This chapter outlines a comprehensive policy framework for cardiovascular disease (CVD) prevention and management, structured around two policy areas: population-level prevention and health system-level care delivery. It emphasises cross-sectoral strategies to address risk factors, such as diet, tobacco, physical inactivity, and environmental determinants. Health system actions focus on early detection, integrated multidisciplinary care, and person-centred approaches, supported by enablers like health literacy, workforce capacity, and robust data systems. Innovative models, including home‑based care, rehabilitation, and patient-reported outcomes, aim to improve quality and sustainability. The chapter highlights governance, financing, and resilience as critical levers for implementation, while calling for stronger efforts to embed environmental sustainability and equity across cardiovascular prevention and care pathways.
The State of Cardiovascular Health in the European Union
Abstract
A comprehensive policy approach is essential for managing cardiovascular prevention and care in the European Union (EU) and meet the needs of a population increasingly living with chronic conditions and multimorbidity. This chapter examines two key intervention areas: population-level prevention and health system care delivery, encompassing a range of policy actions aimed at reducing the burden of risk factors and strengthening healthcare systems through integrated, person-centred care models, guided by the cross-cutting principles of efficiency, equity, resilience and sustainability.
The substantial burden of cardiovascular diseases (CVD) on European societies and healthcare systems calls for the prioritisation of prevention policies, supported and sustained by empowering citizens to make healthy choices throughout the life course. The environments in which people live, work, and age influence health outcomes and therefore warrant consideration in prevention efforts, supported by coordinated cross-sectoral actions. CVD prevention is increasingly framed as a cross-sectoral priority, with growing recognition of the health co-benefits of policies on diet, tobacco, air pollution, and physical activity. However, there is substantial variation in the implementation of the key policy actions that can reduce the unequal burden of CVD.
Diet and nutrition policy continues to evolve, with increasing uptake of structural measures such as, reducing trans fats in food, sugar-sweetened beverage taxes, and healthy food procurement policies in public institutions like schools. In addition, comprehensive marketing restrictions aimed at reducing exposure to unhealthy food advertising, are not yet extensively applied across Europe, even though available evidence suggests they can contribute positively to improving children’s diets.
While tobacco control monitoring and taxation policies are effectively implemented across the region, there is potential for improvement. Implementation of mass media and advertising restrictions remains more heterogeneous, offering opportunities for strengthening tobacco control efforts. Tobacco control is among the most developed policy areas, with widespread adoption of effective measures contributing to declining smoking rates and reductions in CVD. Many countries have implemented legislation on smoke- and aerosol-free environments, cessation support, and youth-focussed restrictions, with growing interest in flavour bans and tobacco-free generation laws. Rising youth vaping and dual use present emerging challenges, with regulatory approaches to e‑cigarettes showing considerable diversity.
Physical activity promotion is widely recognised in national policy, with many countries implementing campaigns, school-based programmes, and infrastructure investments. Promising practices include active travel schemes, physical education in schools, and workplace initiatives; however, their implementation is inconsistent. Groups living in vulnerable situations – such as children, older adults, and disadvantaged populations – remain under-targeted, and cross-sector co‑ordination with areas like transport and urban planning is often limited. Additionally, excessive screen time, online gaming, and gambling contribute to sedentary behaviour, which increases cardiovascular risk through reduced physical activity and can also negatively affect mental health.
Policies aiming at decreasing harmful alcohol consumption, through pricing policies, marketing restrictions, and state‑controlled sales, have been implemented – particularly in Nordic and Baltic regions. Measures like minimum unit pricing have shown measurable health benefits.
Environmental determinants of cardiovascular health are receiving increased policy attention across Europe. air pollution, extreme weather, and climate‑related stressors are more and more recognised as important contributors to cardiovascular risks. While low-emission zones and active transport policies offer promising co-benefits, few countries systematically integrate environmental risks into national cardiovascular planning.
Preventive care and risk detection play an important role in cardiovascular health, with programmes like health checks and high-risk prevention initiatives demonstrating effectiveness in identifying and managing cardiovascular risk factors, particularly in underserved populations. These approaches are generally cost-effective and scalable, but challenges remain in reaching groups living in vulnerable situations and sustaining long-term engagement. Behavioural insights offer valuable tools to enhance adherence and design more effective interventions, but their application remains fragmented and limited.
Low health literacy hinders behavioural change and timely care‑seeking – while it can be improved through context-specific education, few countries target groups living in vulnerable situations. Early recognition of symptoms of acute coronary syndromes or stroke is essential for timely care that significantly reduces morbidity and mortality. Survival after out-of-hospital cardiac arrest depends on public training and automated external defibrillator (AED) availability. National cardiopulmonary resuscitation policies and AED registries vary across Europe, yet have shown to improve outcomes in some countries. Addressing equity is essential in CV care, as women, some ethnic groups, smokers, and people with diabetes face delays and treatment gaps. A full-pathway approach and regional networks can help reduce these disparities.
Improving outcomes in cardiovascular and cerebrovascular care requires a co‑ordinated approach through integrated, multidisciplinary care models across the care continuum – from early detection to post-acute support. Conditions such as atrial fibrillation, cardiomyopathies, diabetes, chronic heart failure, ischemic heart disease, and structural heart diseases benefit from co‑ordinated care pathways that emphasise early detection, specialist collaboration, patient self-management, and lifelong risk factor control. Key policy areas include implementing screening programmes, accrediting expert centres, training primary care providers, and ensuring smooth care transitions across settings.
Early heart failure detection and referral require public and professional awareness, primary care diagnostic tools, and clear referral pathways. Multidisciplinary programmes with and home‑ or clinic-based follow-up and self-management are key to reducing mortality and hospitalisations. Dedicated stroke teams and networks help standardise care and reduce regional disparities in stroke treatment. Mobile Stroke Units improve outcomes and are cost-effective, especially in densely populated areas; they are already in use in countries like France, Germany and Norway. Post-acute stroke care remains limited and needs expansion, being crucial to improve outcomes.
People‑centred care integrates medical treatment with individual preferences, promotes shared decision making, and prioritises overall well-being. People‑centred cardiovascular care improves patient experiences and outcomes, yet lacks widespread adoption. A few countries are investing in health literacy programmes to support self-care and shared decision making. Enhancing patients’ quality of life requires strong investments in discharge planning, self-management and rehabilitation. Early supported discharge accelerates the hospital discharge from hospital by offering specialised multidisciplinary care at home. Few countries have fully implemented early discharge protocols after stroke, acute coronary syndrome and heart procedures. Home‑based care has considerable potential for development across the region and could support the implementation of these innovations across the region.
Rehabilitation and lifelong management are essential and cost-effective components of secondary prevention for people with cardiac diseases and stroke. However, their availability varies greatly across Europe. Embedding rehabilitation in national guidelines, standardised care pathways and innovative delivery models may foster its provision. Alternative approaches like hybrid or home‑based rehabilitation, and automatic discharge referrals can boost participation in rehabilitation programmes. Embedding return-to-work programs in national policies can help position them as a core component of healthcare interventions. Nevertheless, most European countries lack clear guidelines and show wide variation of rehabilitation and return-to-work policies
Condition-specific patient-reported outcome measures (PROMs) for CVD have the potential to improve clinical practice. Some European countries are implementing PROMs to monitor cardiovascular care, yet challenges persist. The systematic collection and use of PROMs data can be facilitated by their integration into data infrastructures, which is being implemented in some countries. Improving patient experience has been associated with better cardiovascular health outcomes and Patient Reported Experience Measurements (PREMs) are being increasingly used to compare care providers and support accreditation, although standardising instruments could enhance comparability.
Addressing inequalities in cardiovascular care requires a comprehensive approach, as disparities encompass various dimensions such as gender, ethnicity, and geography. Groups living in vulnerable situations remain under-targeted in health literacy initiatives and under-treated. Key themes emerge as priorities for enhancing cardiovascular care pathways resilience, including strengthening workforce, adaptable infrastructure, digital innovation, and supply chain resilience. Comprehensive policies are important to enhance healthcare environmental sustainability, notably addressing cardiovascular care delivery.
A comprehensive policy framework is a crucial tool for guiding national efforts to prevent, detect and manage CVD. This chapter explores the CVD policy environment in the EU through two interconnected areas of intervention: 1) population-level prevention and 2) health system-level care delivery (Figure 6.1). These two policy areas relate to the macro‑aspects of the health system context and care delivery included in the report framework (see Chapter 1), encompassing a range of policy actions aimed at reducing the burden of risk factors and strengthening health services to improve health outcomes, guided by the overarching principles of sustainability, efficiency, equity, and resilience. These are essential cross-cutting dimensions for building health systems capable of addressing the increasingly complex needs of an ageing population (OECD, 2024[1]).
The substantial burden of CVD on European societies and healthcare systems calls for the prioritisation of prevention policies, notably primordial, primary and secondary prevention, supported and sustained by empowering citizens to make healthy choices throughout the life course. The environments in which people live, work, and age play a critical role in shaping health outcomes and are therefore central to prevention efforts, requiring co‑ordinated action across sectors beyond healthcare. Evidence‑based Health in All Policies (HiAP) is an approach to achieve equity and intersectoral action. HiAP provides the overarching strategic goal that will help countries to reduce the burden of CVD disease, identifying a broader set of actors able to implement and monitor structural policies. The benefits will exceed the health gains, not just by reducing the non-communicable disease (NCD) burden and the reduced pressure on healthcare systems, increasing healthy life expectancy and resulting in more equal, sustainable and economically stronger societies (Li et al., 2020[2]).
