Invitation

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IMPROVING CARDIOVASCULAR HEALTH IN EUROPE: THE CASE FOR EU AND NATIONAL CVH

PLANS

Hungarian Ministry of Health in collaboration with the European Society of

Cardiology

Ministerial Foreword

At this pivotal moment, under the Hungarian Presidency of the Council, we are poised

to take a decisive step forward in the fight against cardiovascular diseases (CVDs) in

Europe. This leadership opportunity allows us to spearhead initiatives that prioritize

heart health at the highest levels of policy and public discourse. The Hungarian

Presidency is deeply committed to leveraging this period to galvanize support, foster

cross-border collaborations, and champion comprehensive strategies that address the

root causes and disparities associated with CVDs.

Our approach is holistic, recognizing that a multifaceted strategy is required to

effectively combat against cardiovascular diseases. This includes promoting healthy

lifestyles across all age groups, advancing public health policies that target risk

reduction, and ensuring that innovations in medical research and high level healthcare

delivery are equitably accessible. The Presidency aims to highlight the critical role of

prevention, advocating for environments that support physical activity, healthy

nutrition, and mental health and well-being, alongside fighting against – inter alia -

tobacco and alcohol consumption which are significant risk factors for CVDs.

Furthermore, recognizing the disparities in accessing health services as well as in

health outcomes between and within European countries, the Hungarian Presidency

calls for a renewed focus on health equity. This means advocating for policies that

ensure all Europeans, regardless of their socio-economic status or geographical

location, have access to the necessary health services. It involves pushing for

investments in health infrastructure, from rural clinics to advanced urban centres, and

promoting the use of digital health technologies to bridge gaps in care delivery.

Health innovation is another cornerstone of our vision for a heart-healthy Europe. The

Hungarian Presidency encourages the adoption of cutting-edge technologies and

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research in cardiovascular care, from telemedicine to personalized medicine

approaches that can significantly improve patients’ health outcomes. This period of

leadership is seen as an opportunity to foster an innovative and resilient European

health ecosystem that is also responsive to the needs of its citizens.

As we mobilize these efforts, the importance of collaboration cannot be overstated.

The Hungarian Presidency seeks to inspire partnerships across nations, sectors, and

disciplines, bringing together health providers, researchers, policymakers,

communities and patients to share knowledge, experiences and best practices and

resources. This collaborative spirit is essential for achieving sustainable change and

our shared goal of significantly reducing the burden of cardiovascular diseases across

Europe. In line with this, the “Healthier Together” EU non-communicable diseases

initiative will serve as a cornerstone, providing a robust foundation to unite our efforts

and enhance the improvement of collective health outcomes.

To underscore the urgency of our mission, we should carefully consider the stark

realities: cardiovascular diseases are one of the leading causes of mortality worldwide,

claiming nearly 18 million lives each year. In Europe alone, CVDs account for 37% of

all deaths, translating to over 1.7 million lives lost annually. This not only represents a

profound loss of life but also imposes a significant economic burden, costing EU

economies an estimated €282 billion in 2021 alone. These figures are not just statistics;

they represent fathers, mothers, siblings, children and friends whose lives are cut short

by preventable conditions.

Our vision for the future is one where cardiovascular health is not just a matter of

individual concern but a collective priority that shapes policies, health systems, and

societal norms. It is a future where every European has the opportunity to live a longer,

healthier life free from the burden of CVDs. Through the initiatives and leadership of

the Hungarian Presidency, we are committed to contribute to the future, driven by a

commitment to public health, equity, and innovation. Together, we can transform the

landscape of cardiovascular health in Europe, creating a legacy of well-being for

generations to come.

Dr Péter Takács

Minister of State for Health

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Foreword – Professor Franz Weidinger, President of European Society of

Cardiology

Neglect and a lack of public investment in cardiovascular health threatens to undo hard

fought trends in reducing mortality in cardiovascular disease. Today cardiovascular

disease represents not only the biggest cause of death in the EU but is reflective of

deep inequalities and inequities that we see across the Union.

From environment to employment, from climate change to demographic change, from

infrastructure to research investment, the impact of cardiovascular disease can be felt

everywhere except in policy.

The EU institutions aim to adhere to the principle of evidence-based decision making.

Given that cardiovascular disease is the biggest killer in the Union today and comes at

a cost of 100 billion euro more than the entire EU budget, we have the evidence to

justify meaningful policy action.

We should not deceive ourselves in thinking that we can avoid expenditure. We will

pay the price for CVD one way or another. The question is will we decide to invest now

and save lives and protect our economies, or be forced to pay later in lives lost and

broken health systems?

No Member State should be without a plan to tackle the biggest threat to the lives of

its citizens, nor should we view such a plan as solely the responsibility of health

ministries.

Action to promote cardiovascular health is the fight for gender, generational and

geographical equity. It is the fight against ageism and structural inequalities. It is the

means to enable a silver economy and keep our systems sustainable. It is the public

health campaign of this generation.

This paper is intended to inform discussions on cardiovascular health and provide

general policy suggestions which may help to preserve it.

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TABLE OF CONTENTS

Summary ............................................................................................................................................... 5

Current burden of CVDs across the EU........................................................................................ 7

Geographic disparities .................................................................................................................. 9

Gender inequalities ...................................................................................................................... 10

Generational inequalities ........................................................................................................... 12

Improving primary prevention of CVD across all ages .......................................................... 13

Risk factors in the context of primary prevention ................................................................... 15

Improving primary CVD prevention in the primary-care setting – spotlight on Hungary

............................................................................................................................................................... 18

Reducing the impact of environmental stressors ................................................................... 20

CVD and mental health ................................................................................................................... 22

Providing adequate secondary prevention strategies ........................................................... 23

Avoiding repeat cardiovascular events .................................................................................. 25

Restoring CVD innovation in the EU ........................................................................................... 27

Regulatory challenges impeding new CV treatments ........................................................ 28

Enhancing support for personalised CV medicine ............................................................. 28

Supporting registries and real-world studies to enable the EHDS and fuel research 29

Improving access to care and reducing inequalities .......................................................... 30

Righting current wrongs in rehabilitation .................................................................................. 31

Conclusion ......................................................................................................................................... 33

References ......................................................................................................................................... 34

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Summary

Cardiovascular diseases (CVDs) are disorders related to the heart and circulatory

(vascular) system, which include ischaemic heart disease (IHD), stroke, heart failure

(HF), heart rhythm disturbances (e.g., atrial fibrillation), hypertension, congenital heart

diseases, inherited cardiac conditions, and diseases of the aorta, heart valves and

peripheral arteries.

Today cardiovascular disease represents the biggest killer in the EU accounting for 1.7

million deaths each year and comes with an economic cost of 100 billion euro more

than the entire annual EU budget.

This burden is not distributed evenly but is reflective of deep-seated inequalities in the

EU spanning geographies, genders and generations.

In recent years and particularly since COVID-19, there has been an increased

awareness at EU and national level of the threat that CVDs represent to life and

livelihood. The inability of Non-Communicable Disease (NCD) plans to deliver

meaningful results and the ambitions of the EU Beating Cancer plan have put a new

spotlight on the need for action on the biggest threat to the lives of EU citizens.

Just over 50% of CVDs could be prevented by lowering blood pressure, cholesterol

and weight, by stopping smoking and controlling diabetes; however, these risk factors

are highly prevalent in the general EU population, suggesting the need for an increased

roll out of evidence based primary prevention programmes to the benefit of future

generations.

Given that many countries such as the UK demonstrate rising levels of CVD death in

those under 75 years of age, implementing multiple types of prevention measures –

from early life to old age – is crucial1.The issues are much more complex than blaming

individuals – they require population-level policy interventions and a mindset shift.

Environmental stressors also contribute to CV risk. There is increasing understanding

of the links between different CVDs and pollution, noise exposure and climate change,

representing another critical area for action.

Currently, there is lack of screening for CV risk factors, including hypertension, and

also missed opportunities to screen for, and diagnose, a wide range of CVDs that are

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not caused by modifiable factors. Some common CVDs, such as heart failure, are often

diagnosed late in their disease course, missing an important opportunity to delay

progression and leading to an unnecessarily heavy burden of morbidity,

hospitalisations and untimely death. Novel tools have been developed to enable earlier

diagnosis, but these are not always widely available or used. Similarly, some CVDs

can be effectively treated with established and novel treatments or procedures, but

these may not be widely available in certain countries or are not implemented

appropriately.

Many CVDs lack effective treatments that target their molecular cause and, despite the

enormous healthcare burden, the developmental pipeline of new CV drugs is limited,

with no new therapies coming to market in CVD in 2022. Innovation is needed to

develop new diagnostics and treatments, personalised for patient needs, which are

integrated into care models and widely accessible.

Patients with CVD are often at high risk of another CV-related event or disease.

Appropriate secondary prevention strategies, including risk factor control and patient

education, and multidisciplinary rehabilitation should be initiated rapidly to improve

prognosis. Best-practice guidelines have been developed by medical societies,

including the ESC. Yet, access, implementation, quality and adherence are often

suboptimal and there remain wide inequalities between and within EU countries.

It is suggested that a meaningful reduction in the burden of CVDs across the Union

cannot be reached without a stand-alone plan for the EU’s biggest killer. Such an EU

framework, supported by National Action Plans on Cardiovascular Health would

ensure the needs of citizens in prevention, diagnosis treatment and rehabilitation are

effectively met as well as tackling the environmental stressors and co-morbidities that

drive CVDs. The joint action on cardiovascular diseases and diabetes with the funding

of €53 million from EU4health programme provides a basis for developing national

plans and strategies on cardiovascular disease as well as on diabetes and their

interlinked risk factors. In addition, with an unprecedented budget of €75 million

Member States are collaborating under the joint action to address common risk factors.

These collaborative actions are the starting point for both developing national plans in

the future, as well as implementing the joint EU Action Plan in countries with national

action plan already in place.

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Current burden of CVDs across the EU

Despite a decline in CV mortality in many countries in the European Union (EU), CVDs

remain the most common cause of death, accounting for about 1.7 million deaths

across EU-27 member countries, which equates to 37% of all deaths. [Timmis 2022 -

ESC Atlas].

Many patients suffer from the long-term effects of CVDs, living for years with

considerable disability. An estimated 53 million people were living with CVDs in EU-27

in 2021 [Timmis 2022], making CVD the biggest cause of death today.

Figure 1. National causes of death in EU27 [Timmis 2022 - ESC Atlas]

The economic burden is enormous for healthcare systems, for society and for patients

and their families. In 2021, CVDs were estimated to cost the EU €282 billion, which is

roughly 100 billion more than the EU budget [Luengo-Fernandez 2023]. Around €155

billion – 55% of the total – was attributed to direct health and long-term care costs,

equalling 11% of total EU health expenditure. Productivity losses associated with early

mortality and incapacity for work were estimated at €32 billion and €15 billion,

respectively, and the cost of unpaid care by friends/relatives was estimated at €79

billion. When expressed per capita, the total CVD cost equals €630 per EU citizen,

ranging from €381 in Cyprus to €903 in Germany, after adjustment for price

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differentials1. In addition to mortality, morbidity and cost, the experience of a heart

attack or stroke can also have a profound and lasting impact on the quality of life (QoL)

of those affected as well as their families or carers, causing substantial stress, anxiety

and, in some cases, depression, which are associated with significantly worse

outcomes [Iles-Smith 2015; Mitchell 2017].

Figure 2. Total CVD costs per capita adjusted for price differentials [Luengo-

Fernandez 2023]

1 All costs were expressed in 2021 prices and converted to euros where applicable. To account for

price differentials across countries, the purchasing power parity (PPP) method has been employed. [Luengo-Fernandez 2023].

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Geographic disparities

The CVD burden is distributed unevenly across EU member states. 6,300 per 100,000

inhabitants had CVDs across the EU as a whole in 2019, but this varied widely, ranging

from 5,500 in some countries to 7,500 in others. CVD kills considerably more people

in central and eastern parts of the EU, whereas western and northern parts of the EU

are less affected. The CVD mortality is ranging from about 20% of all mortality causes

in Denmark, to over 60% in some central and eastern EU countries.

Figure 3. Prevalence of CVDs across Europe in 2019 [Timmis 2022 - ESC Atlas]

Similar wide EU variations are seen with Disability Adjusted Life Years (DALYs), which

combine information regarding premature death (years of life lost) and disability

caused by CVDs (years lived with CVDs) to provide a summary measure of health lost.

In 2019, median DALYs due to CVDs were more than double in those countries which

the EU recently in comparison to initial EU-14 countries (4,651 versus 2,091 per

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100,000 inhabitants). The differences between less and more prosperous countries

confirm the close correlation between health and wealth. The fact that such huge

variations exist shows that it is possible to achieve the lower rates of CVDs seen in

some more prosperous countries.

Within countries, there are many underserved population groups based on factors

including age, sex, race, socioeconomic status and region [Mensah 2023]. There is a

need to promote epidemiological studies on differences in the prevalence of CVDs by

gender or other inequities. Additional initiatives include targeting vulnerable

communities with multidisciplinary approaches and better training of healthcare

professionals to tackle and raise awareness of differences in care.

Figure 4. DALYs due to CVD [Timmis 2022 - ESC Atlas]

Gender inequalities

In the EU today, more women than men suffer from CVD. Despite this, women are

under-represented in research. A meta-analysis of 86 CVD randomised controlled

trials conducted in Europe between 2010 and 2017 found that only 37.4 % of the 68

000 participants were women. [Jin 2020]

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The cultural mislabelling of CVD as a “men’s disease” may be partly responsible for

the risk of mortality following a heart attack being 20% greater in women compared to

men. Women face a 20% increased risk of developing heart failure or dying within five

years after their first severe heart attack compared with men. [Ezekowitz 2020]

What is also not fully understood is that women during the fertile age have a lower risk

of cardiac events, but this protection fades after menopause thus leaving women with

untreated risk factors vulnerable to develop myocardial infarction, heart failure, and

sudden cardiac death. Furthermore, clinical manifestations of ischaemic heart disease

in women may be different from those commonly observed in males, potentially

contributing to under-recognition of the disease.i Understanding these differences

may enhance the clinical management of CVDs, potentially leading to the development

of new gender-specific diagnostic and therapeutic options. [Stramba-Badiale 2006]

The European Commission has already funded a project related to the gender specific

mechanisms linked to the cardiovascular diseases in women. GENCAD project

provided also fact sheets in all EU languages for health professionals and the general

public related to cardiovascular diseases in women.

GENCAD: Institute of Gender in Medicine (GiM) - Charité – Universitätsmedizin Berlin

(charite.de)

Figure 5. National causes of death in EU27 per gender [Timmis 2022 - ESC Atlas]

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Generational inequalities

While CVDs can occur at any age, their risk and prevalence increase in older people,

which is particularly relevant given Europe’s ageing population. The population aged

65 years or older is predicted to increase significantly in the EU, rising from 90.5 million

at the start of 2019 to an estimated 130 million by 2050 [Eurostat 2020], and there will

be corresponding increases in CVD incidence and burden.

