The WHO specifically endorses task-shifting to trained community health workers to overcome limited health infrastructure in low- and middle-income countries 1.

Monitoring and Quality Improvement

National cardiovascular societies must promote routine prospective collection of validated vital statistics on CVD causes and outcomes 1:

• Assess achievement of lifestyle, risk factor, and therapeutic targets defined in national guidelines 1
• Implement standardized indicators (such as hypertension control rates) with real-time monitoring systems 1
• Use hypertension registries to evaluate program efficacy and make adjustments 1

Critical Implementation Considerations

Common Pitfalls to Avoid

Do not delay pharmacological treatment while waiting for lifestyle modifications to work—most patients with average systolic BP ≥140 mmHg are at high risk and require immediate drug therapy 1. Laboratory testing should not delay or impede starting treatment 1.

Do not treat risk factors in isolation—the total cardiovascular risk approach is essential, as treating individual risk factors without considering overall risk leads to suboptimal outcomes 1.

Do not assume one-size-fits-all approaches work globally—an individual living in a "high-risk country" may have elevated cardiovascular risk despite absence of traditional risk factors due to external factors like air pollution, requiring population-level policy interventions 1.

Addressing Health Inequities

Remote health technologies and telemedicine may overcome obstacles from limited health infrastructure but risk creating new barriers for populations with lower income and education 1. Implementation research is needed to identify populations and contexts where these approaches work and their effects on inequalities 1.

Integration with Daily Clinical Practice

Health professionals must include CVD prevention as an integral part of daily clinical practice 1. Secondary prevention programs incorporating exercise have proven effective in improving processes of care, reducing readmissions, improving functional status, and reducing overall mortality 1.