The overlapping risk factors between CVD and other NCDs, such as cancer, dementia, and mental health conditions offer an opportunity to amplify the impact of preventive policies beyond cardiovascular health, fostering relevant co-benefits to citizens and societies. Thus, an integrated approach to prevention is essential, notably addressing social and economic determinants. Five key policy actions are outlined in this Chapter: 1) reducing tobacco use, 2) promoting healthier diets and sustainable food systems, 3) encouraging physical activity through supportive environments, 4) scaling up risk factor screening and management, 5) addressing emerging issues such as air pollution and climate‑related health risks.
Healthcare systems are increasingly managing a greater proportion of patients with complex needs. Results from the OECD Patient Reported Indicator Surveys (PaRIS) showed that 82% of primary care patients aged 45 years or older suffered from two or more chronic conditions (OECD, 2025[3]). Furthermore, people living with multiple chronic conditions experience worse physical health than people with one chronic condition (OECD, 2025[3]). While delivering care at the most appropriate and least intensive level improves patient experience and cost-effectiveness, implementing patient-centred and integrated care models can further enhance efficiency and resilience in health systems, while reducing health inequalities. At the health system level, priority policies focus on: 1) enhancing early detection and response to cardiovascular events though enhancing health literacy and health systems response; 2) ensuring equitable access to primary care and specialised cardiovascular services; 3) promoting integrated care pathways; 4) expanding home‑based and community care services, and 5) embedding person-centred care approaches. The implementation of these policies can be underpinned by four cross-cutting enablers which will be addressed throughout the chapter, notably: 1) improved health literacy, 2) a well-resourced and supported workforce, 3) robust cardiovascular data systems and registries, and 4) sustained investment in research and innovation.
6.2.1. From national CVD plans to disease‑specific strategies, diverse approaches are being adopted across Europe
Across Europe, countries are implementing a wide range of strategies to address the growing burden of chronic diseases, notably CVD (Table 6.1). In some countries, these efforts are embedded within broader national frameworks, including National Health Plans, non-communicable diseases (NCD) prevention and/or management programmes, and National CVD control plans. Hybrid models combining prevention and disease‑specific strategies within acute care services are in place in some countries. Other countries implemented disease‑specific national control plans, such as for diabetes and stroke or disease management programmes. Disease management programmes are the process of care co‑ordination of patients suffering from specific chronic conditions during their care transitions. It has been proposed as a model to optimise care for patients with complex health needs (Sochalski et al., 2009[4]). Figure 6.2 illustrates how comprehensively national CVD policies address various components of the cardiovascular care pathway. While most countries include elements such as health promotion, disease prevention, early detection, and diagnosis and treatment in their national plans, critical areas such as tackling inequalities and promoting patient-centredness are the least frequently covered.
Note: Disease management programmes are the process of care co‑ordination of patients suffering from specific chronic conditions during their care transitions, which has been proposed as a model to optimise care for patients with complex health needs (Sochalski et al., 2009[4]).
Source: 2025 OECD Cardiovascular Policy and Data Survey, (ESO, 2023[5]; IDF Europe, n.d.[6]; Amgen, 2025[7]; Romanian Ministry of Health, 2025[8]; PWC, 2025[9]; Italian Ministry of Health, 2025[10]; Spanish Ministry of Health, 2022[11]; Bulgarian Ministry of Health, 2021[12]; French Ministry of Solidarity and Health, 2018[13]; Sweden Ministry of Health and Social Affairs, 2025[14]).
Germany implements a wide array of health policies and programmes targeting CVD. Some are broad in scope, targeting general NCD risk factors, while others are more targeted, including Disease Management Programmes for conditions such as coronary heart disease, heart failure, and diabetes. In Denmark, the government introduced a major health reform in September 2024, titled “Health Close to You” (“Sundhed tæt på dig”), shifting responsibilities and resources from hospitals to community-based services. Key measures include training and redistributing more doctors to underserved areas and enhancing collaboration across sectors, aiming to foster high-quality care close to home, thereby reducing inequalities and improving outcomes for patients with complex health needs (Indenrigs- og Sundhedsministeriet[15]; Kleja, 2024[16]; Kromann Reumert, 2024[17]). Italy embeds NCD policies in national health plans through the Piano Nazionale della Prevenzione (2020-2025) which sets national prevention strategies and is implemented via regional prevention plans – and includes equity as a cross-sectional objective (Italian Ministry of Health, 2025[10]), complemented by the Piano Nazionale della Cronicità (updated in 2024) for chronic disease management (Italian Ministry of Health, 2025[18]) and a dedicated National Diabetes Plan (Italian Ministry of Health, 2025[19]). While no single integrated national plan exists for CVD, regionally structured pathways provide organised management for the conditions.
The Portuguese National Health Plan 2030 (PNS 2030) underscores inequality reduction and sustainable health as central objectives. It calls for integrated intervention across prevention, health promotion, and management of chronic diseases (communicable and non-communicable). Within the field of cardiovascular health, the Strategic Plan for Cardiovascular Health in Portugal (led by the Portuguese Society of Cardiology) explicitly links to PNS 2030 goals. It recognises that premature cardiovascular mortality is a major health priority and frames CVD as a “problem of high magnitude.”
The Plan emphasises that sustained progress requires investments in health literacy, research, organisation of services, allocation of resources, and monitoring / evaluation. In line with these priorities, Portugal aims to build a more equitable and evidence‑informed cardiovascular health system, ensuring that prevention and treatment strategies reach all segments of the population – particularly those most affected by premature mortality and gender disparities in cardiovascular outcomes.
Source: Ministry of Health (Portugal), National Health Plan 2030.
Some countries have launched national strategies specifically targeting cardiovascular conditions across the full care pathway. In Portugal, the Strategic Plan for Cardiovascular Health explicitly links to the Portuguese National Health Plan 2030 goals (Portugal Ministry of Health, 2025[20]). Spain has launched the first national Cardiovascular Health Strategy in 2022, aiming to promote equity in cardiovascular health promotion, prevention, and care (Bueno et al., 2025[21]). The strategy is expected to unfold over five years, with each region adapting it based on local priorities, and marks a shift from disease‑specific care to a broader focus on cardiovascular health. Poland’s National Programme for Cardiovascular Diseases (2022-2032) aims to reduce CVD burden through prevention, early detection, and effective treatment, focussing on five priority areas: education, screening, workforce investment, CVD management, and innovation (PWC, 2025[9]).
Living with cardiovascular disease is not just about managing a medical condition; it is about navigating a complex web of physical, emotional, and social challenges. Decision-makers need to prioritise patient-centred care, equitable access to resources, and effective prevention strategies. Listening to patients' lived experiences is key to creating policies that truly meet their needs.
Caius, artist, researcher, patient advocate, and heart attack survivor.
In Ireland, chronic disease prevention and management are supported by initiatives like the National Heart Programme, the National Clinical Programme for Stroke, and the Chronic Disease Management Programme, focussing on prevention, early detection, and integrated care. The National Stroke Strategy (2022‑2027) aims to improve integrated stroke care, expand access to treatments like thrombolysis and thrombectomy, enhance rehabilitation, and promote equity, data-driven planning, and sustainable investment. These efforts align with the Healthy Ireland Framework (2013‑2025), which underpins key strategies such as the National Obesity Policy and the National Physical Activity Plan, also seeking to reduce inequalities. The “Sláintecare Healthy Communities Programme” supports groups living in vulnerable situations with targeted local health interventions. The “Guide for Referral of Patients to the Chronic Disease Specialist Integrated Services”, launched in 2024, supports General Practitioners (GPs) in managing complex cases. The “Enhanced Community Care” programme aims to foster community care, targeting particularly older people and people living with chronic conditions. In this context, partnerships with non-governmental organisations play a relevant role. For instance, the Irish Heart Foundation has established tailored support after hospital discharge for stroke survivors and heart failure patients (Irish Heart Foundation, 2025[22]; Hospital Professional News, 2023[23]).
Note: N=20 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Spain, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Multimorbidity – where individuals live with multiple chronic conditions – poses a growing challenge due to its complexity, often leading to fragmented care and poorer outcomes. Some countries have adopted pan-disease strategies, which go beyond individual illnesses to address social, cognitive, and functional needs (Onder et al., 2015[24]) (see Box 6.2). Such approaches aim to better co‑ordinate care and reduce over-testing, medication overuse, and promote person-centred care. The bidirectional relationship between CVD and cancer requires particular attention (see Box 6.3). Tackling overlapping risk factors, ensuring a person-centred multidisciplinary approach to prevent and manage treatment-related complications among cancer patients, and fostering collaboration between cardiologists and oncologists are key aspects to improve care and outcomes for a population with complex needs (Kuwabara, 2025[25]).
Denmark’s “Multimorbidity strategy”: Denmark’s multimorbidity strategy is a patient-centred, cross-sectoral approach aimed at enhancing integrated and personalised care through prevention, early detection, and long-term management. It features multi-sector collaboration, digital health tools, patient empowerment, and structural reforms to improve care coherence. The strategy has been evolving since the 2010s and aligns with Denmark’s broader 2030 health goals (Healthcare Denmark[26]).
UK’s “Major conditions strategy”: A five‑year initiative (2023‑2028) targeting six major disease groups – cancer, CVD (including stroke and diabetes), chronic respiratory disease, dementia, musculoskeletal disorders, and mental health. It focusses on prevention, early diagnosis, integrated long-term care, and improved co‑ordination across services. The strategy promotes community-based, person-centred care and holistic care models (DHSC, 2023[27]).
Finland’s “Chronic Care Model for Patients with Multiple Diseases in Primary Care”: Primary care model for multimorbidity developed under the ICARE4EU project (2013‑2016), which continues to guide practices in hospital districts and local health centres. It features structured care pathways, shared budgets, digital tools, and self-management support, promoting multidisciplinary, patient-centred care through collaboration between health and social care sectors. The model enables seamless co‑ordination across all levels of care (Hujala et al.[28]).