However, a common misperception is that CVDs are limited to older people, when in

fact, CVDs account for around 23% of deaths before the age of 70 [Timmis 2022],

heavily impacting all ages. Furthermore, individuals can be born with a spectrum of

congenital heart/vessel diseases, and although more than 90% now survive to

adulthood, many have complex CV problems requiring highly specialised care. In

addition, a wide range of inherited CV conditions are related to genetics and are not

linked to modifiable risk factors. These include familial hypercholesterolaemia (a

disease involving very high cholesterol levels), certain cardiomyopathies (a disease of

the heart muscle) and heart rhythm disorders. Such diseases can be detected and

treated early with appropriate screening.

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Improving primary prevention of CVD across all ages

Primary prevention refers to strategies and interventions to reduce the risk of

developing heart and vascular problems in individuals without established CVD who

have not yet experienced a CV event.

To influence the risk factors leading to the development of cardiovascular disease

(CVD) and yield the expected benefits (health gains, life years gained, economic

consequences at individual and societal level), it is essential that the various

prevention interventions and options are defined and designed, not only from a clinical

perspective but also from a public health perspective. Given that the beneficial effects

of influencing risk factors can be identified at the individual and societal level from the

time of intervention, it is proposed to consider related preventive interventions across

the life course. The planning and implementation of prevention activities in daily

practice requires an integrated, multidisciplinary approach.

At present, CVD prevention mainly focuses on risk reduction later in life, and while this

is important, it is also necessary to recognise that CVD development – particularly the

formation of atherosclerotic plaques that lead to heart attacks – starts early [Dendale

2019; Braunwald 2023]. Parents’ behaviours before conception and during pregnancy

can impact CV risk, while childhood is a key period for instilling healthy lifestyle habits.

The ‘tsunami’ of obesity that we are currently seeing is beginning early, with around

one in five children in Europe being overweight or obese [Garrido 2019]. Opinions and

regulation of physical activity in schools differ greatly within Europe. There seems to

be a trend moving away from the norm of regular exercise for children. Coupled with

an unhealthy diet, this potentially lethal combination could have devastating

consequences on the burden of cardiovascular disease (CVD) in the future.

Primary prevention has suffered from a failure to pair individual responsibility with

support for evidence based public health interventions in the field. When focusing on

'cardiovascular health', it becomes evident that both individual responsibility and

preventive measures are crucial. Therefore, it's essential to acknowledge individuals'

roles in preventing lifestyle risk factors for cardiovascular disease and implementing

policies to promote health. [Vassilaki 2015]

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To strengthen the public health approach, more attention must be given to fostering

the idea of "health as a value and experience" from early childhood. Without this

foundation, it will be difficult in the long term to ensure that the public possesses the

necessary competencies and knowledge to maintain good health for as long as

possible. This entails empowering individuals to make informed decisions regarding

both their personal health and the health of their community. However, beyond merely

imparting skills and knowledge, fostering an environment conducive to healthy choices

is equally imperative. The promotion of health literacy and the development of health

understanding are integral components that cannot be overlooked without

strengthening health promotion, particularly in educational and workplace settings. In

addition to individual health promotion, community health promotion programmes

should also be launched, given their key role in prevention and in influencing risk

behaviour towards the desired positive direction.

In this context, cardiovascular prevention strategies should adopt a multifaceted

approach. This involves directing efforts towards the entire population, as well as

targeting specific high-risk or vulnerable groups, and addressing individuals who have

either been diagnosed with or have a history of cardiovascular disease. Emphasising

the significance of patient education and support is crucial, necessitating a tailored

approach that accommodates the diverse needs of patients, encompassing factors

such as educational backgrounds, age, health conditions, cultural backgrounds, and

any disabilities they may have. The goal of patient support is to transform patients from

passive recipients of care into active participants within the healthcare process.

Enhancing the dialogue and collaboration between patients and healthcare providers

can significantly boost the effectiveness and efficiency of prevention, treatment,

rehabilitation, and health promotion activities. For those with established

cardiovascular diseases, a partnership approach to communication and action is

essential. This approach involves sharing information about the risks and benefits of

treatments while considering the individual's needs, preferences, comorbidities,

medications, and other relevant factors.

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Risk factors in the context of primary prevention

A recent global analysis has shown that over half (53–57%) of CVDs are attributable

to five modifiable risk factors: systolic blood pressure, non-high-density lipoprotein

cholesterol, current smoking, body mass index (BMI) and diabetes [Global CV Risk

Consortium 2023]. The ESC Atlas project highlights the alarmingly high levels of these

CV risk factors across the general populations of EU-27 countries [Timmis 2022]:

 More than 1 in 5 had elevated blood pressure (≥140/90 mmHg)

 About 1 in 7 had high cholesterol levels (total cholesterol ≥6.2 mmol/L)

 More than 1 in 5 smoked tobacco

 More than 1 in 5 had obesity (BMI ≥30 kg/m2), a massive rise from 1 in 10 in

1980

 More than 1 in 20 had diabetes

Around 10% of CVD deaths are attributable to smoking. Smokers have a 30% higher

risk of developing coronary heart disease than non-smokers. Secondary smoking is

estimated to increase the risk of stroke by the same amount. Understanding the impact

of smoking, including the effects of emerging tobacco products, on cardiovascular

disease (CVD) is crucial. Recent findings also suggest that e-cigarettes may raise

blood pressure and heart rate, increase arterial stiffness, and lead to poorer

cardiovascular and respiratory health outcomes compared to non-users, as indicated

by measurements like blood pressure, heart rate, exhaled carbon monoxide, and nitric

oxide levels [Gernun 2022].

Additionally, inadequate nutrition is a key lifestyle risk factor for cardiovascular disease,

with strong evidence showing that factors such as overweight/obesity, high salt intake

[Wang 2020], and increased intake of trans fatty acids significantly contribute to the

risk of developing cardiovascular diseases [Guasch-Ferré 2015]. A key to prevention

is the reduction of high nutritional risk factors, excessive salt, saturated fat and trans-

fatty acid intake, which are already present in childhood. With regard to the health

impact of industrial (artificial) trans fatty acids, studies show that they pose a major

health risk, with an intake of just 5 g/day of trans fatty acids, equivalent to 2% of total

energy intake, increasing the risk of cardiovascular disease by 23% [Oomen 2001].

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This intake is 4 to 5 times higher per gram of saturated fatty acids, as they increase

LDL cholesterol levels in the serum, reduce HDL cholesterol levels and increase

triglyceride levels, thus causing a significant atherosclerotic effect.

The consideration of diabetes is also crucial in cardiovascular health because it

markedly increases the risk of various cardiovascular diseases, including coronary

artery disease, heart failure, and stroke. [Shah 2015] High blood sugar levels

associated with diabetes can damage blood vessels and the nerves that control the

heart. Over time, elevated glucose levels can lead to fatty deposits accumulating on

blood vessel walls, causing them to narrow and harden—a condition known as

atherosclerosis—thereby reducing blood flow and forcing the heart to work harder.

Diabetes is often accompanied by unhealthy cholesterol levels, further contributing to

atherosclerosis. Moreover, many people with diabetes have hypertension, a significant

risk factor for heart disease and stroke. Diabetes also promotes increased

inflammation and a greater tendency for blood clot formation, heightening the risk of

cardiovascular events. Additionally, diabetes can lead to diabetic cardiomyopathy,

affecting the heart's structure and function and potentially causing heart failure.

Therefore, effective management of diabetes—including controlling blood sugar, blood

pressure, and cholesterol levels, following a heart-healthy diet, engaging in physical

activity, and avoiding tobacco—is vital in minimizing the risk of cardiovascular

complications.

Governments have a crucial role to play in creating ‘heart healthy’ environments and

opportunities for physical activity and active living for all. The evidence that compact

neighbourhoods with easy access to amenities, parks and public transport underpin a

healthy and sustainable city is rarely effectively incorporated into city planning policy,

which perpetuates physical inactivity [Münzel 2021; Giles-Corti 2022].

Across age groups, simple promotion of healthy behaviour is insufficient. School,

family and community-based education is needed to address the current lack of

knowledge of the impact of an unhealthy lifestyle while behavioural change support is

needed to help children and adults develop healthy habits. Schools4Health project, led

by EuroHealthNet, is EU-wide in scale with partners from Belgium, Denmark,

Germany, Greece, Hungary, Latvia, the Netherlands, Romania, Slovenia and Spain.

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These partners collectively bring extensive knowledge and experience in the fields of

school health and health promotion.

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Improving primary CVD prevention in the primary-care setting – spotlight on

Hungary

Hungary's government measures such as the public health product tax introduced in

2011, compulsory daily physical education in schools, and public catering, school milk

and fruit programmes to promote healthy eating habits have produced significant

results. The introduction of daily physical education has been shown to contribute to

the prevention of childhood obesity, blood pressure problems and to increase health

motivation.

Primary care is a key site for CV prevention and lessons can be learned from a recent

government initiative in Hungary designed to improve provision. Until 2021, primary

care was provided by isolated general practices (GP) consisting of one doctor and one

or two practice nurses, with insufficient focus on preventive activities due to a lack of

time and well-defined tasks [Jancsó 2022]. ‘Three Generations for Health Programme’

was launched in 2019, which focuses on providing preventive and continuous care

services and the mandatory establishment of GP partnerships. A key aim is to assess

CV risk factors and risk levels and to launch personalised interventions in a large

population involving three generations (0–18 years, 40–65 years and 65+ years). Over

800 GPs in Hungary are participating in the programme, with central data analysis to

assess its success.

An analysis of risk factors and guideline-recommended target achievement was

performed at the beginning of the programme start in around 37,000 individuals aged

40–65 years. Of these 31% were found to be at very high CV risk. Achievement of

target blood pressure levels was lower among very high-risk Hungarian individuals

than the European average (49% versus 58%, respectively). Similarly, attainment of

LDL-C target was only 8% among very high-risk patients, also falling below the

European average (29%). Continuous assessment of risk factors over time will provide

key information on progress.

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Recommendation:

It is recommended that the European Commission’s Expert Group on Public Health

actively identify public health policy interventions in primary CVD prevention that have

a proven track record of success and that appropriate funding is provided to implement

these across the EU. There is need for coordinated action at EU level to reduce and

prevent nutritional risk factors (e.g. a European salt reduction programme, in addition

to the existing EU regulation on the maximum levels of trans fatty acids in food). The

subgroup on prevention of non-communicable diseases has agreed to map all national

non-communicable disease policies and programs as a first step when defining future

actions. It should be also highlighted that the major joint action on health determinants

is looking at different types of determinants including commercial.

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Reducing the impact of environmental stressors

In addition to traditional CV risk factors, there is growing evidence that environmental

factors – including air and noise pollution – contribute significantly to the burden of

CVDs [Münzel 2022]. Evidence also links adverse CV health with particles from natural

sources (e.g., desert dust, wildfires and volcano eruptions) [Münzel 2022] and climate-

change-related extremes of temperature [Zhao 2021]. Environmental stressors

contribute to CVD development and also exacerbate existing risk factors or diseases

(e.g., diabetes or hypertension) due to similar mechanisms.

The main components of air pollution include particulate matter (PM; ranging in

diameter from coarse 2.5–10 μm [PM10], fine <2.5 μm [PM2.5] and ultrafine <0.1 μm

particles) and gaseous pollutants including ozone, nitrogen dioxide, carbon monoxide

and sulphur dioxide, produced primarily by combustion of fossil fuels such as oil, gas

and coal. In analyses, increases in PM concentration were related to HF hospitalisation

or death (PM2.5: 1.29% per 10 μg/m3, PM10: 1.30% per 10 μg/m3), with adverse

relationships also observed with gaseous pollutants [Yang 2023]. In other studies, a

10 µg/m3 increase in long-term PM2.5 exposure was associated with an increased risk

of 23% for IHD mortality, 24% for stroke mortality, 13% for incident stroke and 8% for

incident heart attack [Alexeeff 2021].

The mechanisms by which air pollution cause CVDs include general stress responses,

thrombosis and direct damage to the endothelial cells lining blood vessels, leading to

cell stress, inflammation and the accumulation of toxic mediators that increase the risk

of atherosclerotic plaque formation and rupture [Münzel 2018].

In EU, the median PM2.5 was estimated at 12.2 µg/m3 based on 2019 reported data.

There was a big variation between the EU member states, with PM2.5 levels ranging

from 5.6 µg/m3 in Finland to 22.6 µg/m3 in Poland. Thus the difference between the

most PM2.5 polluted and the least polluted country was 4-fold [data based on the ESC

CV Realities 2022]. The air pollution for PM2.5 in Europe is about 2.5 times higher than

the World Health Organization recommendations.

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Noise pollution is estimated to be responsible for 48,000 new cases of CHD per year,

as well as 12,000 premature deaths across Europe [CV Realities 2022]. In addition,

6.5 million people experience chronic sleep disturbances The EU limit of 55 dB is linked

to adverse health consequences, and yet noise above this level is experienced by

around 113 million Europeans (20%) caused by road traffic, by 22 million due to trains

and by 6 million due to aircraft and these figures are likely underestimations [Münzel

2021]. reaction and the release of stress hormone and inflammatory markers [Münzel

2022]. Mitigation of environmental stressors could make a major contribution to CVD

prevention. In Europe, air pollution leads to a loss of approximately 2.9 years in life

expectancy, with 1.7 years considered avoidable through emissions controlled

measures. [Münzel 2022]. For comparison, life reduction caused by cigarette smoking

is in the range of 2.2 years [Lelieveld 2020]. Smart city planning incorporating ‘heart

healthy designs’ is an important mitigation strategy not only for improving physical

activity but also reducing unhealthy environmental exposures since noise, air pollution

or heat islands show an accumulation in urbanised areas. ‘Clean air’ legislation

promoting decreased particle emissions and promotion of public transport should also

be encouraged.

Recommendation:

Funding for research and education on the consequences of pollution and climate

change on CVDs must be intensified dramatically to protect the health of our current

and future generations.

The European Agency for Safety and Health at Work (OSHA) should conduct, if

appropriate, in cooperation with the European Environment Agency, an evaluation on

the extent to which workers are exposed to cardio-hazardous substances or

environments with recommendations on relevant health and safety at work legislation

updates.

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CVD and mental health

The results of several studies, including large case-control population cohort studies,

show that there is a link between chronic stress and increased CVD risk.

