Prevention of Cardiovascular Disease (Joint British Societies' Guideline)

• Estimate 10-year and lifetime CVD risk using JBS3 calculator (www.jbs3risk.com) - if CVD risk <10%, repeat within 5 years
• Risk assessment not needed in patients with existing CVD, diabetes >40 years, CKD stage 3-5 or familial hypercholesterolaemia* - proceed directly to lifestyle intervention and treatment
• JBS3 calculator includes:
   - Age and sex
   - Ethnicity
   - Family CVD history
   - Systolic BP
   - Smoking history
   - History of hypertension, diabetes, CKD, atrial fibrillation, rheumatoid arthritis
   - Height and weight
   - Non-fasting TC and HDL-C

• Reduce BP to <140/90mmHg or
   - <130/80mmHg in stroke, or CKD with albuminuria
   - 120/75-80mmHg in patients <40 years with type I diabetes and persistent albuminuria
   - <150/90mmHg if starting treatment at ≥80 years
• Reduce non-fasting non-HDL-C to <2.5mmol/L
• Maintain HbA_1c 48-58mmol/mol in type I diabetes

• Reduce fat intake; limit saturated fats to <10% of total fat intake
• Consume at least 2 servings of fish (preferably oily) per week
• Consume 5 portions of fruit and vegetables per day
• Limit weekly alcohol intake to <21 units (men) or <14 units (women)
• Limit salt intake to <6g/day
• Lose weight if appropriate
• Undertake regular physical activity comprising ≥150 mins moderate activity (in ≥10 min bouts) or ≥75 mins vigorous activity per week, incl two to three 30-40 min bouts of moderate to high intensity aerobic exercise, plus muscle strengthening activity at least twice weekly
• Stop smoking

• Implement statin therapy to achieve non-fasting non-HDL-C targets in patients with:
   - Established CVD (avoid in haemorrhagic stroke)
   - 10-year CVD risk ≥10%
   - High lifetime CVD risk where lifestyle changes alone insufficient
   - CKD stage 3-5
   - Familial hypercholesterolaemia*
• Type II diabetes and:    
   - ≥40 years
   - >40 years + ≥1 of the following: proliferative retinopathy; treated hypertension; persistent albuminuria; eGFR <60ml/min/1.73m²; autonomic neuropathy
• Type I diabetes and: 
   - ≥50 years
   - 40–50 years unless <5 year history of diabetes and no other CVD risk factors
   - 30-40 years + ≥1 of the following: >20 year history of diabetes and poor glycaemic control (HbA_1c >75mmol/mol); persistent albuminuria; eGFR <60ml/min/1.73m²; proliferative retinopathy; treated hypertension; smoking; autonomic neuropathy; TC ≥5mmol/L with HDL-C <1mmol/L in men or <1.2mmol/L in women; central obesity or family history of premature CVD
   - 18-30 years with persistent albuminuria
• Give aspirin 75-100mg daily (clopidogrel 75mg daily if aspirin not tolerated) in patients with: 
   - Recent MI (in combination with another antiplatelet for 1-12 months if bare-metal stent or 6-12 months if drug-eluting stent)
   - Acute coronary syndrome (in combination with another antiplatelet, eg prasugrel or ticagrelor)
• Give clopidogrel 75mg daily in peripheral arterial disease
• Give aspirin 300mg daily for 2 weeks then clopidogrel 75mg daily after acute ischaemic stroke in patients without atrial fibrillation (alternatively, modified-release dipyridamole +/- aspirin if clopidogrel contraindicated/not tolerated; or modified-release dipyridamole 200mg twice daily +/- aspirin 75-150mg daily if TIAs)
• Give warfarin (or newer oral anticoagulant) in patients with atrial fibrillation who have TIA or recent ischaemic stroke: target INR 2.5 (range 2.0-3.0)
• Ensure glycaemic control in diabetes
• Treat hypertension (see NICE guidance)
• See NICE, SIGN and ESC guidelines on use of beta blockers, ACE inhibitors/angiotensin II antagonists and aldosterone antagonists following MI
• Offer continuous positive airway pressure treatment to patients with obstructive sleep apnoea/hypopnoea syndrome as appropriate 

Further details in relevant prescribing notes/monographs.

*Specialist treatment required.