At the supranational level, the EU has also played a role in shaping cardiovascular policy. Co‑ordinated policy actions have contributed to declines in mortality due to circulatory diseases in recent years (Figure 6.3). These actions have addressed key drivers of CVD through prevention and management, reflecting strong recognition and leadership in tackling CVD and the broader NCD burden as major societal challenges. Additional details on recent EU policies can be found in Annex 6.A and throughout the remainder of this chapter. The WHO leads global efforts: the 2030 Agenda for Sustainable Development identifies noncommunicable diseases (NCDs) as a major obstacle to sustainable development to co‑ordinate and promote actions toward the goal of cutting premature NCD mortality by one‑third by 2030 through prevention and treatment (SDG target 3.4).
Cancer and CVD share overlapping risk factors and pathophysiological mechanisms (Wilcox, 2024[29]). Evidence shows an increased risk of cancer among people living with CVD (de Boer RA, 2019[30]), an increased risk of CVD (especially heart failure) and higher CVD mortality among cancer survivors (Florido R, 2022[31]) (Sturgeon KM, 2019[32]).
The expected increase in cancer incidence is foreseen to increase the incidence of CVD related to cancer treatments (Wilcox, 2024[29]). Furthermore, CV risk factors and CVD increase the risk of CV toxicity after cancer therapy, especially in older adults with cancer, which makes this population a particularly vulnerable one (Ioffe D, 2024[33]).
Management of CVD in people living with cancer and cancer survivors, notably older adults, requires innovative management approaches and people‑centred multidisciplinary care (Ioffe D, 2024[33]).
Note: Data for EU27.
Note: This figure highlights various EU-level initiatives related to cardiovascular diseases. Assessing improvements in circulatory disease mortality requires consideration of additional contributing factors.
Source: Authors/ EUROSTAT 2025, hlth_cd_asdr2.
6.3.1. Addressing CVD risk factors has a number of co-benefits
Tackling CVD on our societies requires action at both the individual and population level, though can bring co-benefits in reducing the burden of other NCDs. The same risk factors that contribute to the CVD burden also contribute to explain the occurrence of obesity, cancers and dementia, such that tackling them fosters co-benefits and multiplies the impact of preventative action beyond the heart and vascular system. One clear example of this is tobacco use, a major modifiable risk factor for CVD, that also contributes to the prevention of multiple other NCDs such as cancer, chronic respiratory conditions, and even cognitive decline. Population-level interventions have demonstrated wide‑reaching health benefits, underscoring the value of integrated prevention strategies that extend beyond cardiovascular health.
Multisectoral action is needed to adequately address the social, behavioural, environmental and commercial factors of NCDs and tackle their burden. Health in All Policies recognises that population health is not merely a product of health sector programmes but largely determined by policies that guide actions in areas such as environment, education, food and agriculture, and economic development among others (Green et al., 2021[34]). For example, though air pollution poses serious health risks, its regulation often falls under environmental, transport, or industrial policy domains rather than health authorities. Indeed, policy in every sector of government has the potential to influence health outcomes and equity. Addressing the prevention of NCDs more broadly therefore requires a multidisciplinary approach that mobilises sectors well beyond healthcare, with health authorities playing a central co‑ordinating role. The environments in which people live, work, study, and play shape daily behaviours and exposures, and thus have a substantial impact on overall health. Co‑ordinated action across sectors is essential to create conditions that support healthier choices and reduce the burden of NCDs. In that sense, CVD prevention policies need to be understood broadly, and actions across sectors is crucial, including mobilising citizens and civil society (European Observatory on Health Systems and Policies & Beger, 2022[35]).
I wish policymakers understood that living with cardiovascular disease is a lifelong journey that affects every aspect of life, not just physical health. Mental health support, social services, and patient-centered care must be integral to all healthcare systems. Investment in prevention, equitable access, and patient education can save lives and reduce long-term costs.
Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.
Health promotion and prevention benefit from a broad approach that extends beyond interventions delivered solely within the healthcare system. Most of the focus is on primary and secondary prevention, usually based on the healthcare system. However, primordial prevention, e.g. prevent drivers of CVD risk, is a substantial aspect of prevention that needs to be prioritised. Legislation on smoke‑ and aerosol-free environments illustrates how prevention efforts can benefit from broad societal collaboration. Such measures have been shown to reduce CVD and offer a model that can be adapted to many national contexts. A notable example is Ireland’s pioneering legislation on smoke- and aerosol-free environments, which helped establish this approach across Europe through a well-co‑ordinated public health policy involving multiple sectors and industries (Box 6.4). Likewise, the WHO-led SAFER initiative provides governments with cost-effective actions to reduce harmful alcohol consumption through stronger regulation, pricing policies, enforcement and treatment access (WHO, 2025[36]).
However, implementation of policies tackling NCD appears to be slowing: between 2021 and 2023, the proportion of countries fully implementing NCD risk factor surveys – including objective measurement – fell from 28% to just 19%. Over the same period, the share of countries with operational multisectoral NCD strategies also declined, dropping from 60% to 55% (WHO, 2025[37]).
6.3.2. Population-level, structural interventions have the strongest impact on health equity and CVD outcomes
There is a hierarchy of effects where more structural, population-based interventions often result in larger health and equity gains, particularly when targeting lifestyle risk factors such as diets and smoking. Interventions aimed at key CVD risk determinants – such as diet and tobacco use – have shown substantial, rapid, and equitable reductions in cardiovascular mortality (Hyseni et al., 2017[38]; Capewell and O’Flaherty, 2011[39]; Popkin et al., 2021[40]). The nature of the implementation plays a critical role: mandatory regulatory approaches are generally more effective at improving health behaviours related to CVD, while voluntary measures show mixed results (Blanchard et al., 2023[41]). Voluntary industry agreements – such as those setting targets for salt or sugar reduction – can be effective, but only when targets are ambitious, progress is independently monitored, and actions are rigorously evaluated (see Section 6.4.2).
Behavioural insights (BI) offer powerful tools for CVD prevention and management by going beyond individual “nudges” to inform systemic, regulatory, and economic policies. While traditional CVD strategies often focus on individual behaviour change – like healthier eating or increased physical activity – BI can also address broader systemic barriers such as food accessibility, pricing, and environmental design. Effective interventions often require a policy mix, combining behavioural tools (e.g. labelling, defaults) with structural measures (e.g. regulation, subsidies). CVD chronic disease management insights can help in improving medication adherence, care co‑ordination and patient engagement. BI helps identify leverage points within systems, align policy coherence across sectors (such as health, agriculture and environment among others), and ensure policies are grounded in real human behaviour (EU Policy Lab, 2016[42]).
Ireland’s introduction of smoke‑free legislation through the Public Health (Tobacco) Acts of 2002 and 2004 stands as a landmark example of structural, cross-sectoral public health policy. By framing second-hand smoke not only as a population health issue but also as a matter of occupational safety, the legislation gained strong legitimacy and public support. Although there was some initial hesitation from the hospitality industry, evidence later showed that venues experienced no negative economic effects, which helped build confidence in the policy. Importantly, the policy led to substantial reductions in CVD morbidity and mortality while also supporting progress toward narrowing health inequalities (Akter et al., 2023[43]).
Ireland’s bold step catalysed a wave of legislative action across Europe. Scotland and the rest of the United Kingdom followed in 2006‑2007 with comprehensive legislation on smoke- and aerosol-free environments, contributing to a regional shift in tobacco control. This momentum continued with the EU’s Tobacco Products Directive 2014/40/EU (TPD) which became applicable in the Member States in May 2016. The Directive introduced several effective tobacco control measures including larger combined health warnings, a ban on characterising flavours and the regulation of ingredients in tobacco products and electronic cigarettes.
In retrospect, Ireland’s approach has been recognised as an example of effective public health framing-aligning the issue to both human rights and workplace safety. This strategic positioning helped generate broad societal support and offered a useful model for other countries such as the United Kingdom, New Zealand, and France. Ireland’s leadership demonstrated how well-framed, evidence‑based legislation can transform environments, protect health, and inspire international policy shifts.
6.4.1. Policy frameworks for CVD prevention
Reducing the burden of CVD requires not only clinical responses but also sustained policy action on key behavioural risk factors – particularly poor diet, physical inactivity, and tobacco use, always with equity lens. In recent years, several international and regional policy frameworks have been developed to help governments translate evidence into effective, scalable interventions. These frameworks (Box 6.5) offer practical tools to navigate complex policy environments, enhance accountability, and foster multisectoral collaboration. Crucially, they shift attention from individual choices to structural determinants, supporting healthier environments and advancing health equity. This section introduces key frameworks that, when strategically applied, can strengthen national prevention efforts and accelerate progress in reducing CVD.
NOURISHING (World Cancer Research Fund):
The NOURISHING framework is a policy tool to promote healthy diets and reduce obesity and non-communicable diseases (NCDs). It offers a structured approach for governments to design, implement, and monitor evidence‑informed interventions across three domains: food environment, food system, and behaviour change communication. The acronym “NOURISHING” highlights ten policy areas that support healthier eating, including nutrition labelling, healthy food provision in public institutions, and the use of economic tools such as taxes and subsidies. By encouraging action across these areas, the framework supports a whole‑of-society approach to creating healthier food environments and improving dietary behaviours.
MOVING (World Cancer Research Fund)
The MOVING framework is a policy tool to support physical activity promotion and reduce the burden of NCDs. It helps governments develop and assess comprehensive strategies by focussing on six key policy areas: Mass media campaigns, Opportunities for physical activity in schools, Volunteer and community programmes, Infrastructure and urban design, National guidelines, and Governance. These components encourage environments that make physical activity more accessible and appealing across populations. The framework supports integrated, multisectoral action to embed physical activity into daily life and promote long-term health benefits.