Depression and mental health problems have been associated with early-onset CVD

and suboptimal cardiovascular health in young adults. [Kwapong 2023] However,

mental disorders also have an impact on cardiovascular disease outcomes, with

studies demonstrating that pre-existing depression is a risk factor for poor prognosis

of acute coronary syndrome. [Lichtman JH 2014]

An epidemiological cohort study by researchers from the Catholic University of Leuven

found that people with major mental illness (schizophrenia, bipolar affective disorder,

major depression) have a higher risk of cardiovascular disease (adjusted hazard ratio:

1.54 CI: 95%) compared to people without these disorders. Anxiety

symptoms/disorders or persistent/severe stressors, PTSD (post-traumatic stress

disorder), although less severe, increase the risk of cardiovascular disease (RR: 1,

41). On the other hand, the authors also point out that there is an inverse association,

i.e. mental disorders/illnesses are common in these patients and substantially increase

the risk of recurrent cardiovascular disease and cardiovascular mortality. [De Hert M,

2018]

In a Swedish cohort study of population-controlled twins, the hazard ratio for any CVD,

looking at the year after diagnosis of any of the stress-related psychiatric disorders

(acute stress reaction, adjustment disorder, post-traumatic stress disorder), was 1.64

(95% CI). The highest (6.95) hazard ratio was for heart failure. [Song H 2019]

The Commission communication for a comprehensive approach on mental health has

created a comprehensive framework for the member States and the EU for tackling

mental health issues. Therefore, risk factors related to mental health can be also

addressed via a number of actions, including best and promising practices related to

mental health as available at Best practices - European Commission (europa.eu)

23

Providing adequate secondary prevention strategies

Detection of modifiable risk factors (including high blood pressure, high cholesterol and

diabetes) and subclinical CVD, before an individual experiences a major event or

symptoms, provide key opportunities to prevent or delay morbidity and mortality.

However, as highlighted in the EUROASPIRE project, detection and treatment at the

early stages of disease is often suboptimal [Kotseva 2017].

In addition to CVDs caused by modifiable factors, individuals may be born with a wide

spectrum of congenital CVDs that affect them in infancy and lead to complex CV

problems in adulthood. There are also many rare CVDs that collectively affect a large

population of children and adults. Inherited CV conditions affect millions of children and

adults, including some cardiomyopathies and familial hypercholesterolaemia (FH).

Screening for these CVDs can enable early detection and diagnosis; however, this is

currently lacking for many diseases or is not widely available in all countries. For

example, FH results in life-long cholesterol elevations leading to premature CV events

(from aged 30 years) and premature deaths. In Europe, over 500,000 children and

2,000,000 adults are affected by FH [Bedlington 2022]. However, only 5% of children

are identified and subsequently only a small fraction of all affected individuals receives

life-saving treatment.

Early diagnosis of clinical CVDs, when the individual has established disease, provides

the opportunity to reverse/delay the trajectory and reduce the burden, but again,

diagnosis is often missed or delayed. As an example, HF is a commonly occurring CVD

(median prevalence of 17 cases per 1,000 people) that is associated with frequent

hospitalisations and high mortality [Seferovic 2021; Crespo-Leiro 2016]. Around 60–

80% of HF cases are diagnosed in the emergency department (ED) [Bayes-Genis

2023], although many patients have symptoms that should have triggered an

assessment earlier.

Better detection and thus earlier treatment could make a tremendous difference in

CVDs linked to other chronic conditions or therapies, including, but not limited to,

diabetes and chronic kidney disease.

24

Individuals with type 2 diabetes mellitus (T2DM) face a 2–3 times higher cardiovascular

risk than people without diabetes and see their life expectancy reduced by 10–14

years.ii The number of adults diagnosed with diabetes in the EU has almost doubled

over the last decade, from about 17 million in 2000 to 33 million in 2019 and it’s

projected to increase to 38 million by 2030.iii

To identify people at risk of developing diabetes, the Finnish Diabetes Risk Score

(FINDRISC) can be used to predict the 10-year risk for developing type 2 diabetes.

FINDRISC uses age, BMI, physical activity, vegetable & fruit intake, medical treatment

of hypertension, history of hyperglycemia and family history to determine risk of

developing diabetes. Depending on the score, further investigations such as the

measurement of HbA1c may be needed. [Lindström J 2003]

A systematic global CVD risk assessment is recommended in individuals with any

major vascular risk factor i.e. family history of premature CVD, FH, CVD risk factors

such as smoking, arterial hypertension, diabetes, raised lipid level, obesity, or

comorbidities increasing CVD risk.

A Systematic CV risk assessment in the general population in men >40 years of age

and in women >50 years of age or postmenopausal with no known ASCVD risk factors

may be considered.

Recommendation:

There is a need for stronger emphasis on the system-wide development of health and

risk assessments and age-related screening in primary care. Special attention should

be paid to targeted risk assessment, screening and more effective care for

hypertension, diabetes and lipid metabolism disorders. The timely and frequent

performance of these assessments and screening, and timely initiation of care

activities, contribute significantly to increasing the number of healthy life years.

It is suggested that European Council Recommendations on a Joint Cardiovascular-

Diabetes Health Check would be the most effective policy mechanism to promote

secondary prevention and would provide a common framework for national secondary

prevention programmes for CVD.

25

Screening of cardiovascular diseases takes place in primary care most often and

therefore it falls under the national responsibility for organizing and financing health

services as stipulated in article 168 of the Treaty of the functioning of the EU. However,

if member states wish to discuss overall practices related to such screening this can

take place at an appropriate EU level forum (such as the public health expert group).

Avoiding repeat cardiovascular events

Nearly half of all CV events occur in people with established heart disease, and 25–

30% of strokes are repeat events [Jernberg 2015; Hankey 2014]. One in five patients

discharged from hospital after a heart attack has another heart attack, stroke, or dies

of CV illness within the first year [Jernberg 2015].

Results from EUROASPIRE highlight that most patients have suboptimal risk factor

control in the 6 months after a heart attack [Kotseva 2019]. At least 20% of patients

did not receive heart-protective medications, 58% did not met blood pressure targets

and 71% did not achieve LDL-C goals. High LDL-C levels could be due to low statin

doses and failure to prescribe combination therapy, due to cost and/or difficulties

accessing newer therapies. Adherence is also poor with LDL-C-lowering therapy,

which may be due to patient concerns about side effects and a lack of understanding

of their disease [Karalis 2023].

Best-practice secondary prevention within the first year can mitigate a large part of the

risk of recurrent events, providing an estimated gain of around 7 CV event-free years

[van Trier 2023] and can also improve QoL, with cost-savings due to reduced

hospitalisations and healthcare utilisation.

Secondary prevention should be initiated immediately in the hospital after a major CV

event with the optimisation of preventive medication. A discharge protocol should

inform outpatient facilities and primary care. Long-term management should include

regular assessment of risk factors, symptoms and vital signs, continued patient

education and advice on a healthy lifestyle, monitoring of medication adherence and

support for self-management.

26

Digital technologies may be useful in optimising risk factor control in secondary

prevention. For example, with easy-to-apply telemedicine techniques, more than 70%

of heart-attack patients reached recommended LDL-C levels after 1 years’ follow-up in

a Spanish study [Ruiz 2022].

Recommendation:

It is recommended to reallocate the burden of hospital care as appropriate,

emphasizing primary and community care alongside self-management, supported by

digital health solutions (EACH, 2022). Monitoring the cost-effectiveness of prescribed

therapies and other innovations is essential. Recommendations should focus on

improving adherence to medical advice, particularly concerning preventive

medications and promoting appropriate health behaviours, including risk awareness.

27

Restoring CVD innovation in the EU

Currently, the pipeline of new CV drugs is limited compared with many other clinical

areas including oncology and contrasts with the huge number of in-need patients

[Warner 2020; Szymanski 2023]. In 2021, three new CV drugs were approved by the

European Medicine Agency (EMA) among 92 positive opinions. In 2020 and 2022, no

new CV drugs were approved and only one has received a positive EMA opinion in

2023. Despite representing the biggest burden of disease, the pipeline for new

treatments is not reflective of a market environment appropriately calibrated to develop

new solutions for CVD.

Figure 6 – Pipeline summary of key therapy areas [EFPIA Pipeline Innovation

Review, 2022,]

In order for innovation in CVD to be restored, research budgets need to be allocated

based at least some extent, on the mortality and morbidity of diseases.

28

Regulatory challenges impeding new CV treatments

Challenges causing lagging drug innovation include the duration and expense of CV

clinical trials needed for regulatory evaluation and approvals, and the complexities of

the approval process itself [Warner 2020]. There is also a perception that the price

payers would be willing to pay for CV drugs – which are expected to yield a moderate

beneficial effect on a large number of eligible patients – would not bring sufficient

financial gains to industry given the high costs associated with bringing new drugs to

the market [Wallentin 2019].

Enhancing patient engagement in trial design, with convenient participation and

meaningful endpoints may help to improve recruitment and retention, which are major

trial expenses. Indeed, research priorities should be set based on what patients

themselves identify as gaps and needs. In a survey involving patients with advanced

HF, the main research priority identified by patients was further research on treatments

that have the biggest impact on the Quality of life [Taylor 2020].

Enhancing support for personalised CV medicine

Research is needed to better understand and treat the 40–50% of CVDs that cannot

be attributed to major modifiable risk factors, including numerous orphan CVDs.

Currently, most CV treatments do not target the exact cause of the disease at the

molecular level, but rather try to fix downstream processes non-specifically. With

technological advances, more cause-specific and personalised management

strategies have been developed for certain cancers and neurological diseases, and

these ‘precision’ approaches are now becoming a reality in CV medicine.

New drug targets may be identified using advanced technology e.g., genomics

(assesses gene expression) and proteomics (assesses protein expression). Although

this research may appear expensive to conduct in the short term, it has the potential

to bring considerable long-term gains and has already proved successful. Advanced

technology may also provide ways to predict patient’s response to certain treatments,

29

for example, genetic variants have been identified that reduce responsiveness or

increase side effects to antiplatelet medications. [Sethi 2023].

Recommendation:

A longer-term perspective is needed towards funding to fuel a move towards a more

personalised patient-care pathway including the development of a dedicated CV health

mission as part of the next Framework Programme for Research and Innovation with

more structured collaboration and emphasis on the translation of research into

implementation and new models of care.

Supporting registries and real-world studies to enable the EHDS and fuel

research

Only 25% of national CVD Registries in the EU are supported with public funding

[Dawson 2021]. Despite strong interest from medical societies in expanding registries

and real-world observational studies, a lack of resources to facilitate this is cited as the

most common barrier.

This lack of support for the centralisation of high-quality data and real-world evidence

serves to undermine the goals of the European Health Data Space (EHDS). Any

functional EHDS will be dependent on the ability to generate robust data and this

cannot be done if the bulk of society’s understanding of CVDs is primarily dependent

on the private sector and charitable donations.

Improvements can only be made if the epidemiology of CVDs in Europe and their real-

world monitoring and treatment patterns are accurately understood and built on a

strong evidence base.

Recommendation:

The creation of a ‘European Cardiovascular Health Data Knowledge Centre’ to bring

together existing data and initiatives is suggested as a potential solution. One of the

primary goals would be to provide comprehensive and standardised data to support

treatment and care innovation, personalized management, and the enhancement of

30

care delivery through integrated, data-driven care pathways and outcomes

measurement, all based on the latest real-world evidence.

Improving access to care and reducing inequalities

Access to specialist acute care is unequal across Europe and there is a need for

governments to set targets for access to specialist care, such as stroke or cardiac care

units. For example, the Action Plan for Stroke in Europe aims to achieve 90% of

patients being treated in dedicated stroke units by 2030 [Norrving 2018].

Access to lifesaving treatments is also suboptimal. For example, four therapies are

recommended to reduce mortality, prevent recurrent hospitalisations and improve the

clinical status, functional capacity and QoL in patients with HF [McDonagh 2021 &

2023], and yet many are not prescribed these therapies or do not receive treatment

promptly or at sufficient doses [Jankowska 2023; Khan 2021]. Strategies proposed to

help optimise treatment include more standardised care pathways, improved use of

digital tools (e.g., integration of guidelines into primary care workflow), improved

education for primary care practitioners and patients, and improved access and

affordability of therapies [Jankowska 2023].

Access to lifesaving procedures is problematic and varies widely across the EU [CV

Realities 2022]. Middle-income countries are severely under-resourced compared with

high-income countries in terms of cardiological person-power, leading to procedural

deficits e.g., in coronary interventions, ablation procedures, device implantation (e.g.,

pacemakers and implantable cardioverter defibrillators) and in heart valve procedures

(e.g., transcatheter aortic valve implantation) [CV Realities 2022].

31

Righting current wrongs in rehabilitation

After a CV event or stroke, and in patients hospitalised with HF, multidisciplinary

rehabilitation involving medical treatment, counselling, psychological support, exercise

prescription/advice and education are crucial to help prevent recurrence, improve

functional capacity, recovery and psychological well-being [Ambrosetti 2021].

Rehabilitation should involve a multidisciplinary team and a clear plan for discharge

from the hospital with documented responsibility for continuing rehabilitation needs in

the community. Providing information and education on the perception of disease,

empowerment and self-management are recommended.

A recent survey found that cardiac rehabilitation was available in 91% of European

countries; however, there is only one spot for every seven patients in need, with well

over 3 million more spots needed per year to treat patients with IHD alone [Abreu

2019]. When examined by region, one spot for every two patients was available for

northern countries, but this reduced to one spot for every 13 patients in southern

countries and one spot for every 21 patients for eastern countries. When provided,

cardiac rehabilitation is often of suboptimal quality, with short duration [Ruivo 2023].

Results from the EUROASPIRE survey found that of almost 8,000 patients

interviewed, only 51% were advised to participate in a cardiac rehabilitation

programme and of these, 81% attended at least half of the sessions with wide variation

between countries [Kotseva 2018].

Barriers to implementing prevention and rehabilitation at the patient level include low

education, older age, lack of benefit awareness, comorbidities, transport problems and

financial concerns [Ruivo 2023]. At the personnel level, barriers include lack of

automatic referral, no financial incentives, lack of multidisciplinary teams and time

consumption. Healthcare obstacles include reimbursement issues, lack of specialised

locations and geographical issues. A lack of cardiology training, guidance documents,

national accreditation and electronic database registries were also identified.

Life after a CVD event must be included in any national CVD plan to address survivors’

and their families’ long-term unmet needs and minimum standards set for what every

CV survivor should receive regardless of where they live.

32

Recommendation:

Building on the Stroke Action Plan for Europe, it is recommended that in hospital and

community based rehabilitation for cardiovascular patients should be included in all

national cardiovascular health programmes in member states.

33

Conclusion

As it stands today, there is no stand-alone plan to tackle the EU’s biggest killer.

An EU Cardiovascular Health (CVH) Plan with clear deliverables and common targets

accompanied by National CVH plans, would preserve the lives and livelihoods of

Europeans for generations to come.

A genuine effort to fund evidence based public health interventions in primary

prevention across the EU can give youth a future and unshackle the concepts of old

age and ill-health.

Early detection of cardiovascular disease and its risk factors could prevent premature

death and future costs to the healthcare system.

Dedicated research programmes for cardiovascular health research could help

translate novel ideas trapped in the mind of researchers without the necessary funding

and transform this into an opportunity for necessary new age treatments to reduce the

burden of CVDs.

Rehabilitation policies that recognise a patient’s needs after they have left the hospital

could ease the suffering of millions and rapidly accelerate their return to the life they

wish to lead.

Investing in a dedicated Cardiovascular Health Plan would not only offer the necessary

practical framework to address the EU-wide challenge of cardiovascular disease

(CVD), but it would also signal a commitment by all Member States to systematically

address inequalities and strive for improvement. This proactive approach signifies that

the EU's leading cause of mortality will not go unchallenged. This could also take into

account the ongoing actions and discussions which are taking place under the two

major joint actions related to help determinants and cardiovascular diseases.