MPOWER (World Health Organization)
The MPOWER framework is a set of evidence‑based measures to assist countries in implementing effective tobacco control policies and reducing tobacco-related harm. Each letter in MPOWER stands for a key action area: Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit, Warn about the dangers of tobacco, Enforce bans on advertising, promotion, and sponsorship, and Raise taxes on tobacco products. Together, these six strategies provide a practical roadmap for governments to reduce tobacco use, save lives, and meet international commitments under the WHO Framework Convention on Tobacco Control.
6.4.2. Food and nutrition policy
Dietary risks remain an important contributor to the CVD burden and a one of the key factors in the rising prevalence of obesity and diabetes (see Chapter 3). Encouraging healthier diets will benefit from continued efforts to reduce salt, fat and sugar intake and to support shifts toward alternatives to ultra-processed foods (UPF), usually calorie dense, with high salt, fat and sugar content. The energy share from UPFs across 22 European countries varies from 14 to 44%, with the lowest intakes in Italy and Romania, while the highest intakes are in Sweden and the United Kingdom (Mertens, Colizzi and Peñalvo, 2021[44]). With the exception of Finland, Spain and the United Kingdom, most countries are reporting increases in UPF, matching a global trend on increasing dominance of UPF in food systems (Mertens, Colizzi and Peñalvo, 2021[44]; Popkin and Ng, 2021[45]).1
Using the NOURISHING policy index (Table 6.2), the policy landscape shows considerable variation across European countries, both in scope and intensity of action. EU-level food environment policies were rated as weak for 65% and very weak for 23% of the 26 policy indicators covering food composition, labelling, promotion, prices, provision, retail and trade domains. Countries such as Norway, Finland, and the UK nations (England, Wales, and Northern Ireland) demonstrate relatively broad engagement, implementing policies across nearly all domains, including front-of-pack labelling, school food standards, reformulation strategies, marketing regulation, and public awareness campaigns. These countries have also taken steps in areas such as creating healthy retail environments and healthier food supply chains. Germany and Czechia have implemented measures in areas such as labelling and food quality, but have introduced fewer policies in domains such as advertising regulation and public awareness. Outside Europe, Singapore has several public health policies that are in place or under development to reduce CVD risk factors by targeting sugar, sodium, saturated fat, and trans-fat intake. Key upcoming measures include extending the current Nutri-Grade labelling and advertising restrictions on beverages to key contributors of sodium and saturated fat intake for residents by mid-2027.Particularly underdeveloped across most countries are the domains related to retail environment incentives and cross-sectoral supply chain actions. This uneven implementation underscores the need for greater policy ambition, and highlights both the diversity of policy environments and the uneven progress toward creating healthier food environments in the region. This heterogeneity is consistent with analyses done using the FOOD-EPI index to identify important gaps in policies and particularly in infrastructure support. For the 24 infrastructure support indicators (including considerations on Health in All Policies, system-based approaches, funding, monitoring, governance and leadership), 63% were rated as moderate and 33% as weak (the PEN Consortium, 2022[46]).
Marketing regulations on food advertising can be a powerful tool to improve dietary quality, particularly in children (WHO, 2023[47]; Boyland et al., 2022[48]). Marketing restrictions on unhealthy food – particularly to children – are implemented in the European Region, with few countries adopting comprehensive measures, some with mandatory policies (Norway, Portugal, and the United Kingdom for example) (Norwegian Ministry of Health and Care Services, 2025[49]; HSPM, 2017[50]; UK Parliament, 2025[51]). Best practice countries include restrictions across multiple media platforms (e.g. TV, digital, packaging) and in settings such as schools, with strict monitoring and penalties for non-compliance (Taillie et al., 2019[52]).
Note : Results are placed in 5 categories: poor (1), fair (2), moderate (3), good(4) and excellent (5) or no policies identified (N/A), as assessed against the NOURISHING policy benchmarking tool, https://www.wcrf.org/research-policy/policy/nutrition-policy/nourishing-nutrition-policy-benchmarking-tool/.
Source: WCRFI (2023[53]), NOURISHING nutrition policy index brief, https://www.wcrf.org/research-policy/library/nourishing-nutrition-policy-index-brief/.
Salt reduction
Most countries in the WHO European Region (52 out of 53, or 98%) reported salt consumption levels exceeding the WHO’s recommended maximum. In nearly all of these countries, men consume more salt than women and on-average, Western and Northern European countries tend to have the lowest salt intake, while the highest levels are observed in Central and Eastern European countries (Kwong et al., 2022[54]). (see Chapter 3 for more discussion).
Mandatory targets, legally binding limits on the amount of salt in food products, seem to provide potentially the highest health and economic benefits. For example, recent analysis in Australia suggest that implementing mandatory WHO benchmarks could lead to cost savings within the first decade, potentially preventing around 2 743 deaths from CVD and 43 971 new cases, and highly cost-effective over the course of a lifetime (Marklund et al., 2024[55]).
Policy reversals can result in missed opportunities to improve population health and equity. An illustrative example is the UK’s shift from the Food Standards Agency (FSA) salt reformulation programme to the Responsibility Deal. While voluntary, the FSA programme included strict, externally audited compliance and the credible threat of mandatory, enforceable targets. In contrast, the Responsibility Deal diluted many of these features, particularly around monitoring. Between 2003 and 2010, salt intake in England fell steadily (by 0.20 g/day in men and 0.12 g/day in women), but after the Responsibility Deal introduction in 2011, reductions slowed to 0.11 g/day in men and 0.07 g/day in women. This slowdown is linked to around 9 900 additional CVD cases between 2011 and 2018, with up to 26 000 more projected by 2025, and may have worsened health inequalities.
While progress is happening, few countries have implemented national salt reduction policies. Best practices include mandatory salt limits in Portugal, comprehensive reduction programmes in Finland and Ireland, and procurement standards in Northern Ireland. Most countries rely on voluntary agreements, indicating a major opportunity in this area (WCRFI, 2023[53]). The WHO European Salt Action Network (ESAN) – established in 2007 and currently comprising 35 Member States – provides a key technical and policy platform to support countries in the World Health Organization European Region to accelerate sodium reduction through evidence‑based strategies, co‑ordinated action, and shared lessons, directly addressing the high salt consumption levels and policy gaps discussed (WHO, 2025[56]).
Taxing added salt has been explored as one possible approach to help reduce population sodium intake and support improvements in cardiovascular health, particularly when applied broadly to processed and packaged foods. Simulation studies suggest that comprehensive salt taxation could contribute to reductions in salt consumption of around 5‑15%, with potential long-term health benefits. While only a few countries have introduced such measures, Hungary’s Public Health Product Tax (PHPT) – in place since 2011 – provides a useful early example. The policy includes a levy on salty snacks and has been associated with decreases in the consumption of taxed products and reformulation efforts in a number of items (WCRFI[53]).
Added sugar
Excessive added sugar consumption contributes to the NCD burden in Europe and is an issue not only for adults but more concerningly for children. In Europe, sugar intake contributes 15%–21% of energy in adults and 16%–26% in children. Added sugars account for 7%–11% of adults’ and 11%–17% of children’s energy intake (Azaïs-Braesco et al., 2017[57]). Recent European studies highlight concerning levels of sugar consumption among children and adolescents. According to the Identification and Prevention of Dietary- and Lifestyle‑Induced Health Effects in Children and Infants study (IDEFICS), young children already consume high amounts of sugar – boys average 98 grammes of total sugars per day, while girls consume around 93 grammes. Of that, free sugars account for the majority: 81 grammes for boys and 77 grammes for girls, making up approximately 18% of their daily energy intake – well above health recommendations (< 10%) (Graffe et al., 2019[58]).
The situation appears even more critical among adolescents. The Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study found that teenagers consume an average of 137.5 grammes of total sugars daily, with 110 grammes coming specifically from free sugars. This represents nearly 20% of their energy intake from free sugars alone. Alarmingly, 94% of adolescents exceed the World Health Organization’s recommendation that free sugars make up no more than 10% of daily energy intake. (Mesana et al., 2016[59]).
Taxing and regulating sugar – especially through taxes on sugary drinks and healthy school food policies – is an increasingly adopted approach to reducing excessive sugar consumption (European Commission, 2025[60]). Countries like England, Ireland, Hungary, Northern Ireland and Scotland are at the forefront of this movement, implementing comprehensive approaches that combine fiscal measures with marketing restrictions and nutrition education. These integrated policies not only incentivise product reformulation by manufacturers but also promote healthier consumer choices, especially among children and vulnerable populations. (Box 6.6) (WCRFI, 2023[53]).
Fruit and vegetables
Fruit and vegetable intake varies considerably across European countries, providing a unique opportunity to promote policy action to improve its accessibility and affordability (see Chapter 3). Subsidies on healthy foods, particularly fruits and vegetables, are consistently effective in increasing their consumption across diverse populations. On average, a 10% price subsidy leads to a 14% increase in fruit and vegetable intake, with stronger effects observed in lower-income groups, thus improving both diet quality and health equity. Subsidies not only enhance affordability but also lead to greater reductions in diet-related risk factors, especially when combined with taxes on unhealthy foods (Wolfenden et al., 2021[61]; Pearson-Stuttard et al., 2017[62]).
Trans-fats
As of April 2021, the European Union implemented a regulation capping trans-fat at 2 grammes per 100 grammes of fat in food products, harmonizing standards across member states (European Commission[63]). Evidence from England suggests the measure could reduce coronary heart disease mortality by around 3% and generate net economic benefits of approximately EUR 350 million over five years, while also contributing to reduced health inequalities. Other states follow suit such as Canada, the United States, Singapore, South Africa and Brazil and WHO has set an ambition to eliminate artificial trans-fats from food systems and supply chains (WHO[64]). Thereafter, following WHO’s ambition, Singapore implemented a full ban on partially hydrogenated oils (PHOs), the main source of artificial trans-fats, as an ingredient in all foods in 2021.
Introduced:
April 2018, following government consultation and inclusion in the Budget 2016 and Finance Bill 2017 (HM Revenue & Customs, 2016[65]).
New policy for the United Kingdom, but similar policies existed
Momentum gained from work in Mexico and mobilisation of public opinion, strong support from public (Pell et al., 2019[66])
Design:
A two‑tier tax targeting manufacturers/importers:
18p per litre for drinks with 5‑7.9 g sugar/100 ml
24p per litre for drinks with 8 g+ sugar/100 ml.
Exemptions include pure fruit juice, milk-based drinks (≥75% milk), milk alternatives, powdered drinks, and small producers (Action on Sugar, 2025[67]).
Incentivised Reformulation:
By 2019, 65% of drinks originally above 5 g/100 ml were reformulated to below the threshold – reducing the levy‑liable range from 52% to 15% of market share (Action on Sugar, 2025[67]).
Between 2015‑2020, the sugar content in affected drinks dropped by ~46% (Action on Sugar, 2025[67]).
Impacts on Purchasing & Consumption:
Households bought 15 g less sugar from drinks per week (overall), with the largest reductions in the most deprived areas (Cobiac et al., 2024[68]).
Promotions and sales shifted toward lower‑sugar products.
Health Outcomes (Modelling):
Over 10 years, predicted avoidance of ~64 100 cases of childhood overweight/obesity and ~3 600 fewer dental caries in children/adolescents (Cobiac et al., 2024[68]).
Also modelled improvements in life expectancy and a small reduction in health inequalities.
Industry Economics:
Initial announcement caused a short‑term dip in manufacturers’ domestic turnover, but these effects did not persist post‑implementation (Law et al., 2020[69]).
Revenue & Reinvestment:
Raised an estimated GBP 520 million in its first year, though later revised to ~GBP 240 million after reformulation reduced tax liability (Action on Sugar, 2025[67]).
Funds supported school sports infrastructure and breakfast clubs (Action on Sugar, 2025[67]).
Policy Evolution:
Annual consumer price index (CPI)‑linked rate increases began April 2025 (HMRC, 2025[70]).
Formal consultation in 2024‑2025 proposes:
Lowering the levy threshold to 4 g sugar/100 ml,
Including previously exempt milk‑based drinks (with lactose allowance),
Potentially adding a third tier or increasing rates for highest‑sugar drinks (HMRC, 2025[70]).
6.4.3. Modifying the places where we learn, work and entertain to improve diets
Sports stadia have strong potential to support public health but are often associated with unhealthy behaviours due to the promotion of unhealthy food, harmful alcohol use, and tobacco. A study across 88 stadia in 10 European countries, part-funded by the EU, examined existing health-related practices. Using a detailed questionnaire, researchers collected data on food offerings, physical activity, tobacco policies, mental health, sustainability, and social responsibility. Results showed wide variation across countries and sports. Despite these differences, the study identified examples of good practice and emphasised the untapped opportunity for stadia to promote healthier lifestyles and a way to reach “hard to reach” populations. This led to the creation of the European Healthy Stadia Network, an active, ongoing campaign to improve not only diets but smoke‑free stadiums and overall health and well-being of sports fans, stadium staff and their communities (Healthy Stadia, 2024[71]).
Schools significantly influence children’s dietary habits, with robust evidence showing that nutrition policies combining healthy food provision and education improve intake of fruits and vegetables and reduce sugary food consumption (Hodder et al., 2022[72]). National evaluations – for example, Finland’s free school meals and Scotland’s meal standards – report improved diet quality and equity. The EU School Scheme has also shown positive effects on awareness and short-term eating behaviours when educational components are interactive and consistent (EPRS, 2022[73]).
At the policy level, the EU supports school-based nutrition through the EU School Scheme (Regulation (EU) 2016/791), which funds the distribution of fruit, vegetables, milk, and related educational activities. The EU supports actions to improve dietary habits, including through the food industry-led EU Code of Conduct on Responsible Food Business and Marketing Practices, as well as Food 2030 (European Commission[74]; European Commission[75]). In addition, the EU supports national reformulation initiatives to reduce the levels of saturated fats, sugar and salt and promotes the consumption of fruit and vegetables. The Commission has completed a review of the successful EU school scheme on fruits, vegetables and milk and milk products, and proposed its continuation beyond 2027 (European Commission[76]). WHO Europe also collaborates with member states to develop and align national school food policies (European Commission, 2025[77]). Crucially, this set of actions can result also in positive impact in the local food environments where the schools are, multiplying the benefits of the intervention (Bryant et al., 2023[78]). In this aspect, and interesting proposal is the SCHOOLS4CHANGE project, that elaborated a comprehensive, legally robust, and adaptable framework of innovative, sustainable, and healthy public food procurement criteria and practices designed to transform school meals and food systems by integrating environmental, social, economic, and health dimensions to achieve improved quality, accessibility, and sustainability across diverse local contexts (SchoolFood4Change, 2023[79]).
The Commission is supporting Member States in addressing risk factors via policies, projects and funding on health promotion and disease prevention. The ‘Healthier together’ non-communicable diseases initiative provides the strategic framework for action to prevent and manage non-communicable diseases and their risk factors. Through the EU4Health programme, support has been provided to implement relevant actions of the ‘Healthier together’ initiative. Collaborative actions between Member States such as the Joint Action PreventNCD are important tools in preventing and managing non-communicable diseases (NCDs). By targeting health determinants, the European Commission supports Member States and stakeholders in developing and implementing actions on health promotion and disease prevention. Through sustained investment and collaboration, preventive measures can significantly reduce the NCD burden, promoting healthy and active lifestyles and reducing the burden healthcare systems.
Universal and Free: All pupils in basic education receive a free, hot meal every school day, mandated since 1948 and now also extended to upper secondary education.
Nutritionally Balanced: Meals follow national nutrition guidelines and cover about one‑third of daily nutritional needs, including a main dish, vegetables, bread, and milk or alternatives.
Educational Role: School meals are treated as part of nutrition education, with teachers encouraged to eat with students and healthy eating integrated into the curriculum.
Inclusive and Monitored: Special diets are accommodated, and quality is assessed using the Meal Quality Index developed by Finland’s public health institute (THL).
Equity and Health Impact: The programme supports equal access to healthy food, improves dietary habits, and reduces food insecurity and health disparities among children.
Source: FAO (2023[80]), School Food Global Hub: Finland, https://www.fao.org/platforms/school-food/around-the-world/europe-and-central-asia/finland/en; LSHTM/SMC (2023[81]), School Meals Case Study: Finland, https://www.schoolmealscoalition.org/sites/default/files/2024-05/Kuusipalo_Manninen_2023_Food_Meals_Case_Study_Finland.pdf.
A widely recognised example of leveraging the education sector to improve diets is Finland’s School Meals Programme, which provides a comprehensive approach to realising the full potential of a place‑based intervention (Box 6.7). However, key evidence gaps remain in assessing long-term health impact, differential effects by socio-economic status or ethnicity, and there are only a few in-depth studies of policy implementation across countries. For example, a recent mapping exercise of schools and various municipalities showed that many countries has procurement policies that integrate as well sustainability requirements, but barriers persists, such as the high cost of healthier food alternatives, rigid legal frameworks precluding healthier food procurement decisions, and the burden of administrative loads, particularly for smaller localities (SF4C, 2022[82]).
6.4.4. Substantial progress has been made on controlling tobacco smoking
There are significant differences in smoking prevalence across Europe (Chapter 3), though controlling tobacco remains crucial in all countries to tackle CVD. Approximately one fifth of coronary heart diseases are attributable to tobacco use and exposure to second-hand smoke. In 2023, an average of 18% of adults smoked daily across EU countries. In 2023, an average of 18% of adults smoked daily across EU countries. While individual policies – such as taxation, smoking restrictions, and health warnings – are effective on their own, the most impactful approach is implementing them simultaneously (Akter et al., 2024[83]) (Figure 6.3). Other measures, such as flavour bans and free or discounted nicotine replacement therapy, also show positive impacts on quit rates, with flavour bans reducing e‑cigarette consumption. Comprehensive implementation of MPOWER policies at the national level has been associated with a 7% reduction in smoking prevalence and a 13.8% decrease in cigarette consumption (Ngo et al., 2017[84]). Furthermore, smoke‑free legislation correlates with lower risks of CVD events (OR 0.90; 95% CI 0.86‑0.94) and hospitalisations for CVD or respiratory diseases (OR 0.91; 95% CI 0.87‑0.95) (Akter et al., 2023[43]).
The whole spectrum of effective policy actions to reduce the harms of tobacco smoking are considered or under implementation in EU countries. Particularly relevant are the interest in flavour restrictions – a key issue particularly to reduce smoking in the youth- in 15 countries, alongside with age restrictions, marketing restrictions, and educational and behavioural interventions. Furthermore, end game goals and consideration of tobacco-free generation policies are also increasingly attracting policy attention.
Among the MPOWER components, most countries in Europe have strong policy measures on monitoring and taxation. The greatest variation amongst not complete measures is observed in smoke‑free environments, mass media campaigns, and advertising regulation. For smoke‑free environments, scores range widely: countries like Belgium, Denmark, Estonia and Italy tend to have more limited implementation, while others such as Czechia and Lithuania have moderate to strong policies. In terms of reach and frequency of anti-tobacco messages in mass media, disparities are stark – Austria, Portugal, Sweden and Switzerland showed less intensity in public campaigns, whereas countries like Latvia, Lithuania and Poland are closer to have stronger actions in place. These variations reflect differing levels of commitment to structural and promotional tobacco control policies and point to clear areas for policy strengthening in several countries, and a more harmonised approach to implementation across the region.