34

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PRACTICAL INFORMATION NOTE

2

LIST OF CONTENTS

List of Contents ......................................................................................................................2

General Information ................................................................................................................3

Deadlines ...............................................................................................................................3

Accreditations .........................................................................................................................3

Badges ...................................................................................................................................4

Liaison Officers.......................................................................................................................4

Interpretation ..........................................................................................................................5

Arrival and Departure .............................................................................................................5

Transportation ........................................................................................................................5

From the airport to the city ..................................................................................................5

Facilities .................................................................................................................................6

Bilateral Meetings ...................................................................................................................6

Security ..................................................................................................................................7

Accommodation......................................................................................................................7

Venues ...................................................................................................................................7

Venue of the Conference ........................................................................................................8

venue of the Welcome Reception and Networking .................................................................9

Preliminary Program ...............................................................................................................9

Media ...................................................................................................................................13

Other Practical Information ...................................................................................................13

Contact Information ..............................................................................................................13

3

GENERAL INFORMATION

The Hungarian Presidency of the Council of the European Union is pleased to provide the

following practical information to help you to prepare for the High-Level Conference on

Cardiovascular Health (CV Health Conference), to be held in Budapest on the 3rd and 4th

of July, 2024.

DEADLINES

When? What? Where/who?

6th June The Novento Presidency

accreditation platform opens.

Novento presidency

accreditation platform.

22th June, 23:59 The Novento Presidency

accreditation platform closes.

Novento presidency

accreditation platform.

At the airport Distribution of accreditations

for ministerial delegations.

By a LIO (Liaison Officer).

During registration, at

the conference venue

Distribution of accreditations

for non-ministerial

delegations.

By LOC (Local Organizing

Committee).

ACCREDITATIONS

Delegations are kindly asked to appoint a Delegation Accreditation Officer (DAO) who

will be responsible for the accreditation of every member of their delegation. Please

communicate the name, cell phone number and e-mail address of the DAO and the

title of the event to [email protected] as soon as possible.

The appointed DAO will receive an e-mail containing a link and necessary credentials (log-in

information) for the official presidency accreditation platform to register the members of their

delegation.

We kindly ask you to register at your earliest convenience via the accreditation platform. The

online accreditation platform will be open from 6th June until 22th June.

Please make sure that personal details are correctly entered on the platform, as certain

information (e.g. your name) will appear on the badges. Please note that only accredited

4

delegates will have access to the official meeting and other official programme venues. If you

have any questions regarding your registration, please contact

[email protected].

All personal information provided for accreditation will be processed in accordance with the

EU General Data Protection Regulation (GDPR), which can be found at the accreditation

system.

BADGES

Access to the meeting venue requires a valid personalized badge, which can be

obtained after the registration request had been approved and the accreditation is confirmed

by a confirmation message through Novento. Badges will be distributed at the conference

venue upon arrival, or by the designated Liaison Officer (in case of ministerial delegations).

Delegates will receive one single badge for a several-day event. Please make sure to

wear your badges visibly at the meeting venue and official programme venues.

Please note that all participants are required to carry their ID cards or passports, in order to

comply with the on-the-spot identification process.

In case of loss of a badge, please report it immediately to: [email protected]. The

validity of the badge will be immediately terminated, while the organisers will create a new

badge upon your request.

For further information regarding the badges of any delegate, please contact

[email protected].

LIAISON OFFICERS

To ensure that your visit runs smoothly, a Liaison Officer will be assigned to accompany your

HoD throughout the event and provide any logistical assistance required on site.

Supervised by a coordinator, the Liaison Officer will:

• serve as a single point of contact;

• welcome and accompany the delegation during the Presidency events;

• assist the delegation to ensure successful participation in the meeting;

• provide logistical assistance and administrative support at the venue;

• provide and distribute accreditation pins and badges on arrival.

5

INTERPRETATION

The Conference will be held in English, without the use of interpretation services.

ARRIVAL AND DEPARTURE

All delegations are kindly asked to provide the arrival and departure details in the

accreditation system:

• for delegations travelling by car or train: date and time of arrival, the border crossing

point to Hungary, and arrival destination point,

• for delegations travelling by plane: date and time of arrival and departure, as well as

the flight number and the airline.

TRANSPORTATION

FROM THE AIRPORT TO THE CITY

Delegates who arrive with a commercial flight will arrive to Terminal 2A or 2B of Budapest

Liszt Ferenc International Airport. Please note that shuttle service is only provided to

ministerial delegations on behalf of the Presidency. Ministerial delegations are kindly

asked to mark their luggage with a national coloured ribbon.

Non-ministerial delegations are responsible for their own travel arrangements.

• Budapest Airport Shuttle Service

Budapest Airport itself offers an airport shuttle service for an extra fee, called MiniBUD

(www.minibud.hu).

• Public Transport (Budapest Transport Centre – BKK)

Public transport bus line 100E Airport Express provides a direct and fast connection to

the city centre. Single ticket costs 2.200 HUF, tickets can be purchased at the ticket

machines at the airport.

For more information regarding public transportation within the city, please consult the

website of BKK, where you can also learn about the costs of different types of tickets and

information on public transport routes: https://bkk.hu/en/

6

• Taxi

At your landing spot, Budapest Liszt Ferenc International Airport, you have the

opportunity to book a taxi to get you to your accommodation. The official partner of

Budapest Airport is Főtaxi (tel. +36 1 222 2 222, https://fotaxi.hu/en/). Főtaxi operates a

designated office outside of the arrival terminal.

FACILITIES

The Hungarian Presidency will provide all necessary services, such as a cloakroom, internet

connection, and working facilities for delegations at the Ministry of Interior, the official

meeting venue. The Wi-Fi password will be provided at the location. It is allowed to bring

your luggage into the Ministry of Interior, which will be secured by a hostess at the venue.

BILATERAL MEETINGS

A limited number of bilateral meeting boxes will be available at the Ministry of Interior.

Reservations will be handled on a „first come-first served” basis. The Hungarian Presidency

7

does not provide interpretation for bilateral meetings. You can book a meeting in advance by

sending an e-mail to [email protected].

Please indicate:

• the preferred time slot (the standard duration is 15 minutes, however it can be

prolonged);

• the number of participants.

SECURITY

Providing a safe environment for our delegations is of paramount importance to the

Hungarian Presidency. For security reasons, badges must be worn visibly during the

official programme. Access to the meeting venue will be denied in the absence of a visibly

worn badge.

Please note that all delegates except the participating ministers will have to go via security

check while entering the meeting venue.

ACCOMMODATION

The Hungarian Presidency will book and cover the costs of accommodation for the

participating ministers (suite) + 1 delegate (standard) for the night of the two-day conference

at the Kempinski Hotel.

Non-ministerial delegations are responsible for their own reservation arrangements and

covering the costs of their hotel rooms. Any additional expenses (beverages, minibar,

parking, meals, laundry services, etc.) must be covered by the delegates themselves.

In case you have questions or need hotel recommendations, please contact us at the

following email address: [email protected].

VENUES

The CV Health Conference will be held at two locations, all within walking distance of each

other.

When? Venue Address

3 July 2024 Ball Room Apáczai Csere János utca 4

8

Marriot Hotel Budapest 1052 Budapest

4 July 2024 Marble Hall, Ministry of

Interior

József Attila utca 2-4

1051 Budapest

VENUE OF THE CONFERENCE

The Conference will be held at the Marble Hall of the Ministry of Interior.

The main building of the Ministry of Interior is located in the former headquarters of the

Hungarian Commercial Bank of Pest, a huge block facing the Danube with four internal

yards, built in the beginning of the 20th century. This part houses the offices of the Minister

and the State Secretaries along with the Marble Hall, the main venue of the ceremonial

events. The buildings show features of multiple styles, ranging from neo-Classicism through

Art Nouveau, while the interior spaces suggest elegance through the richly coloured marble

surfaces and the embossed copper designs.

9

VENUE OF THE WELCOME RECEPTION AND

NETWORKING

The Welcome Reception and Networking

on 3rd July will be organized in the

Ballroom of Marriot Hotel Budapest,

which is a 10 minute walk from the

conference venue. It offers a spectacular

panoramic view on the Danube and the

Buda side as well as an elegant location

for the welcome dinner.

PRELIMINARY PROGRAM

Please note that this programme is subject to change.

3RD JULY, 2024 (WEDNESDAY)

18:00-20:30 Welcome Reception and Networking at Marriot Hotel Budapest

4TH JULY, 2024 (THURSDAY)

08:00-09:00 Registration of Participants

09:00-09:15 Opening remarks by:

• Dr. Sándor Pintér, Minister of Interior, emphasizing the critical

importance of cardiovascular health and setting the expectations for the

day.

09:15-09:30 A View on the Data

Presentation of the key findings of the paper “Improving cardiovascular

health in Europe: the case for EU and National CVH plans” – Introduction to

the key data on burden of CVD and inequalities.

• Speaker: Prof. Franz Weidinger, President of the European Society of

10

Cardiology

09:30-09:45 Presentation by Prof. Béla Merkely – Honorary President of the Hungarian

Society of Cardiology

09:45-11:00 Panel 1 – Primary Prevention and Risk Factors What we know works

and what we are not doing?

Focusing on strategies for preventing cardiovascular disease through

lifestyle changes, management of risk factors and the environmental

stressors that drive the CVD burden.

• Keynote speaker: Prof. Zoltán Vokó, President, Hungarian Association

of Public Health Training and Research Institutes

• Moderator: Prof. Paul Dendale, Chair of Department of Cardiology,

Hassalt, Belgium

Panelists:

• Prof. Thomas Münzel, Chief of the Department of Cardiology, Center

for Cardiology, University Medical Center Mainz, Germany

• Dr. Anna Páldy, President, Hungarian Society of Hygienists

• Prof. Lis Neubeck, Professor of Cardiovascular Health in the School of

Health and Social Care at Edinburgh Napier University, Scotland

• Prof. Victor Aboyans, Head of the Dept. of Cardiology at the

Dupuytren University Hospital in Limoges, France

11:00-11:20 Coffee Break

11:20-12:20 Panel 2 – Secondary Prevention: How we can preserve life and

livelihoods?

Exploring approaches to early detection of CVDs and to prevent the

recurrence of cardiovascular events in individuals with existing heart

disease, including medication, lifestyle adjustments, and monitoring.

• Keynote speaker: Prof. Dr. Péter Andréka, President, Health

Professional College and Director General, Gottsegen National

Cardiovascular Center, Hungary

• Moderator: Prof. Francesco Cosentino, Professor of Cardiology,

Karolinska Institute and University Hospital, Stockholm

Panelists:

11

• Prof. István Wittman, President, Hungarian Diabetes Association

• Mr. Frédéric Clement, Vice-Chair, MedTech Europe Cardiovascular

Sector Group

• Prof. Fausto Pinto, Past President, World Heart Federation

• Neil Johnson, Executive Director, Global Heart Hub

• Dr. Ottó Skorán, BEMOSZ (Association of Patients' Organizations in

Hungary) / SZÍVSN National Patient Association

12:20-13:20 Lunch Break at the Reception Hall of the Ministry of Interior

13:20-14:20 Ministerial Panel

• Moderator: Prof. Elias Mossialos, Professor of Health Policy, Deputy

Head of the Department of Health Policy, Director of LSE Health

Panelists:

• Representative of WHO

• Izabela Leszczyna, Minister of Health of Poland (TBC)

• Dr. Karl Lauterbach, Minister of Health of Germany (TBC)

• Adonis Georgiadis, Minister of Health of Greece

• Dr. Javier Padilla, Secretary of State for Health, Spain

• Dr. Péter Takács, Minister of State for Health of Hungary

14:20-15:20 Panel 3 – Treatment and Innovation: What’s holding back the new age

in CV care?

Examining the current bottlenecks in CVD research and how to overcome

them.

• Keynote speaker: Prof. Miklós Szócska, Health Services Management

Training Centre, Semmelweis University

• Moderator: Prof. Gerhard Hindricks, Professor of Cardiology at the

Charite University Hospital, Berlin, Germany

Panelists:

• Alar Irs, Chair of EMA Cardiovascular Working Party

• Vasilisa Sazonov Ph.D, EFPIA CVH Sector Group

• Csaba Poroszlai, Medicines for Europe

• Prof. Piotr Szymanski, Head of the Clinical Cardiology Department at

12

National Institute of Medicine MSWiA Hospital in Warsaw, Poland

• Prof. Csaba Bödör, Head of Department of Pathology and

Experimental Cancer Research at Semmelweis University

15:20-15:40 Coffee Break

15:40-16:40 Panel 4 – Rehabilitation and Patient Centered Support: Care beyond

the Clinic

Discussion on the importance of rehabilitation for patients following cardiac

events, and the role of support networks in patient recovery and quality of

life.

• Keynote speaker: Dr. Emil Toldy-Schedel, Vice President, Hungarian

Cardiovascular Rehabilitation Society

• Moderator: Prof. Donna Fitzsimons, Head of the School of Nursing &

Midwifery, Member of Senate in Queen's University Belfast, Northern

Ireland

Panelists:

• Arlene Wilke, Director General, Stroke Alliance for Europe

• Hans Snijder, Board Member of European Heart Network, CEO of the

Dutch Heart Foundation

• Prof. Ana Abreu, Professor of Cardiology Hospital de Santa Maria

Faculty of Medicine, Lisbon, Portugal

• Dr. Dániel Aradi Ph.D, Head of Interventional Cardiology Working

Group, Hungarian Society of Cardiology; Associate Professor at

Semmelweis University and State Heart Hospital, Balatonfüred, Hungary

16:40-17:00 Closing remarks – Making Europe a Global Leader in CV Research,

Management and Care

Concluding the conference with final thoughts and a call to action,

summarizing key insights from the day and outlining steps forward.

Speakers:

• Dr. Dávid Becker, President, Hungarian Society of Cardiology

• Dr. Péter Takács, Minister of State for Health, Ministry of Interior

13

Evening Dinner at the Reception Hall of the Ministry of Interior

MEDIA

Photographs and video footage from events organised by the Hungarian Presidency will be

available on its official channels and the channels of the EU institutions.

Photos will be published on the official website of the Presidency and may be used free of

charge with a clear mention of the photographer.

For any media-related questions, please contact us at the following email address:

[email protected].

OTHER PRACTICAL INFORMATION

Emergency number: 112 (fire brigade, medical assistance)

Electricity: The voltage in Hungary is 230V, 50 Hz.

Local time: Central European Summer Time Zone (CEST) – GMT +2:00

Country code: Hungary +36

Currency: The official currency of Hungary is the Hungarian Forint. For official daily

exchange rates, please consult the website of the Magyar Nemzeti Bank (National Bank of

Hungary): https://www.mnb.hu/en/arfolyamok

Weather in Hungary: https://met.hu/en/idojaras/

Tap water: Hungarian water is regularly tested for quality and is safe to drink.

Smoking: Smoking is only allowed in the designated area of the official meeting spaces.

CONTACT INFORMATION

Should you have any questions regarding the logistical aspects of the event, or about the

details of the programme, please contact us at the following e-mail address:

[email protected].

1

IMPROVING CARDIOVASCULAR HEALTH IN EUROPE: THE CASE FOR EU AND NATIONAL CVH

PLANS

Hungarian Ministry of Health in collaboration with the European Society of

Cardiology

Ministerial Foreword

At this pivotal moment, under the Hungarian Presidency of the Council, we are poised

to take a decisive step forward in the fight against cardiovascular diseases (CVDs) in

Europe. This leadership opportunity allows us to spearhead initiatives that prioritize

heart health at the highest levels of policy and public discourse. The Hungarian

Presidency is deeply committed to leveraging this period to galvanize support, foster

cross-border collaborations, and champion comprehensive strategies that address the

root causes and disparities associated with CVDs.

Our approach is holistic, recognizing that a multifaceted strategy is required to

effectively combat against cardiovascular diseases. This includes promoting healthy

lifestyles across all age groups, advancing public health policies that target risk

reduction, and ensuring that innovations in medical research and high level healthcare

delivery are equitably accessible. The Presidency aims to highlight the critical role of

prevention, advocating for environments that support physical activity, healthy

nutrition, and mental health and well-being, alongside fighting against – inter alia -

tobacco and alcohol consumption which are significant risk factors for CVDs.

Furthermore, recognizing the disparities in accessing health services as well as in

health outcomes between and within European countries, the Hungarian Presidency

calls for a renewed focus on health equity. This means advocating for policies that

ensure all Europeans, regardless of their socio-economic status or geographical

location, have access to the necessary health services. It involves pushing for

investments in health infrastructure, from rural clinics to advanced urban centres, and

promoting the use of digital health technologies to bridge gaps in care delivery.

Health innovation is another cornerstone of our vision for a heart-healthy Europe. The

Hungarian Presidency encourages the adoption of cutting-edge technologies and

2

research in cardiovascular care, from telemedicine to personalized medicine

approaches that can significantly improve patients’ health outcomes. This period of

leadership is seen as an opportunity to foster an innovative and resilient European

health ecosystem that is also responsive to the needs of its citizens.

As we mobilize these efforts, the importance of collaboration cannot be overstated.

The Hungarian Presidency seeks to inspire partnerships across nations, sectors, and

disciplines, bringing together health providers, researchers, policymakers,

communities and patients to share knowledge, experiences and best practices and

resources. This collaborative spirit is essential for achieving sustainable change and

our shared goal of significantly reducing the burden of cardiovascular diseases across

Europe. In line with this, the “Healthier Together” EU non-communicable diseases

initiative will serve as a cornerstone, providing a robust foundation to unite our efforts

and enhance the improvement of collective health outcomes.

To underscore the urgency of our mission, we should carefully consider the stark

realities: cardiovascular diseases are one of the leading causes of mortality worldwide,

claiming nearly 18 million lives each year. In Europe alone, CVDs account for 37% of

all deaths, translating to over 1.7 million lives lost annually. This not only represents a

profound loss of life but also imposes a significant economic burden, costing EU

economies an estimated €282 billion in 2021 alone. These figures are not just statistics;

they represent fathers, mothers, siblings, children and friends whose lives are cut short

by preventable conditions.

Our vision for the future is one where cardiovascular health is not just a matter of

individual concern but a collective priority that shapes policies, health systems, and

societal norms. It is a future where every European has the opportunity to live a longer,

healthier life free from the burden of CVDs. Through the initiatives and leadership of

the Hungarian Presidency, we are committed to contribute to the future, driven by a

commitment to public health, equity, and innovation. Together, we can transform the

landscape of cardiovascular health in Europe, creating a legacy of well-being for

generations to come.

Dr Péter Takács

Minister of State for Health

3

Foreword – Professor Franz Weidinger, President of European Society of

Cardiology

Neglect and a lack of public investment in cardiovascular health threatens to undo hard

fought trends in reducing mortality in cardiovascular disease. Today cardiovascular

disease represents not only the biggest cause of death in the EU but is reflective of

deep inequalities and inequities that we see across the Union.

From environment to employment, from climate change to demographic change, from

infrastructure to research investment, the impact of cardiovascular disease can be felt

everywhere except in policy.

The EU institutions aim to adhere to the principle of evidence-based decision making.

Given that cardiovascular disease is the biggest killer in the Union today and comes at

a cost of 100 billion euro more than the entire EU budget, we have the evidence to

justify meaningful policy action.

We should not deceive ourselves in thinking that we can avoid expenditure. We will

pay the price for CVD one way or another. The question is will we decide to invest now

and save lives and protect our economies, or be forced to pay later in lives lost and

broken health systems?

No Member State should be without a plan to tackle the biggest threat to the lives of

its citizens, nor should we view such a plan as solely the responsibility of health

ministries.

Action to promote cardiovascular health is the fight for gender, generational and

geographical equity. It is the fight against ageism and structural inequalities. It is the

means to enable a silver economy and keep our systems sustainable. It is the public

health campaign of this generation.

This paper is intended to inform discussions on cardiovascular health and provide

general policy suggestions which may help to preserve it.

4

TABLE OF CONTENTS

Summary ............................................................................................................................................... 5

Current burden of CVDs across the EU........................................................................................ 7

Geographic disparities .................................................................................................................. 9

Gender inequalities ...................................................................................................................... 10

Generational inequalities ........................................................................................................... 12

Improving primary prevention of CVD across all ages .......................................................... 13

Risk factors in the context of primary prevention ................................................................... 15

Improving primary CVD prevention in the primary-care setting – spotlight on Hungary

............................................................................................................................................................... 18

Reducing the impact of environmental stressors ................................................................... 20

CVD and mental health ................................................................................................................... 22

Providing adequate secondary prevention strategies ........................................................... 23

Avoiding repeat cardiovascular events .................................................................................. 25

Restoring CVD innovation in the EU ........................................................................................... 27

Regulatory challenges impeding new CV treatments ........................................................ 28

Enhancing support for personalised CV medicine ............................................................. 28

Supporting registries and real-world studies to enable the EHDS and fuel research 29

Improving access to care and reducing inequalities .......................................................... 30

Righting current wrongs in rehabilitation .................................................................................. 31

Conclusion ......................................................................................................................................... 33

References ......................................................................................................................................... 34

5

Summary

Cardiovascular diseases (CVDs) are disorders related to the heart and circulatory

(vascular) system, which include ischaemic heart disease (IHD), stroke, heart failure

(HF), heart rhythm disturbances (e.g., atrial fibrillation), hypertension, congenital heart

diseases, inherited cardiac conditions, and diseases of the aorta, heart valves and

peripheral arteries.

Today cardiovascular disease represents the biggest killer in the EU accounting for 1.7

million deaths each year and comes with an economic cost of 100 billion euro more

than the entire annual EU budget.

This burden is not distributed evenly but is reflective of deep-seated inequalities in the

EU spanning geographies, genders and generations.

In recent years and particularly since COVID-19, there has been an increased

awareness at EU and national level of the threat that CVDs represent to life and

livelihood. The inability of Non-Communicable Disease (NCD) plans to deliver

meaningful results and the ambitions of the EU Beating Cancer plan have put a new

spotlight on the need for action on the biggest threat to the lives of EU citizens.

Just over 50% of CVDs could be prevented by lowering blood pressure, cholesterol

and weight, by stopping smoking and controlling diabetes; however, these risk factors

are highly prevalent in the general EU population, suggesting the need for an increased

roll out of evidence based primary prevention programmes to the benefit of future

generations.

Given that many countries such as the UK demonstrate rising levels of CVD death in

those under 75 years of age, implementing multiple types of prevention measures –

from early life to old age – is crucial1.The issues are much more complex than blaming

individuals – they require population-level policy interventions and a mindset shift.

Environmental stressors also contribute to CV risk. There is increasing understanding

of the links between different CVDs and pollution, noise exposure and climate change,

representing another critical area for action.

Currently, there is lack of screening for CV risk factors, including hypertension, and

also missed opportunities to screen for, and diagnose, a wide range of CVDs that are

6

not caused by modifiable factors. Some common CVDs, such as heart failure, are often

diagnosed late in their disease course, missing an important opportunity to delay

progression and leading to an unnecessarily heavy burden of morbidity,

hospitalisations and untimely death. Novel tools have been developed to enable earlier

diagnosis, but these are not always widely available or used. Similarly, some CVDs

can be effectively treated with established and novel treatments or procedures, but

these may not be widely available in certain countries or are not implemented

appropriately.

Many CVDs lack effective treatments that target their molecular cause and, despite the

enormous healthcare burden, the developmental pipeline of new CV drugs is limited,

with no new therapies coming to market in CVD in 2022. Innovation is needed to

develop new diagnostics and treatments, personalised for patient needs, which are

integrated into care models and widely accessible.

Patients with CVD are often at high risk of another CV-related event or disease.

Appropriate secondary prevention strategies, including risk factor control and patient

education, and multidisciplinary rehabilitation should be initiated rapidly to improve

prognosis. Best-practice guidelines have been developed by medical societies,

including the ESC. Yet, access, implementation, quality and adherence are often

suboptimal and there remain wide inequalities between and within EU countries.

It is suggested that a meaningful reduction in the burden of CVDs across the Union

cannot be reached without a stand-alone plan for the EU’s biggest killer. Such an EU

framework, supported by National Action Plans on Cardiovascular Health would

ensure the needs of citizens in prevention, diagnosis treatment and rehabilitation are

effectively met as well as tackling the environmental stressors and co-morbidities that

drive CVDs. The joint action on cardiovascular diseases and diabetes with the funding

of €53 million from EU4health programme provides a basis for developing national

plans and strategies on cardiovascular disease as well as on diabetes and their

interlinked risk factors. In addition, with an unprecedented budget of €75 million

Member States are collaborating under the joint action to address common risk factors.

These collaborative actions are the starting point for both developing national plans in

the future, as well as implementing the joint EU Action Plan in countries with national

action plan already in place.

7

Current burden of CVDs across the EU

Despite a decline in CV mortality in many countries in the European Union (EU), CVDs

remain the most common cause of death, accounting for about 1.7 million deaths

across EU-27 member countries, which equates to 37% of all deaths. [Timmis 2022 -

ESC Atlas].

Many patients suffer from the long-term effects of CVDs, living for years with

considerable disability. An estimated 53 million people were living with CVDs in EU-27

in 2021 [Timmis 2022], making CVD the biggest cause of death today.

Figure 1. National causes of death in EU27 [Timmis 2022 - ESC Atlas]

The economic burden is enormous for healthcare systems, for society and for patients

and their families. In 2021, CVDs were estimated to cost the EU €282 billion, which is

roughly 100 billion more than the EU budget [Luengo-Fernandez 2023]. Around €155

billion – 55% of the total – was attributed to direct health and long-term care costs,

equalling 11% of total EU health expenditure. Productivity losses associated with early

mortality and incapacity for work were estimated at €32 billion and €15 billion,

respectively, and the cost of unpaid care by friends/relatives was estimated at €79

billion. When expressed per capita, the total CVD cost equals €630 per EU citizen,

ranging from €381 in Cyprus to €903 in Germany, after adjustment for price

8

differentials1. In addition to mortality, morbidity and cost, the experience of a heart

attack or stroke can also have a profound and lasting impact on the quality of life (QoL)

of those affected as well as their families or carers, causing substantial stress, anxiety

and, in some cases, depression, which are associated with significantly worse

outcomes [Iles-Smith 2015; Mitchell 2017].

Figure 2. Total CVD costs per capita adjusted for price differentials [Luengo-

Fernandez 2023]

1 All costs were expressed in 2021 prices and converted to euros where applicable. To account for

price differentials across countries, the purchasing power parity (PPP) method has been employed. [Luengo-Fernandez 2023].

9

Geographic disparities

The CVD burden is distributed unevenly across EU member states. 6,300 per 100,000

inhabitants had CVDs across the EU as a whole in 2019, but this varied widely, ranging

from 5,500 in some countries to 7,500 in others. CVD kills considerably more people

in central and eastern parts of the EU, whereas western and northern parts of the EU

are less affected. The CVD mortality is ranging from about 20% of all mortality causes

in Denmark, to over 60% in some central and eastern EU countries.

Figure 3. Prevalence of CVDs across Europe in 2019 [Timmis 2022 - ESC Atlas]

Similar wide EU variations are seen with Disability Adjusted Life Years (DALYs), which

combine information regarding premature death (years of life lost) and disability

caused by CVDs (years lived with CVDs) to provide a summary measure of health lost.

In 2019, median DALYs due to CVDs were more than double in those countries which

the EU recently in comparison to initial EU-14 countries (4,651 versus 2,091 per

10

100,000 inhabitants). The differences between less and more prosperous countries

confirm the close correlation between health and wealth. The fact that such huge

variations exist shows that it is possible to achieve the lower rates of CVDs seen in

some more prosperous countries.

Within countries, there are many underserved population groups based on factors

including age, sex, race, socioeconomic status and region [Mensah 2023]. There is a

need to promote epidemiological studies on differences in the prevalence of CVDs by

gender or other inequities. Additional initiatives include targeting vulnerable

communities with multidisciplinary approaches and better training of healthcare

professionals to tackle and raise awareness of differences in care.

Figure 4. DALYs due to CVD [Timmis 2022 - ESC Atlas]

Gender inequalities

In the EU today, more women than men suffer from CVD. Despite this, women are

under-represented in research. A meta-analysis of 86 CVD randomised controlled

trials conducted in Europe between 2010 and 2017 found that only 37.4 % of the 68

000 participants were women. [Jin 2020]

11

The cultural mislabelling of CVD as a “men’s disease” may be partly responsible for

the risk of mortality following a heart attack being 20% greater in women compared to

men. Women face a 20% increased risk of developing heart failure or dying within five

years after their first severe heart attack compared with men. [Ezekowitz 2020]

What is also not fully understood is that women during the fertile age have a lower risk

of cardiac events, but this protection fades after menopause thus leaving women with

untreated risk factors vulnerable to develop myocardial infarction, heart failure, and

sudden cardiac death. Furthermore, clinical manifestations of ischaemic heart disease

in women may be different from those commonly observed in males, potentially

contributing to under-recognition of the disease.i Understanding these differences

may enhance the clinical management of CVDs, potentially leading to the development

of new gender-specific diagnostic and therapeutic options. [Stramba-Badiale 2006]

The European Commission has already funded a project related to the gender specific

mechanisms linked to the cardiovascular diseases in women. GENCAD project

provided also fact sheets in all EU languages for health professionals and the general

public related to cardiovascular diseases in women.

GENCAD: Institute of Gender in Medicine (GiM) - Charité – Universitätsmedizin Berlin

(charite.de)

Figure 5. National causes of death in EU27 per gender [Timmis 2022 - ESC Atlas]

12

Generational inequalities

While CVDs can occur at any age, their risk and prevalence increase in older people,

which is particularly relevant given Europe’s ageing population. The population aged

65 years or older is predicted to increase significantly in the EU, rising from 90.5 million

at the start of 2019 to an estimated 130 million by 2050 [Eurostat 2020], and there will

be corresponding increases in CVD incidence and burden.