Cigarette affordability across Europe continues to be a concern. Only seven countries – Belgium, Czechia, Finland, France, Germany, the Slovak Republic and the United Kingdom – have made cigarettes less affordable since 2014, indicating effective use of price and tax policies to reduce tobacco consumption. In contrast, 11 countries – Estonia, Ireland, Latvia, Lithuania, Iceland, Poland, Portugal, Slovenia, Spain, Sweden and Türkiye – have seen cigarettes become more affordable. The remaining countries – Austria, Denmark, Greece, Italy, the Netherlands, Norway, Luxembourg and Switzerland – show no significant change, reflecting stagnation in tobacco affordability measures. This imbalance highlights the need for stronger and more consistent tax and pricing policies across the region to ensure cigarettes become less affordable over time.
On 16 July 2025, the Commission proposed modernising the Tobacco Taxation Directive to raise minimum excise rates from 2028. Aligned with the EU’s Beating Cancer Plan to reduce smoking below 5% by 2040, from a 24% prevalence, the revision harmonises tax definitions for tobacco and tobacco related products, notably e‑cigarettes and nicotine pouches, partially adjusting the tax rates to purchasing-power adjustments average income. It is also extending the scope of the directive to new products (such as e‑cigarettes) to be covered by new minimum taxes, as well as including raw tobacco in the existing electronic system for recording and monitoring the movement of excise goods within the EU to further curb illicit trade. The proposal will not only boost revenues by EUR 15 billion, but will save EUR 6 billion in healthcare (European Commission, 2025[85]). Furthermore, the European Commission has recommended strengthening smoke‑free environments by extending restrictions to outdoor areas such as playgrounds, transport hubs, and spaces near healthcare and education facilities, and including emerging products like heated tobacco and e‑cigarettes (European Commission, 2024[86]).
Most European countries have well established and strong approaches to smoking cessation (Table 6.4). For this it is essential to educate the workforce and adopt best practices. The European Network for Smoking and Tobacco Prevention, a network collaborating institutions from 15 countries worked to develop an accredited eLearning course and curriculum on Tobacco-Treatment Delivery, highlighted as a best practice by the EU commission, and aligned with WHO guidelines for compliance with Article 14 of the FTCC (European Commission, 2021[87]; FCTC, 2013[88]). Amongst European best practices is EPIC, a Danish endgame‑aligned programme offering free, personalised cessation support via hospital referrals, municipal follow-up, and medication – targeting disadvantaged smokers and achieving strong quit rates, reduced inequalities, and high satisfaction – serving as a scalable model for EU tobacco-control efforts (European Commission[89]).
The EU aims for a tobacco use prevalence of less than 5% by 2040 with its Tobacco-Free Generation goal, aligning with the tobacco endgame approach (EU, 2021[90]). Most countries in the region have implemented effective tobacco control measures, but further progress is needed to achieve this ambition. Eight countries had official governmental endgame goals, and an additional six EU MS had similar proposals from government, civil society or research entities (Ollila et al., 2024[91]). These actions include restrictions on the sale of tobacco and related products and raising the age limit to above 18 years Product standards were mainly used to regulate flavours, whereas no measures to substantially reduce addictiveness were reported. Market-oriented measures targeting industry profits were predominantly missing, and countries often did not have concrete tools to prevent potential industry influence.
Tobacco-free generation (TFG) legislation is gaining policy momentum across Europe, with several countries such as Finland, France, Ireland, Luxembourg, the Netherlands, Norway and Türkiye considering this approach to achieve the endgame tobacco goal, while the United Kingdom has introduced a bill to support it. Unlike traditional age‑limit laws, TFG communicates that there is no safe age to begin tobacco use, while allowing access for older, already dependent individuals. Successful implementation relies on public support, strong retail licensing, and complementary measures such as excise taxes and youth-focussed education campaigns. The policy anticipates resistance from ideological, practical and the tobacco industry opposition. The New Zealand law was repealed a year after it was passed, suggesting that it requires careful framing and legal design to withstand pushback and maximise long-term public health gains (Berrick, 2025[92]).
E-cigarettes may pose a risk to tobacco control progress. The increased use of e‑cigarettes is resulting in policy action and sparking public health concerns, especially among the youth (WHO, 2024[93]). The Tobacco Products Directive (2014/40/EU) partially harmonised e‑cigarette regulations across Europe, allowing individual countries to set their own rules regarding certain aspects such as their public use and flavours (European Parliament, 2014[94]). (see also Annex 6.A). Variation in regulations across countries can complicate oversight. Flavoured products, popular with adolescents, have been linked to health risks such as oxidative stress and other adverse effects. (Stratton, Kwan and Eaton, 2018[95])].
The concurrent use of e‑cigarettes and cigarettes (“dual use”) is a concern, highlighted by results from the recent Tackling second-hand tobacco smoke and electronic cigarette emissions (TackSHS) survey. TackSHS involved a face‑to-face survey conducted in 2017‑2018 in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain) (TackSHS Project Investigators, 2023[96]). It found that 2.4% of people surveyed reported current use of electronic cigarette, ranging from 0.6% in Spain to 7.2% in England. Importantly, amongst 272 electronic cigarette users, 52.6% were dual users (TackSHS Project Investigators, 2023[96]).
The rise in teen addiction and in particular dual use among young people is concerning, though emerging evidence suggests targeted policy interventions can counter this trend. Across 32 European countries, more than one in four adolescents aged 15‑16 reported ever using both e‑cigarettes and cigarettes (dual use), while 6% were current dual users (Ollila et al., 2023[97]). However, more comprehensive national e‑cigarette regulations have been to linked to reduced dual use (OR=0.80; 95% CI 0.67 to 0.95), as was perceived difficulty in obtaining cigarettes (Ollila et al., 2023[97]; Hamoud et al., 2024[98]), emphasising the role of comprehensive tobacco and e‑cigarette regulations in tackling the dual use trend.
There are concerns that the use of e‑cigarettes by youths may serve as a gateway to traditional smoking. Longitudinal studies from the United Kingdom and other countries indicate that adolescent vapers are more likely to initiate combustible cigarette use compared to their non-vaping (Tokle, Brunborg and Vedøy, 2021[99]; Aladeokin and Haighton, 2019[100]). These findings raise concerns that e‑cigarettes may undermine tobacco control progress by fostering new nicotine dependencies and renormalising smoking behaviours (Parnham et al., 2024[101]). In response to such risks, Singapore has in place a multi-pronged approach to reduce nicotine use through a mix of regulatory measures, public education initiatives and cessation services. Recent regulatory moves include the expansion of smoke‑free areas, Standardised Packaging measures with graphic health warnings for tobacco products, increase in tobacco taxation and raising the minimum legal age for purchase of tobacco products to 21. Specific to vaping, the import, distribution, sale, supply, use and possession of e‑vaporisers/e‑cigarettes is strictly prohibited in Singapore.
European countries have adopted diverse regulatory approaches to e‑cigarettes. The EU Tobacco Products Directive (2014/40/EU) limits nicotine concentrations to 20 mg/mL, restricts refill containers volumes to 10 mL and cartridges/tanks volume to 2 ml, and mandates child-resistant packaging, product health warnings (European Parliament, 2014[94]) Age restrictions (18+) are enforced across Member States, while many have implemented or are considering flavour bans to reduce youth appeal. Croatia, for example, has introduced policies on tobacco and vaping, including age restrictions, price increases, marketing controls, flavour restrictions, and educational and behavioural interventions, and is currently moving towards a stricter regulatory approach. Several countries are now addressing environmental concerns through bans on single use (disposable) vapes. Belgium’s ban is set to take effect in 2025, with similar measures in progress in France and the United Kingdom (Gov.UK, 2025[102]; Public, 2025[103]). Ireland’s proposed legislation also includes advertising restrictions and plain packaging rules for vaping products (Institute of Public Health, 2024[104]).
6.4.5. Progress in tackling harmful use of alcohol
Countries across Europe have overall advanced policies to tackle harmful alcohol consumption based on key European and International frameworks, though there are differences among countries. Specifically, the European Framework for Action on Alcohol 2022‑2025 sets out six key priority areas: pricing policies, marketing restrictions, availability controls, health information and labelling, health services’ response, and community action (WHO, 2022[105]). Specifically, the SAFER initiative, led by WHO, includes cost-effective actions to help governments reducing the alcohol related harm and strongly targets commercial factors directly through stronger regulation, pricing policies, enforcement of the regulations including driving laws and treatment access (WHO, 2025[106]).
There is uneven implementation across Europe. Norway and Sweden have implemented state alcohol monopolies and strict marketing controls (WHO, 2024[107]), while Estonia and Lithuania adopted WHO “best buy” policies, resulting in marked reductions in alcohol-related mortality (Rehm et al., 2023[108])). These measures align closely with the WHO Global Alcohol Action Plan 2022‑2030 (WHO, 2024[109]) and the European Framework for Action on Alcohol 2022‑2025 (WHO, 2022[110]).The COVID‑19 pandemic added complexity, as drinking patterns shifted and highlighted disparities in policy reach (Kilian et al., 2022[111]). For example, while Ireland and Scotland have adopted minimum unit pricing to target cheap alcohol (Berdzuli et al., 2020[112]), other countries rely primarily on taxation and availability measures. Some countries have rolled back policies, leading to increased alcohol-related harm (Rehm et al., 2023[108]). Overall, the region has made progress, and further sustained actions are needed to fully align with WHO frameworks.