However, a common misperception is that CVDs are limited to older people, when in

fact, CVDs account for around 23% of deaths before the age of 70 [Timmis 2022],

heavily impacting all ages. Furthermore, individuals can be born with a spectrum of

congenital heart/vessel diseases, and although more than 90% now survive to

adulthood, many have complex CV problems requiring highly specialised care. In

addition, a wide range of inherited CV conditions are related to genetics and are not

linked to modifiable risk factors. These include familial hypercholesterolaemia (a

disease involving very high cholesterol levels), certain cardiomyopathies (a disease of

the heart muscle) and heart rhythm disorders. Such diseases can be detected and

treated early with appropriate screening.

13

Improving primary prevention of CVD across all ages

Primary prevention refers to strategies and interventions to reduce the risk of

developing heart and vascular problems in individuals without established CVD who

have not yet experienced a CV event.

To influence the risk factors leading to the development of cardiovascular disease

(CVD) and yield the expected benefits (health gains, life years gained, economic

consequences at individual and societal level), it is essential that the various

prevention interventions and options are defined and designed, not only from a clinical

perspective but also from a public health perspective. Given that the beneficial effects

of influencing risk factors can be identified at the individual and societal level from the

time of intervention, it is proposed to consider related preventive interventions across

the life course. The planning and implementation of prevention activities in daily

practice requires an integrated, multidisciplinary approach.

At present, CVD prevention mainly focuses on risk reduction later in life, and while this

is important, it is also necessary to recognise that CVD development – particularly the

formation of atherosclerotic plaques that lead to heart attacks – starts early [Dendale

2019; Braunwald 2023]. Parents’ behaviours before conception and during pregnancy

can impact CV risk, while childhood is a key period for instilling healthy lifestyle habits.

The ‘tsunami’ of obesity that we are currently seeing is beginning early, with around

one in five children in Europe being overweight or obese [Garrido 2019]. Opinions and

regulation of physical activity in schools differ greatly within Europe. There seems to

be a trend moving away from the norm of regular exercise for children. Coupled with

an unhealthy diet, this potentially lethal combination could have devastating

consequences on the burden of cardiovascular disease (CVD) in the future.

Primary prevention has suffered from a failure to pair individual responsibility with

support for evidence based public health interventions in the field. When focusing on

'cardiovascular health', it becomes evident that both individual responsibility and

preventive measures are crucial. Therefore, it's essential to acknowledge individuals'

roles in preventing lifestyle risk factors for cardiovascular disease and implementing

policies to promote health. [Vassilaki 2015]

14

To strengthen the public health approach, more attention must be given to fostering

the idea of "health as a value and experience" from early childhood. Without this

foundation, it will be difficult in the long term to ensure that the public possesses the

necessary competencies and knowledge to maintain good health for as long as

possible. This entails empowering individuals to make informed decisions regarding

both their personal health and the health of their community. However, beyond merely

imparting skills and knowledge, fostering an environment conducive to healthy choices

is equally imperative. The promotion of health literacy and the development of health

understanding are integral components that cannot be overlooked without

strengthening health promotion, particularly in educational and workplace settings. In

addition to individual health promotion, community health promotion programmes

should also be launched, given their key role in prevention and in influencing risk

behaviour towards the desired positive direction.

In this context, cardiovascular prevention strategies should adopt a multifaceted

approach. This involves directing efforts towards the entire population, as well as

targeting specific high-risk or vulnerable groups, and addressing individuals who have

either been diagnosed with or have a history of cardiovascular disease. Emphasising

the significance of patient education and support is crucial, necessitating a tailored

approach that accommodates the diverse needs of patients, encompassing factors

such as educational backgrounds, age, health conditions, cultural backgrounds, and

any disabilities they may have. The goal of patient support is to transform patients from

passive recipients of care into active participants within the healthcare process.

Enhancing the dialogue and collaboration between patients and healthcare providers

can significantly boost the effectiveness and efficiency of prevention, treatment,

rehabilitation, and health promotion activities. For those with established

cardiovascular diseases, a partnership approach to communication and action is

essential. This approach involves sharing information about the risks and benefits of

treatments while considering the individual's needs, preferences, comorbidities,

medications, and other relevant factors.

15

Risk factors in the context of primary prevention

A recent global analysis has shown that over half (53–57%) of CVDs are attributable

to five modifiable risk factors: systolic blood pressure, non-high-density lipoprotein

cholesterol, current smoking, body mass index (BMI) and diabetes [Global CV Risk

Consortium 2023]. The ESC Atlas project highlights the alarmingly high levels of these

CV risk factors across the general populations of EU-27 countries [Timmis 2022]:

 More than 1 in 5 had elevated blood pressure (≥140/90 mmHg)

 About 1 in 7 had high cholesterol levels (total cholesterol ≥6.2 mmol/L)

 More than 1 in 5 smoked tobacco

 More than 1 in 5 had obesity (BMI ≥30 kg/m2), a massive rise from 1 in 10 in

1980

 More than 1 in 20 had diabetes

Around 10% of CVD deaths are attributable to smoking. Smokers have a 30% higher

risk of developing coronary heart disease than non-smokers. Secondary smoking is

estimated to increase the risk of stroke by the same amount. Understanding the impact

of smoking, including the effects of emerging tobacco products, on cardiovascular

disease (CVD) is crucial. Recent findings also suggest that e-cigarettes may raise

blood pressure and heart rate, increase arterial stiffness, and lead to poorer

cardiovascular and respiratory health outcomes compared to non-users, as indicated

by measurements like blood pressure, heart rate, exhaled carbon monoxide, and nitric

oxide levels [Gernun 2022].

Additionally, inadequate nutrition is a key lifestyle risk factor for cardiovascular disease,

with strong evidence showing that factors such as overweight/obesity, high salt intake

[Wang 2020], and increased intake of trans fatty acids significantly contribute to the

risk of developing cardiovascular diseases [Guasch-Ferré 2015]. A key to prevention

is the reduction of high nutritional risk factors, excessive salt, saturated fat and trans-

fatty acid intake, which are already present in childhood. With regard to the health

impact of industrial (artificial) trans fatty acids, studies show that they pose a major

health risk, with an intake of just 5 g/day of trans fatty acids, equivalent to 2% of total

energy intake, increasing the risk of cardiovascular disease by 23% [Oomen 2001].

16

This intake is 4 to 5 times higher per gram of saturated fatty acids, as they increase

LDL cholesterol levels in the serum, reduce HDL cholesterol levels and increase

triglyceride levels, thus causing a significant atherosclerotic effect.

The consideration of diabetes is also crucial in cardiovascular health because it

markedly increases the risk of various cardiovascular diseases, including coronary

artery disease, heart failure, and stroke. [Shah 2015] High blood sugar levels

associated with diabetes can damage blood vessels and the nerves that control the

heart. Over time, elevated glucose levels can lead to fatty deposits accumulating on

blood vessel walls, causing them to narrow and harden—a condition known as

atherosclerosis—thereby reducing blood flow and forcing the heart to work harder.

Diabetes is often accompanied by unhealthy cholesterol levels, further contributing to

atherosclerosis. Moreover, many people with diabetes have hypertension, a significant

risk factor for heart disease and stroke. Diabetes also promotes increased

inflammation and a greater tendency for blood clot formation, heightening the risk of

cardiovascular events. Additionally, diabetes can lead to diabetic cardiomyopathy,

affecting the heart's structure and function and potentially causing heart failure.

Therefore, effective management of diabetes—including controlling blood sugar, blood

pressure, and cholesterol levels, following a heart-healthy diet, engaging in physical

activity, and avoiding tobacco—is vital in minimizing the risk of cardiovascular

complications.

Governments have a crucial role to play in creating ‘heart healthy’ environments and

opportunities for physical activity and active living for all. The evidence that compact

neighbourhoods with easy access to amenities, parks and public transport underpin a

healthy and sustainable city is rarely effectively incorporated into city planning policy,

which perpetuates physical inactivity [Münzel 2021; Giles-Corti 2022].

Across age groups, simple promotion of healthy behaviour is insufficient. School,

family and community-based education is needed to address the current lack of

knowledge of the impact of an unhealthy lifestyle while behavioural change support is

needed to help children and adults develop healthy habits. Schools4Health project, led

by EuroHealthNet, is EU-wide in scale with partners from Belgium, Denmark,

Germany, Greece, Hungary, Latvia, the Netherlands, Romania, Slovenia and Spain.

17

These partners collectively bring extensive knowledge and experience in the fields of

school health and health promotion.

18

Improving primary CVD prevention in the primary-care setting – spotlight on

Hungary

Hungary's government measures such as the public health product tax introduced in

2011, compulsory daily physical education in schools, and public catering, school milk

and fruit programmes to promote healthy eating habits have produced significant

results. The introduction of daily physical education has been shown to contribute to

the prevention of childhood obesity, blood pressure problems and to increase health

motivation.

Primary care is a key site for CV prevention and lessons can be learned from a recent

government initiative in Hungary designed to improve provision. Until 2021, primary

care was provided by isolated general practices (GP) consisting of one doctor and one

or two practice nurses, with insufficient focus on preventive activities due to a lack of

time and well-defined tasks [Jancsó 2022]. ‘Three Generations for Health Programme’

was launched in 2019, which focuses on providing preventive and continuous care

services and the mandatory establishment of GP partnerships. A key aim is to assess

CV risk factors and risk levels and to launch personalised interventions in a large

population involving three generations (0–18 years, 40–65 years and 65+ years). Over

800 GPs in Hungary are participating in the programme, with central data analysis to

assess its success.

An analysis of risk factors and guideline-recommended target achievement was

performed at the beginning of the programme start in around 37,000 individuals aged

40–65 years. Of these 31% were found to be at very high CV risk. Achievement of

target blood pressure levels was lower among very high-risk Hungarian individuals

than the European average (49% versus 58%, respectively). Similarly, attainment of

LDL-C target was only 8% among very high-risk patients, also falling below the

European average (29%). Continuous assessment of risk factors over time will provide

key information on progress.

19

Recommendation:

It is recommended that the European Commission’s Expert Group on Public Health

actively identify public health policy interventions in primary CVD prevention that have

a proven track record of success and that appropriate funding is provided to implement

these across the EU. There is need for coordinated action at EU level to reduce and

prevent nutritional risk factors (e.g. a European salt reduction programme, in addition

to the existing EU regulation on the maximum levels of trans fatty acids in food). The

subgroup on prevention of non-communicable diseases has agreed to map all national

non-communicable disease policies and programs as a first step when defining future

actions. It should be also highlighted that the major joint action on health determinants

is looking at different types of determinants including commercial.

20

Reducing the impact of environmental stressors

In addition to traditional CV risk factors, there is growing evidence that environmental

factors – including air and noise pollution – contribute significantly to the burden of

CVDs [Münzel 2022]. Evidence also links adverse CV health with particles from natural

sources (e.g., desert dust, wildfires and volcano eruptions) [Münzel 2022] and climate-

change-related extremes of temperature [Zhao 2021]. Environmental stressors

contribute to CVD development and also exacerbate existing risk factors or diseases

(e.g., diabetes or hypertension) due to similar mechanisms.

The main components of air pollution include particulate matter (PM; ranging in

diameter from coarse 2.5–10 μm [PM10], fine <2.5 μm [PM2.5] and ultrafine <0.1 μm

particles) and gaseous pollutants including ozone, nitrogen dioxide, carbon monoxide

and sulphur dioxide, produced primarily by combustion of fossil fuels such as oil, gas

and coal. In analyses, increases in PM concentration were related to HF hospitalisation

or death (PM2.5: 1.29% per 10 μg/m3, PM10: 1.30% per 10 μg/m3), with adverse

relationships also observed with gaseous pollutants [Yang 2023]. In other studies, a

10 µg/m3 increase in long-term PM2.5 exposure was associated with an increased risk

of 23% for IHD mortality, 24% for stroke mortality, 13% for incident stroke and 8% for

incident heart attack [Alexeeff 2021].

The mechanisms by which air pollution cause CVDs include general stress responses,

thrombosis and direct damage to the endothelial cells lining blood vessels, leading to

cell stress, inflammation and the accumulation of toxic mediators that increase the risk

of atherosclerotic plaque formation and rupture [Münzel 2018].

In EU, the median PM2.5 was estimated at 12.2 µg/m3 based on 2019 reported data.

There was a big variation between the EU member states, with PM2.5 levels ranging

from 5.6 µg/m3 in Finland to 22.6 µg/m3 in Poland. Thus the difference between the

most PM2.5 polluted and the least polluted country was 4-fold [data based on the ESC

CV Realities 2022]. The air pollution for PM2.5 in Europe is about 2.5 times higher than

the World Health Organization recommendations.

21

Noise pollution is estimated to be responsible for 48,000 new cases of CHD per year,

as well as 12,000 premature deaths across Europe [CV Realities 2022]. In addition,

6.5 million people experience chronic sleep disturbances The EU limit of 55 dB is linked

to adverse health consequences, and yet noise above this level is experienced by

around 113 million Europeans (20%) caused by road traffic, by 22 million due to trains

and by 6 million due to aircraft and these figures are likely underestimations [Münzel

2021]. reaction and the release of stress hormone and inflammatory markers [Münzel

2022]. Mitigation of environmental stressors could make a major contribution to CVD

prevention. In Europe, air pollution leads to a loss of approximately 2.9 years in life

expectancy, with 1.7 years considered avoidable through emissions controlled

measures. [Münzel 2022]. For comparison, life reduction caused by cigarette smoking

is in the range of 2.2 years [Lelieveld 2020]. Smart city planning incorporating ‘heart

healthy designs’ is an important mitigation strategy not only for improving physical

activity but also reducing unhealthy environmental exposures since noise, air pollution

or heat islands show an accumulation in urbanised areas. ‘Clean air’ legislation

promoting decreased particle emissions and promotion of public transport should also

be encouraged.

Recommendation:

Funding for research and education on the consequences of pollution and climate

change on CVDs must be intensified dramatically to protect the health of our current

and future generations.

The European Agency for Safety and Health at Work (OSHA) should conduct, if

appropriate, in cooperation with the European Environment Agency, an evaluation on

the extent to which workers are exposed to cardio-hazardous substances or

environments with recommendations on relevant health and safety at work legislation

updates.

22

CVD and mental health

The results of several studies, including large case-control population cohort studies,

show that there is a link between chronic stress and increased CVD risk.

Depression and mental health problems have been associated with early-onset CVD

and suboptimal cardiovascular health in young adults. [Kwapong 2023] However,

mental disorders also have an impact on cardiovascular disease outcomes, with

studies demonstrating that pre-existing depression is a risk factor for poor prognosis

of acute coronary syndrome. [Lichtman JH 2014]

An epidemiological cohort study by researchers from the Catholic University of Leuven

found that people with major mental illness (schizophrenia, bipolar affective disorder,

major depression) have a higher risk of cardiovascular disease (adjusted hazard ratio:

1.54 CI: 95%) compared to people without these disorders. Anxiety

symptoms/disorders or persistent/severe stressors, PTSD (post-traumatic stress

disorder), although less severe, increase the risk of cardiovascular disease (RR: 1,

41). On the other hand, the authors also point out that there is an inverse association,

i.e. mental disorders/illnesses are common in these patients and substantially increase

the risk of recurrent cardiovascular disease and cardiovascular mortality. [De Hert M,

2018]

In a Swedish cohort study of population-controlled twins, the hazard ratio for any CVD,

looking at the year after diagnosis of any of the stress-related psychiatric disorders

(acute stress reaction, adjustment disorder, post-traumatic stress disorder), was 1.64

(95% CI). The highest (6.95) hazard ratio was for heart failure. [Song H 2019]

The Commission communication for a comprehensive approach on mental health has

created a comprehensive framework for the member States and the EU for tackling

mental health issues. Therefore, risk factors related to mental health can be also

addressed via a number of actions, including best and promising practices related to

mental health as available at Best practices - European Commission (europa.eu)

23

Providing adequate secondary prevention strategies

Detection of modifiable risk factors (including high blood pressure, high cholesterol and

diabetes) and subclinical CVD, before an individual experiences a major event or

symptoms, provide key opportunities to prevent or delay morbidity and mortality.

However, as highlighted in the EUROASPIRE project, detection and treatment at the

early stages of disease is often suboptimal [Kotseva 2017].

In addition to CVDs caused by modifiable factors, individuals may be born with a wide

spectrum of congenital CVDs that affect them in infancy and lead to complex CV

problems in adulthood. There are also many rare CVDs that collectively affect a large

population of children and adults. Inherited CV conditions affect millions of children and

adults, including some cardiomyopathies and familial hypercholesterolaemia (FH).

Screening for these CVDs can enable early detection and diagnosis; however, this is

currently lacking for many diseases or is not widely available in all countries. For

example, FH results in life-long cholesterol elevations leading to premature CV events

(from aged 30 years) and premature deaths. In Europe, over 500,000 children and

2,000,000 adults are affected by FH [Bedlington 2022]. However, only 5% of children

are identified and subsequently only a small fraction of all affected individuals receives

life-saving treatment.

Early diagnosis of clinical CVDs, when the individual has established disease, provides

the opportunity to reverse/delay the trajectory and reduce the burden, but again,

diagnosis is often missed or delayed. As an example, HF is a commonly occurring CVD

(median prevalence of 17 cases per 1,000 people) that is associated with frequent

hospitalisations and high mortality [Seferovic 2021; Crespo-Leiro 2016]. Around 60–

80% of HF cases are diagnosed in the emergency department (ED) [Bayes-Genis

2023], although many patients have symptoms that should have triggered an

assessment earlier.

Better detection and thus earlier treatment could make a tremendous difference in

CVDs linked to other chronic conditions or therapies, including, but not limited to,

diabetes and chronic kidney disease.

24

Individuals with type 2 diabetes mellitus (T2DM) face a 2–3 times higher cardiovascular

risk than people without diabetes and see their life expectancy reduced by 10–14

years.ii The number of adults diagnosed with diabetes in the EU has almost doubled

over the last decade, from about 17 million in 2000 to 33 million in 2019 and it’s

projected to increase to 38 million by 2030.iii

To identify people at risk of developing diabetes, the Finnish Diabetes Risk Score

(FINDRISC) can be used to predict the 10-year risk for developing type 2 diabetes.

FINDRISC uses age, BMI, physical activity, vegetable & fruit intake, medical treatment

of hypertension, history of hyperglycemia and family history to determine risk of

developing diabetes. Depending on the score, further investigations such as the

measurement of HbA1c may be needed. [Lindström J 2003]

A systematic global CVD risk assessment is recommended in individuals with any

major vascular risk factor i.e. family history of premature CVD, FH, CVD risk factors

such as smoking, arterial hypertension, diabetes, raised lipid level, obesity, or

comorbidities increasing CVD risk.

A Systematic CV risk assessment in the general population in men >40 years of age

and in women >50 years of age or postmenopausal with no known ASCVD risk factors

may be considered.

Recommendation:

There is a need for stronger emphasis on the system-wide development of health and

risk assessments and age-related screening in primary care. Special attention should

be paid to targeted risk assessment, screening and more effective care for

hypertension, diabetes and lipid metabolism disorders. The timely and frequent

performance of these assessments and screening, and timely initiation of care

activities, contribute significantly to increasing the number of healthy life years.

It is suggested that European Council Recommendations on a Joint Cardiovascular-

Diabetes Health Check would be the most effective policy mechanism to promote

secondary prevention and would provide a common framework for national secondary

prevention programmes for CVD.

25

Screening of cardiovascular diseases takes place in primary care most often and

therefore it falls under the national responsibility for organizing and financing health

services as stipulated in article 168 of the Treaty of the functioning of the EU. However,

if member states wish to discuss overall practices related to such screening this can

take place at an appropriate EU level forum (such as the public health expert group).

Avoiding repeat cardiovascular events

Nearly half of all CV events occur in people with established heart disease, and 25–

30% of strokes are repeat events [Jernberg 2015; Hankey 2014]. One in five patients

discharged from hospital after a heart attack has another heart attack, stroke, or dies

of CV illness within the first year [Jernberg 2015].

Results from EUROASPIRE highlight that most patients have suboptimal risk factor

control in the 6 months after a heart attack [Kotseva 2019]. At least 20% of patients

did not receive heart-protective medications, 58% did not met blood pressure targets

and 71% did not achieve LDL-C goals. High LDL-C levels could be due to low statin

doses and failure to prescribe combination therapy, due to cost and/or difficulties

accessing newer therapies. Adherence is also poor with LDL-C-lowering therapy,

which may be due to patient concerns about side effects and a lack of understanding

of their disease [Karalis 2023].

Best-practice secondary prevention within the first year can mitigate a large part of the

risk of recurrent events, providing an estimated gain of around 7 CV event-free years

[van Trier 2023] and can also improve QoL, with cost-savings due to reduced

hospitalisations and healthcare utilisation.

Secondary prevention should be initiated immediately in the hospital after a major CV

event with the optimisation of preventive medication. A discharge protocol should

inform outpatient facilities and primary care. Long-term management should include

regular assessment of risk factors, symptoms and vital signs, continued patient

education and advice on a healthy lifestyle, monitoring of medication adherence and

support for self-management.

26

Digital technologies may be useful in optimising risk factor control in secondary

prevention. For example, with easy-to-apply telemedicine techniques, more than 70%

of heart-attack patients reached recommended LDL-C levels after 1 years’ follow-up in

a Spanish study [Ruiz 2022].

Recommendation:

It is recommended to reallocate the burden of hospital care as appropriate,

emphasizing primary and community care alongside self-management, supported by

digital health solutions (EACH, 2022). Monitoring the cost-effectiveness of prescribed

therapies and other innovations is essential. Recommendations should focus on

improving adherence to medical advice, particularly concerning preventive

medications and promoting appropriate health behaviours, including risk awareness.

27

Restoring CVD innovation in the EU

Currently, the pipeline of new CV drugs is limited compared with many other clinical

areas including oncology and contrasts with the huge number of in-need patients

[Warner 2020; Szymanski 2023]. In 2021, three new CV drugs were approved by the

European Medicine Agency (EMA) among 92 positive opinions. In 2020 and 2022, no

new CV drugs were approved and only one has received a positive EMA opinion in

2023. Despite representing the biggest burden of disease, the pipeline for new

treatments is not reflective of a market environment appropriately calibrated to develop

new solutions for CVD.

Figure 6 – Pipeline summary of key therapy areas [EFPIA Pipeline Innovation

Review, 2022,]

In order for innovation in CVD to be restored, research budgets need to be allocated

based at least some extent, on the mortality and morbidity of diseases.

28

Regulatory challenges impeding new CV treatments

Challenges causing lagging drug innovation include the duration and expense of CV

clinical trials needed for regulatory evaluation and approvals, and the complexities of

the approval process itself [Warner 2020]. There is also a perception that the price

payers would be willing to pay for CV drugs – which are expected to yield a moderate

beneficial effect on a large number of eligible patients – would not bring sufficient

financial gains to industry given the high costs associated with bringing new drugs to

the market [Wallentin 2019].

Enhancing patient engagement in trial design, with convenient participation and

meaningful endpoints may help to improve recruitment and retention, which are major

trial expenses. Indeed, research priorities should be set based on what patients

themselves identify as gaps and needs. In a survey involving patients with advanced

HF, the main research priority identified by patients was further research on treatments

that have the biggest impact on the Quality of life [Taylor 2020].

Enhancing support for personalised CV medicine

Research is needed to better understand and treat the 40–50% of CVDs that cannot

be attributed to major modifiable risk factors, including numerous orphan CVDs.

Currently, most CV treatments do not target the exact cause of the disease at the

molecular level, but rather try to fix downstream processes non-specifically. With

technological advances, more cause-specific and personalised management

strategies have been developed for certain cancers and neurological diseases, and

these ‘precision’ approaches are now becoming a reality in CV medicine.

New drug targets may be identified using advanced technology e.g., genomics

(assesses gene expression) and proteomics (assesses protein expression). Although

this research may appear expensive to conduct in the short term, it has the potential

to bring considerable long-term gains and has already proved successful. Advanced

technology may also provide ways to predict patient’s response to certain treatments,

29

for example, genetic variants have been identified that reduce responsiveness or

increase side effects to antiplatelet medications. [Sethi 2023].

Recommendation:

A longer-term perspective is needed towards funding to fuel a move towards a more

personalised patient-care pathway including the development of a dedicated CV health

mission as part of the next Framework Programme for Research and Innovation with

more structured collaboration and emphasis on the translation of research into

implementation and new models of care.

Supporting registries and real-world studies to enable the EHDS and fuel

research

Only 25% of national CVD Registries in the EU are supported with public funding

[Dawson 2021]. Despite strong interest from medical societies in expanding registries

and real-world observational studies, a lack of resources to facilitate this is cited as the

most common barrier.

This lack of support for the centralisation of high-quality data and real-world evidence

serves to undermine the goals of the European Health Data Space (EHDS). Any

functional EHDS will be dependent on the ability to generate robust data and this

cannot be done if the bulk of society’s understanding of CVDs is primarily dependent

on the private sector and charitable donations.

Improvements can only be made if the epidemiology of CVDs in Europe and their real-

world monitoring and treatment patterns are accurately understood and built on a

strong evidence base.

Recommendation:

The creation of a ‘European Cardiovascular Health Data Knowledge Centre’ to bring

together existing data and initiatives is suggested as a potential solution. One of the

primary goals would be to provide comprehensive and standardised data to support

treatment and care innovation, personalized management, and the enhancement of

30

care delivery through integrated, data-driven care pathways and outcomes

measurement, all based on the latest real-world evidence.

Improving access to care and reducing inequalities

Access to specialist acute care is unequal across Europe and there is a need for

governments to set targets for access to specialist care, such as stroke or cardiac care

units. For example, the Action Plan for Stroke in Europe aims to achieve 90% of

patients being treated in dedicated stroke units by 2030 [Norrving 2018].

Access to lifesaving treatments is also suboptimal. For example, four therapies are

recommended to reduce mortality, prevent recurrent hospitalisations and improve the

clinical status, functional capacity and QoL in patients with HF [McDonagh 2021 &

2023], and yet many are not prescribed these therapies or do not receive treatment

promptly or at sufficient doses [Jankowska 2023; Khan 2021]. Strategies proposed to

help optimise treatment include more standardised care pathways, improved use of

digital tools (e.g., integration of guidelines into primary care workflow), improved

education for primary care practitioners and patients, and improved access and

affordability of therapies [Jankowska 2023].

Access to lifesaving procedures is problematic and varies widely across the EU [CV

Realities 2022]. Middle-income countries are severely under-resourced compared with

high-income countries in terms of cardiological person-power, leading to procedural

deficits e.g., in coronary interventions, ablation procedures, device implantation (e.g.,

pacemakers and implantable cardioverter defibrillators) and in heart valve procedures

(e.g., transcatheter aortic valve implantation) [CV Realities 2022].

31

Righting current wrongs in rehabilitation

After a CV event or stroke, and in patients hospitalised with HF, multidisciplinary

rehabilitation involving medical treatment, counselling, psychological support, exercise

prescription/advice and education are crucial to help prevent recurrence, improve

functional capacity, recovery and psychological well-being [Ambrosetti 2021].

Rehabilitation should involve a multidisciplinary team and a clear plan for discharge

from the hospital with documented responsibility for continuing rehabilitation needs in

the community. Providing information and education on the perception of disease,

empowerment and self-management are recommended.

A recent survey found that cardiac rehabilitation was available in 91% of European

countries; however, there is only one spot for every seven patients in need, with well

over 3 million more spots needed per year to treat patients with IHD alone [Abreu

2019]. When examined by region, one spot for every two patients was available for

northern countries, but this reduced to one spot for every 13 patients in southern

countries and one spot for every 21 patients for eastern countries. When provided,

cardiac rehabilitation is often of suboptimal quality, with short duration [Ruivo 2023].

Results from the EUROASPIRE survey found that of almost 8,000 patients

interviewed, only 51% were advised to participate in a cardiac rehabilitation

programme and of these, 81% attended at least half of the sessions with wide variation

between countries [Kotseva 2018].

Barriers to implementing prevention and rehabilitation at the patient level include low

education, older age, lack of benefit awareness, comorbidities, transport problems and

financial concerns [Ruivo 2023]. At the personnel level, barriers include lack of

automatic referral, no financial incentives, lack of multidisciplinary teams and time

consumption. Healthcare obstacles include reimbursement issues, lack of specialised

locations and geographical issues. A lack of cardiology training, guidance documents,

national accreditation and electronic database registries were also identified.

Life after a CVD event must be included in any national CVD plan to address survivors’

and their families’ long-term unmet needs and minimum standards set for what every

CV survivor should receive regardless of where they live.

32

Recommendation:

Building on the Stroke Action Plan for Europe, it is recommended that in hospital and

community based rehabilitation for cardiovascular patients should be included in all

national cardiovascular health programmes in member states.

33

Conclusion

As it stands today, there is no stand-alone plan to tackle the EU’s biggest killer.

An EU Cardiovascular Health (CVH) Plan with clear deliverables and common targets

accompanied by National CVH plans, would preserve the lives and livelihoods of

Europeans for generations to come.

A genuine effort to fund evidence based public health interventions in primary

prevention across the EU can give youth a future and unshackle the concepts of old

age and ill-health.

Early detection of cardiovascular disease and its risk factors could prevent premature

death and future costs to the healthcare system.

Dedicated research programmes for cardiovascular health research could help

translate novel ideas trapped in the mind of researchers without the necessary funding

and transform this into an opportunity for necessary new age treatments to reduce the

burden of CVDs.

Rehabilitation policies that recognise a patient’s needs after they have left the hospital

could ease the suffering of millions and rapidly accelerate their return to the life they

wish to lead.

Investing in a dedicated Cardiovascular Health Plan would not only offer the necessary

practical framework to address the EU-wide challenge of cardiovascular disease

(CVD), but it would also signal a commitment by all Member States to systematically

address inequalities and strive for improvement. This proactive approach signifies that

the EU's leading cause of mortality will not go unchallenged. This could also take into

account the ongoing actions and discussions which are taking place under the two

major joint actions related to help determinants and cardiovascular diseases.