6.4.6. Policies to promote physical activity can reduce cardiovascular risk across the life course
Physical activity benefits cardiovascular health at every stage of life – from foetal development to older adulthood. Starting and maintaining an active lifestyle can help prevent heart disease and reduce other health risks as people age. Physical activity levels remain insufficient, with one in three adults not meeting recommended levels and almost half of the population never engaging in sports or exercise (see Chapter 3). This is even more concerning among children and teenagers, of whom very few achieve recommended levels. The COVID‑19 pandemic compounded the issue by restricting physical activity and increasing sedentarism. Additionally, excessive screen time, online gaming, and gambling contribute to sedentary behaviour, which increases cardiovascular risk through reduced physical activity and can also negatively affect mental health (Council of Europe, 2025[113]).
Increased physical activity can play a substantial role in helping to control cardiovascular risk factors. For example, it can lower systolic blood pressure by 7 mmHg, increase “good” high-density lipoprotein (HDL) cholesterol by 5‑10%, reduce triglycerides by 50% and reduce “bad” low-density lipoprotein (LDL) cholesterol by 5%. Crucially, physical activity improves glycaemic control, reduces fat mass and increases well-being and mental health, which can contribute to reducing the progression to obesity and diabetes. Mobile and technology-assisted health applications can be a helpful aid in increasing physical activity uptake, increase step counts, increase vigorous health activity and decrease sedentary behaviours (Singh et al., 2024[114]). At the same time, addressing behavioural addictions such as excessive internet use, online gaming, and gambling is increasingly recognised as part of prevention strategies; for instance, Italy recently allocated EUR 5 million to initiatives targeting these issues among youth (Council of Europe, 2025[113]). Most European countries have at least one national policy or action plan spanning health, education, sports, transport, and urban planning. Policies that target very high-need groups, such as young children, the elderly, or socially disadvantaged groups, need to be developed (Table 6.3) (Box 6.8).
Note: Results are placed in 5 categories: poor (1), fair (2), moderate (3), good (4) and excellent (5) or no policies identified (N/A), as assessed against the assessed against the MOVING Physical Activity Policy Benchmarking Tool.
Source: WCRFI (2025[115]), MOVING physical activity policy benchmarking tool, World Cancer Research Fund, https://www.wcrf.org/research-policy/policy/physical-activity-policy/moving-physical-activity-policy-benchmarking-tool/ (accessed on 15 July 2025); WCRFI (n.d.[116]), MOVING physical activity policy index, World Cancer Research Fund, https://www.wcrf.org/research-policy/policy/physical-activity-policy/moving-physical-activity-policy-index/ (accessed on 15 July 2025).
Fostering a life course approach can guide policy action. Starting as early as pregnancy, where prenatal exercise may improve foetal heart development and reduce gestational complications. In childhood, promoting active play and reducing sedentary behaviour in home and childcare settings helps develop motor skills and lowers long-term CVD risk. For adolescents and adults, interventions include school sports, workplace wellness programmes, and community efforts like walkable environments and active commuting incentives. Older adults benefit from low-impact activities such as walking or tai chi, which support heart health while accommodating mobility limitations, emphasising regular movement over extended inactivity (Perry et al., 2023[117]).
Co‑ordination & Funding: 78% of EU countries have a national co‑ordination mechanism for HEPA (Health-Enhancing Physical Activity), and 93% allocate specific funding – mainly from health, sports, and education sectors. These structures are vital for multisectoral collaboration.
Policy Implementation: All countries reported at least one national sports-for-all policy. 204 total HEPA policies were noted, mostly multisectoral. 93% target specific population groups (e.g. older adults, low-income populations), and all countries include evaluation plans.
Sports & Health Settings: Only 30% EU countries implemented the “Sports Club for Health” programme, though more have similar national initiatives. 74% promote physical activity counselling by health professionals, and 81% include physical activity in health curricula, mainly for doctors and physiotherapists.
Schools & Workplaces: All Member States include physical education in schools and related promotion programmes. 96% train PE teachers in HEPA. 59% promote active travel to school, 77% to work, and 78% have workplace activity programmes.
Urban Planning & Special Populations: Only 26% apply the IMPALA (improving infrastructure for leisure‑time physical activity in the local arena) infrastructure guidelines; 81% have frameworks for access to facilities for disadvantaged groups and active ageing.
Public Awareness: 89% of countries conducted national campaigns, using TV, social media, and public events to raise awareness of physical activity benefits.
Source: WHO (2024[118]), Health-enhancing physical activity in the European Union, 2024, https://iris.who.int/handle/10665/379360.
6.4.7. Policies targeting environmental risk factors for CVD are emerging in response to multiple environmental crisis
Air pollution is associated with a range of NCDs, including CVD. Both short- and long-term increases in air pollution have an impact. Short-term increases in air pollution are linked to increased incidence of and mortality from ischemic heart disease, and long-term exposure increase the risk of atrial fibrillation and hospitalisation or death from heart failure (Rajagopalan and Landrigan, 2021[119]).
Policy interventions in Europe are key to reducing the harmful impact of air pollution on health, and progress has been made. Mortality attributable to air pollution has decreased substantially across Europe, in particular for asthma, ischemic heart disease and stroke, moving Europe closer to achieving the target of 55% reduction in attributable deaths set by the Zero Pollution action plan (European Commission, 2025[120]). Policy on low emission zones are particularly impactful, and involve reducing car use in urban centres. They have been linked to 1 to 8% reductions in CVD outcomes in several German cities, in London and in Tokyo (Chamberlain et al., 2023[121]). Indoor air pollution is also becoming an increasingly important public health consideration for high income countries, particularly for older adults (Ndlovu and Nkeh-Chungag, 2024[122]). Benefits extend to other respiratory conditions and accident reduction, emphasising the role of these structural policies in increasing policy co-benefits.
Extreme weather events are associated with cardiovascular morbidity and mortality. For example, in a recent meta‑analysis, exposure to environmental stressors like extreme temperature and hurricanes were associated with increased morbidity and mortality from CVD, disproportionally affecting older adults, individuals from racial and ethnic minoritised groups, and lower-wealth communities. This highlights the need to tackle the ongoing challenges posed by climate change and extreme weather events and to adapt the healthcare system to respond appropriately (Kazi et al., 2024[123]). Finally, an* emerging association of ambient noise in communities and CVD is increasingly compelling, although more research is needed to conclude on concrete public health action (Lyzwinski, 2014[124]).
Detecting CVD early and controlling clinical risk factors at the individual can save money and improve equity. There are many effective ways to control CVD at the primary, secondary and tertiary prevention level, however approaches and implementation vary across Europe. The Conclusions on the improvement of cardiovascular health in the European Union have recommended scaling up timely screening and early detection, including the assessment of kidney function as part of the European strategy to improve cardiovascular health (European Council, 2024[125]). A survey of 13 European countries showed that the majority implemented some form of CVD prevention strategy between 2011 and 2021, yet the scale and consistency of delivery remain limited. National strategies exist in a few countries, such as Estonia, while others rely on fragmented measures, often without adequate infrastructure or reimbursement, such as the absence of funded cardiac rehabilitation in Romania (ESC, 2023[126]).
Population-level interventions that focus on high-risk groups can be highly effective for early detection and screening of CVD. Systemic screening programmes for conditions such as hypertension and diabetes, combined with proactive management strategies, can significantly improve early diagnosis and timely initiation of treatment (Groenewegen et al., 2024[127]; Handelsman et al., 2023[128]). Leveraging primary care for routine blood pressure checks and diabetes screening, alongside timely initiation of treatment, is critical to prevent progression to severe disease. Increasing statin use among adults over 40, particularly those with diabetes, also demonstrates strong evidence for reducing CVD risk (Galea G, 2025[129]).. These measures align with existing EU capacities and can deliver measurable health gains within a single political term.
6.5.1. Risk assessment as a mechanism to target higher risk individuals
CVD risk assessment is a mechanism for identifying individuals who are more likely to experience events like heart attacks or strokes, especially those without a prior diagnosis. Its primary purpose is to enable early intervention through personalised prevention strategies – such as lifestyle changes or medications – before any symptoms appear. By estimating a person’s future risk, healthcare providers can tailor treatments, allocate resources more efficiently, and empower patients to make informed decisions.
Targeting high-risk individuals with preventive measures leads to greater impact, as interventions yield more benefit when applied to those with higher baseline risk. Example risk assessment tools include the WHO cardiovascular risk charts and SCORE2 (Systematic COronary Risk Evaluation 2) – as well as a number of nationally validated tools (WHO[130]; ESC Cardiovascular risk collaboration, 2021[131]).2 Most recommendations emphasise conducting cardiovascular risk assessments in adults over 40 who have identifiable and easily measurable risk factors – such as smoking, obesity, family history of CVD, or hypertension – but who have not yet been diagnosed with CVD. However, the implementation of these assessments needs to align with the capacity of each health system and follow national protocols, ensuring that global recommendations are adapted to local contexts.
Individual-level approaches to detect and reduce cardiovascular risk by tackling cardiovascular risk lifestyle and clinical factors can be effective, cost-effective, and equitable. For example, the National Health Service (NHS) Health Checks programme showed increased detection of elevated risk factors, obesity, diabetes, and chronic kidney disease (in the context of CVD prevention), with increased participation of women and people aged 60 and over, but studies reporting conflicting results in terms of reducing inequalities. The statutory review of the programme in 2021 concluded that the programme is achieving largely its objectives, is cost-effective and targeted interventions can reduce inequalities. (Office for Health Improvement & Disparities, 2021[132]). Targeting the programme to communities socio-economically disadvantaged can further improve the reduction on inequalities (O’Flaherty et al., 2021[133]; Kypridemos et al., 2018[134]).
The scalability of this type of systemic approach is complex, and effectiveness in specific populations need to be shown. The piloting of a High-Risk Prevention Programme (HRPP) in Ireland showed measurable improvements in weight, BMI, and physical activity in socio-economically disadvantaged populations, suggesting its potential as a scalable intervention (Broughan et al., 2024[135]).