34

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PRACTICAL INFORMATION NOTE

2

LIST OF CONTENTS

List of Contents ......................................................................................................................2

General Information ................................................................................................................3

Deadlines ...............................................................................................................................3

Accreditations .........................................................................................................................3

Badges ...................................................................................................................................4

Liaison Officers.......................................................................................................................4

Interpretation ..........................................................................................................................5

Arrival and Departure .............................................................................................................5

Transportation ........................................................................................................................5

From the airport to the city ..................................................................................................5

Facilities .................................................................................................................................6

Bilateral Meetings ...................................................................................................................6

Security ..................................................................................................................................7

Accommodation......................................................................................................................7

Venues ...................................................................................................................................7

Venue of the Conference ........................................................................................................8

venue of the Welcome Reception and Networking .................................................................9

Preliminary Program ...............................................................................................................9

Media ...................................................................................................................................13

Other Practical Information ...................................................................................................13

Contact Information ..............................................................................................................13

3

GENERAL INFORMATION

The Hungarian Presidency of the Council of the European Union is pleased to provide the

following practical information to help you to prepare for the High-Level Conference on

Cardiovascular Health (CV Health Conference), to be held in Budapest on the 3rd and 4th

of July, 2024.

DEADLINES

When? What? Where/who?

6th June The Novento Presidency

accreditation platform opens.

Novento presidency

accreditation platform.

22th June, 23:59 The Novento Presidency

accreditation platform closes.

Novento presidency

accreditation platform.

At the airport Distribution of accreditations

for ministerial delegations.

By a LIO (Liaison Officer).

During registration, at

the conference venue

Distribution of accreditations

for non-ministerial

delegations.

By LOC (Local Organizing

Committee).

ACCREDITATIONS

Delegations are kindly asked to appoint a Delegation Accreditation Officer (DAO) who

will be responsible for the accreditation of every member of their delegation. Please

communicate the name, cell phone number and e-mail address of the DAO and the

title of the event to [email protected] as soon as possible.

The appointed DAO will receive an e-mail containing a link and necessary credentials (log-in

information) for the official presidency accreditation platform to register the members of their

delegation.

We kindly ask you to register at your earliest convenience via the accreditation platform. The

online accreditation platform will be open from 6th June until 22th June.

Please make sure that personal details are correctly entered on the platform, as certain

information (e.g. your name) will appear on the badges. Please note that only accredited

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delegates will have access to the official meeting and other official programme venues. If you

have any questions regarding your registration, please contact

[email protected].

All personal information provided for accreditation will be processed in accordance with the

EU General Data Protection Regulation (GDPR), which can be found at the accreditation

system.

BADGES

Access to the meeting venue requires a valid personalized badge, which can be

obtained after the registration request had been approved and the accreditation is confirmed

by a confirmation message through Novento. Badges will be distributed at the conference

venue upon arrival, or by the designated Liaison Officer (in case of ministerial delegations).

Delegates will receive one single badge for a several-day event. Please make sure to

wear your badges visibly at the meeting venue and official programme venues.

Please note that all participants are required to carry their ID cards or passports, in order to

comply with the on-the-spot identification process.

In case of loss of a badge, please report it immediately to: [email protected]. The

validity of the badge will be immediately terminated, while the organisers will create a new

badge upon your request.

For further information regarding the badges of any delegate, please contact

[email protected].

LIAISON OFFICERS

To ensure that your visit runs smoothly, a Liaison Officer will be assigned to accompany your

HoD throughout the event and provide any logistical assistance required on site.

Supervised by a coordinator, the Liaison Officer will:

• serve as a single point of contact;

• welcome and accompany the delegation during the Presidency events;

• assist the delegation to ensure successful participation in the meeting;

• provide logistical assistance and administrative support at the venue;

• provide and distribute accreditation pins and badges on arrival.

5

INTERPRETATION

The Conference will be held in English, without the use of interpretation services.

ARRIVAL AND DEPARTURE

All delegations are kindly asked to provide the arrival and departure details in the

accreditation system:

• for delegations travelling by car or train: date and time of arrival, the border crossing

point to Hungary, and arrival destination point,

• for delegations travelling by plane: date and time of arrival and departure, as well as

the flight number and the airline.

TRANSPORTATION

FROM THE AIRPORT TO THE CITY

Delegates who arrive with a commercial flight will arrive to Terminal 2A or 2B of Budapest

Liszt Ferenc International Airport. Please note that shuttle service is only provided to

ministerial delegations on behalf of the Presidency. Ministerial delegations are kindly

asked to mark their luggage with a national coloured ribbon.

Non-ministerial delegations are responsible for their own travel arrangements.

• Budapest Airport Shuttle Service

Budapest Airport itself offers an airport shuttle service for an extra fee, called MiniBUD

(www.minibud.hu).

• Public Transport (Budapest Transport Centre – BKK)

Public transport bus line 100E Airport Express provides a direct and fast connection to

the city centre. Single ticket costs 2.200 HUF, tickets can be purchased at the ticket

machines at the airport.

For more information regarding public transportation within the city, please consult the

website of BKK, where you can also learn about the costs of different types of tickets and

information on public transport routes: https://bkk.hu/en/

6

• Taxi

At your landing spot, Budapest Liszt Ferenc International Airport, you have the

opportunity to book a taxi to get you to your accommodation. The official partner of

Budapest Airport is Főtaxi (tel. +36 1 222 2 222, https://fotaxi.hu/en/). Főtaxi operates a

designated office outside of the arrival terminal.

FACILITIES

The Hungarian Presidency will provide all necessary services, such as a cloakroom, internet

connection, and working facilities for delegations at the Ministry of Interior, the official

meeting venue. The Wi-Fi password will be provided at the location. It is allowed to bring

your luggage into the Ministry of Interior, which will be secured by a hostess at the venue.

BILATERAL MEETINGS

A limited number of bilateral meeting boxes will be available at the Ministry of Interior.

Reservations will be handled on a „first come-first served” basis. The Hungarian Presidency

7

does not provide interpretation for bilateral meetings. You can book a meeting in advance by

sending an e-mail to [email protected].

Please indicate:

• the preferred time slot (the standard duration is 15 minutes, however it can be

prolonged);

• the number of participants.

SECURITY

Providing a safe environment for our delegations is of paramount importance to the

Hungarian Presidency. For security reasons, badges must be worn visibly during the

official programme. Access to the meeting venue will be denied in the absence of a visibly

worn badge.

Please note that all delegates except the participating ministers will have to go via security

check while entering the meeting venue.

ACCOMMODATION

The Hungarian Presidency will book and cover the costs of accommodation for the

participating ministers (suite) + 1 delegate (standard) for the night of the two-day conference

at the Kempinski Hotel.

Non-ministerial delegations are responsible for their own reservation arrangements and

covering the costs of their hotel rooms. Any additional expenses (beverages, minibar,

parking, meals, laundry services, etc.) must be covered by the delegates themselves.

In case you have questions or need hotel recommendations, please contact us at the

following email address: [email protected].

VENUES

The CV Health Conference will be held at two locations, all within walking distance of each

other.

When? Venue Address

3 July 2024 Ball Room Apáczai Csere János utca 4

8

Marriot Hotel Budapest 1052 Budapest

4 July 2024 Marble Hall, Ministry of

Interior

József Attila utca 2-4

1051 Budapest

VENUE OF THE CONFERENCE

The Conference will be held at the Marble Hall of the Ministry of Interior.

The main building of the Ministry of Interior is located in the former headquarters of the

Hungarian Commercial Bank of Pest, a huge block facing the Danube with four internal

yards, built in the beginning of the 20th century. This part houses the offices of the Minister

and the State Secretaries along with the Marble Hall, the main venue of the ceremonial

events. The buildings show features of multiple styles, ranging from neo-Classicism through

Art Nouveau, while the interior spaces suggest elegance through the richly coloured marble

surfaces and the embossed copper designs.

9

VENUE OF THE WELCOME RECEPTION AND

NETWORKING

The Welcome Reception and Networking

on 3rd July will be organized in the

Ballroom of Marriot Hotel Budapest,

which is a 10 minute walk from the

conference venue. It offers a spectacular

panoramic view on the Danube and the

Buda side as well as an elegant location

for the welcome dinner.

PRELIMINARY PROGRAM

Please note that this programme is subject to change.

3RD JULY, 2024 (WEDNESDAY)

18:00-20:30 Welcome Reception and Networking at Marriot Hotel Budapest

4TH JULY, 2024 (THURSDAY)

08:00-09:00 Registration of Participants

09:00-09:15 Opening remarks by:

• Dr. Sándor Pintér, Minister of Interior, emphasizing the critical

importance of cardiovascular health and setting the expectations for the

day.

09:15-09:30 A View on the Data

Presentation of the key findings of the paper “Improving cardiovascular

health in Europe: the case for EU and National CVH plans” – Introduction to

the key data on burden of CVD and inequalities.

• Speaker: Prof. Franz Weidinger, President of the European Society of

10

Cardiology

09:30-09:45 Presentation by Prof. Béla Merkely – Honorary President of the Hungarian

Society of Cardiology

09:45-11:00 Panel 1 – Primary Prevention and Risk Factors What we know works

and what we are not doing?

Focusing on strategies for preventing cardiovascular disease through

lifestyle changes, management of risk factors and the environmental

stressors that drive the CVD burden.

• Keynote speaker: Prof. Zoltán Vokó, President, Hungarian Association

of Public Health Training and Research Institutes

• Moderator: Prof. Paul Dendale, Chair of Department of Cardiology,

Hassalt, Belgium

Panelists:

• Prof. Thomas Münzel, Chief of the Department of Cardiology, Center

for Cardiology, University Medical Center Mainz, Germany

• Dr. Anna Páldy, President, Hungarian Society of Hygienists

• Prof. Lis Neubeck, Professor of Cardiovascular Health in the School of

Health and Social Care at Edinburgh Napier University, Scotland

• Prof. Victor Aboyans, Head of the Dept. of Cardiology at the

Dupuytren University Hospital in Limoges, France

11:00-11:20 Coffee Break

11:20-12:20 Panel 2 – Secondary Prevention: How we can preserve life and

livelihoods?

Exploring approaches to early detection of CVDs and to prevent the

recurrence of cardiovascular events in individuals with existing heart

disease, including medication, lifestyle adjustments, and monitoring.

• Keynote speaker: Prof. Dr. Péter Andréka, President, Health

Professional College and Director General, Gottsegen National

Cardiovascular Center, Hungary

• Moderator: Prof. Francesco Cosentino, Professor of Cardiology,

Karolinska Institute and University Hospital, Stockholm

Panelists:

11

• Prof. István Wittman, President, Hungarian Diabetes Association

• Mr. Frédéric Clement, Vice-Chair, MedTech Europe Cardiovascular

Sector Group

• Prof. Fausto Pinto, Past President, World Heart Federation

• Neil Johnson, Executive Director, Global Heart Hub

• Dr. Ottó Skorán, BEMOSZ (Association of Patients' Organizations in

Hungary) / SZÍVSN National Patient Association

12:20-13:20 Lunch Break at the Reception Hall of the Ministry of Interior

13:20-14:20 Ministerial Panel

• Moderator: Prof. Elias Mossialos, Professor of Health Policy, Deputy

Head of the Department of Health Policy, Director of LSE Health

Panelists:

• Representative of WHO

• Izabela Leszczyna, Minister of Health of Poland (TBC)

• Dr. Karl Lauterbach, Minister of Health of Germany (TBC)

• Adonis Georgiadis, Minister of Health of Greece

• Dr. Javier Padilla, Secretary of State for Health, Spain

• Dr. Péter Takács, Minister of State for Health of Hungary

14:20-15:20 Panel 3 – Treatment and Innovation: What’s holding back the new age

in CV care?

Examining the current bottlenecks in CVD research and how to overcome

them.

• Keynote speaker: Prof. Miklós Szócska, Health Services Management

Training Centre, Semmelweis University

• Moderator: Prof. Gerhard Hindricks, Professor of Cardiology at the

Charite University Hospital, Berlin, Germany

Panelists:

• Alar Irs, Chair of EMA Cardiovascular Working Party

• Vasilisa Sazonov Ph.D, EFPIA CVH Sector Group

• Csaba Poroszlai, Medicines for Europe

• Prof. Piotr Szymanski, Head of the Clinical Cardiology Department at

12

National Institute of Medicine MSWiA Hospital in Warsaw, Poland

• Prof. Csaba Bödör, Head of Department of Pathology and

Experimental Cancer Research at Semmelweis University

15:20-15:40 Coffee Break

15:40-16:40 Panel 4 – Rehabilitation and Patient Centered Support: Care beyond

the Clinic

Discussion on the importance of rehabilitation for patients following cardiac

events, and the role of support networks in patient recovery and quality of

life.

• Keynote speaker: Dr. Emil Toldy-Schedel, Vice President, Hungarian

Cardiovascular Rehabilitation Society

• Moderator: Prof. Donna Fitzsimons, Head of the School of Nursing &

Midwifery, Member of Senate in Queen's University Belfast, Northern

Ireland

Panelists:

• Arlene Wilke, Director General, Stroke Alliance for Europe

• Hans Snijder, Board Member of European Heart Network, CEO of the

Dutch Heart Foundation

• Prof. Ana Abreu, Professor of Cardiology Hospital de Santa Maria

Faculty of Medicine, Lisbon, Portugal

• Dr. Dániel Aradi Ph.D, Head of Interventional Cardiology Working

Group, Hungarian Society of Cardiology; Associate Professor at

Semmelweis University and State Heart Hospital, Balatonfüred, Hungary

16:40-17:00 Closing remarks – Making Europe a Global Leader in CV Research,

Management and Care

Concluding the conference with final thoughts and a call to action,

summarizing key insights from the day and outlining steps forward.

Speakers:

• Dr. Dávid Becker, President, Hungarian Society of Cardiology

• Dr. Péter Takács, Minister of State for Health, Ministry of Interior

13

Evening Dinner at the Reception Hall of the Ministry of Interior

MEDIA

Photographs and video footage from events organised by the Hungarian Presidency will be

available on its official channels and the channels of the EU institutions.

Photos will be published on the official website of the Presidency and may be used free of

charge with a clear mention of the photographer.

For any media-related questions, please contact us at the following email address:

[email protected].

OTHER PRACTICAL INFORMATION

Emergency number: 112 (fire brigade, medical assistance)

Electricity: The voltage in Hungary is 230V, 50 Hz.

Local time: Central European Summer Time Zone (CEST) – GMT +2:00

Country code: Hungary +36

Currency: The official currency of Hungary is the Hungarian Forint. For official daily

exchange rates, please consult the website of the Magyar Nemzeti Bank (National Bank of

Hungary): https://www.mnb.hu/en/arfolyamok

Weather in Hungary: https://met.hu/en/idojaras/

Tap water: Hungarian water is regularly tested for quality and is safe to drink.

Smoking: Smoking is only allowed in the designated area of the official meeting spaces.

CONTACT INFORMATION

Should you have any questions regarding the logistical aspects of the event, or about the

details of the programme, please contact us at the following e-mail address:

[email protected].