Patient engagement with CVD prevention programmes continues to be challenging, and often people with the most need or from disadvantaged groups are the least likely to benefit. The Scaling up Packages of Interventions for CVD prevention in selected sites in Europe and Sub-Saharan Africa (SPICES) project in France, which leveraged trained community champions and brief advice, highlighted the limitations of individual-level engagement, particularly when public awareness and readiness to change are low and the population is more disadvantaged (Le Goff et al., 2024[136]). Understanding the behavioural drivers behind prevention disengagement can enhance participation in prevention initiatives, and particularly in reducing health inequalities (Stuart-Shor et al., 2012[137]). The NHS Health Checks in England has identified as a priority to improve individual uptake of the programme and achieve sustained engagement, including more integration with national and local government and integrated care boards to maximise opportunities for participation and increase prescription rates of evidence‑based interventions to improve cardiovascular risk (Office for Health Improvement & Disparities, 2021[132]).
Training in preventive care remains uneven, and public awareness campaigns have limited measurable impact. The European Society of Cardiology’s (ESC) introduction of accreditation and certification for prevention centres and professionals is a step toward harmonising standards and improving quality, but broader and more co‑ordinated implementation efforts are still needed (ESC, 2023[126]).
6.6.1. Health literacy improvements could prevent and reduce treatment-seeking delays for life‑threatening conditions
Understanding behavioural drivers behind disengagement is key to strengthening CVD prevention and reducing inequalities. Patient-centred and multifaceted interventions – engaging patients, providers, and systems – can improve outcomes such as blood pressure control, obesity, regardless of literacy level (Halladay et al., 2017[138]; AHA, 2018[139]).
However, limited public awareness and low engagement, especially in underserved areas, remain barriers. The SPICES project in France, leveraging trained community champions, highlighted the limitations of individual-level engagement in underserved rural areas (Le Goff et al., 2024[136]). Cardiomyopathies – frequently inherited primary myocardial diseases – may cause severe symptoms and increase the risk of sudden cardiac death. Policies to strengthen patient and family screening programmes, including health literacy initiatives and adherence to guidelines for screening and care for these patients, may enhance cardiomyopathy care (see Chapter 3).
Early recognition of symptoms of acute coronary syndromes (ACS) or stroke is essential to ensure timely care, significantly reducing morbidity and mortality. For ischemic stroke, clinical benefits from thrombolytic therapy and mechanical thrombectomy are both time‑dependent (AHA/ASA[140]). Similarly, in ACS, particularly ST-elevation myocardial infarction (STEMI), delays in reperfusion therapy are directly associated with increased mortality. From the four phases of the timeframe of acute CVD, the first two are dependent on citizens behaviour. These phases are: 1) time from symptom onset to the decision to seek care, 2) time from the decision to seek care to first medical contact, and 3) time from first medical contact to hospital arrival, and 4) time from admission to treatment (Moser et al., 2006[141]; Lachkhem, Rican and Minvielle, 2018[142]).
I have experienced sudden heart-related symptoms in situations where help was not immediately available – twice while driving alone on the highway, and once while swimming. In each case, I felt intense tachycardia, dizziness, and fear, unsure if I was about to lose consciousness or have a more serious event like a stroke or cardiac arrest. These moments were terrifying and left me feeling vulnerable and unsafe in everyday situations. They also highlight the unpredictability of living with a heart condition and the need for better emergency planning, public awareness, and personal support tools for people managing chronic cardiovascular disease.
Angela, 53, mother, in menopause and living with multiple chronic conditions.
Low health literacy can delay care for life‑threatening events, yet it is a modifiable factor through targeted education context-specific education (Nutbeam and Lloyd, 2021[143])). Many individuals fail to seek care quickly due to a lack of awareness or knowledge. Factors influencing acute stroke delays are often related to pre‑hospital phase, notably recognition of stroke symptoms (Lachkhem, Rican and Minvielle, 2018[142]). Investing in public education to recognise warning signs – such as facial drooping, arm weakness, and speech difficulties in stroke, or chest pain in ACS – can enhance timely care and improve outcomes. In specific contexts, instead of self-presenting to a primary care physician without the resources to diagnose ACS, it is important that the public can recognise ischemic symptoms and activate the pre‑hospital pathway.
6.6.2. Countries are developing health literacy initiatives to improve early response to acute cardiovascular events, although challenges persist to ensure country-level dissemination
Several countries have implemented health literacy initiatives focussed on early response to life‑threatening cardiovascular events (Box 6.7). According to the OECD Policy Survey on Cardiovascular Health, 15 countries reported public awareness initiatives related to symptoms of stroke and ACS. The Netherlands provides health resources through the Heart Foundation and media campaigns on timely access and automated external defibrillator (AED) education. In Sweden, health campaigns are often led by NGOs or local authorities, which hinders national-level assessments. Canada collaborates with provincial governments on public awareness campaigns.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
National awareness campaigns can include assessments of their effects on clinical outcomes, such as reductions in morbidity and mortality. The National stroke awareness campaign in England, the “Act FAST”, which stands for “Face, Arms, Speech, Time to call 999” (Kothari et al., 1999[144]), has improved public recognition of stroke symptoms and improved emergency responses, leading to a notable rise in thrombolysis treatments and a shift away from GP referrals toward emergency services (Flynn et al., 2014[145]). However, effectiveness varied across populations, with lower impact in minority groups and limited recognition of symptoms not addressed by the campaign. In September 2025, Ireland has launched a 3‑year stroke public awareness campaign, also emphasising the FAST approach, aiming to raise awareness to stroke symptoms and the importance of seeking care early (HSE, 2025[146]).
Population training and availability of registered automated external defibrillator in public spaces vary widely in Europe and are crucial to improve survival after cardiac arrest
Sudden cardiac death (SCD) comprises a leading cause of death in European countries (see Chapter 2). At the community level, out-of-hospital cardiac arrest (OHCA) frequently results in poor outcomes, showing wide variation in incidence and outcomes across Europe (Gräsner et al., 2016[147]; Gräsner et al., 2020[148]). An international prospective study including registry data from 28 countries, collected between September and November 2022, reported that 66% of patients with OHCA died on scene (Gräsner et al., 2025[149]) (Figure 6.5).
The majority of OHCA cases are attributed to Acute Coronary Syndromes, therefore primary PCI may be a potential component of post-resuscitation care for selected patients. Streamlining patient transfer to specialised hospitals – specifically, cardiac arrest centres – may improve clinical outcomes, although further evidence is needed (Yeung J, 2019[150]). European clinical guidelines recommend the implementation of tailored strategies to ensure that patients with suspected ACS, following successful resuscitation, are directly transferred to a primary PCI centre (ESC, 2023[151]).. Indicators to monitor time‑critical care for people with STEMI and OHCA need further standardisation across European countries (see Chapter 4).
Note: Data from 32 033 confirmed out-of-hospital cardiac arrest where cardiopulmonary resuscitation was initiated by emergency medical services (EMS) or bystanders, across 28 countries. *Includes patients discharged alive or at 30 days, based on all CPR started by EMS.
Source: Gräsner et al. (2025[149]), “European registry of cardiac arrest study THREE (EuReCa- THREE) – EMS response time influence on outcome in Europe”, https://doi.org/10.1016/j.resuscitation.2025.110704.
Considering that around 80% of the OHCA occur at home, raising population awareness and training is crucial (ESC, 2025[152]). Each five‑minute delay to return of spontaneous circulation after OHCA was associated with a 38% increased risk of death (Gräsner et al., 2020[148]). Furthermore, outcomes after a bystander-witnessed shock are better than Emergency Medical Services (EMS)-treated OHCA: 30‑day survival after bystander-witnessed shockable OHCA ranged from 12% to 47%, compared to 3% to 20% for EMS-treated OHCA (Kiguchi et al., 2020[153]).
Expanding CPR training at population level could boost bystander CPR and AED use. CPR training rates were reported as 44% in high-income and 40% in upper-middle‑income populations (Birkun, 2023[154]). Across Europe, bystander CPR rates vary widely, averaging 58% (range 13‑82%), while AED use remains low at 28% (range 4‑59%) (Gräsner et al., 2021[155]). Community-based interventions have shown to improve OHCA outcomes, including survival with a favourable neurological outcome (Simmons, McIsaac and Ohle, 2023[156]). The presence of bystanders at symptom onset may also decrease the pre‑hospital delay by overcoming low patient knowledge (Lachkhem, Rican and Minvielle, 2018[142]). Health literacy interventions can also target caregivers and coworkers of patients at high-risk of stroke. Most of the calls to activate EMS during a stroke are conducted by family members (60%), 18% by paid caregivers, and 18% by coworkers (Wein et al., 2000[157]).
Measures to improve immediate care by the community in the event of OHCA have been implemented in some European countries (Figure 6.6). According to the 2025 OECD Cardiovascular Policy and Data Survey, ten countries are implementing health literacy programmes related to OHCA and 11 countries are addressing the public availability of AED. Since 2005, Denmark implemented various nationwide strategies (see Box 6.9), resulting in an increase of bystander CPR, from 21% in 2001 to 45% in 2010 and an increase in 30‑day survival following OHCA from 4% to 11% (Wissenberg et al., 2013[158]).
Norway launched its national AED registry in 2017, where AEDs are registered and linked to an emergency medical communication centre (Steenstrup, Kramer-Johansen and Berge, 2025[159]), alongside initiatives to raise population awareness. The national registry allows the communication centres to guide bystanders to retrieve an AED in the event of a cardiac arrest. In 2023, 79% of OHCA in Norway received bystander CPR before ambulance arrival. AED use before arrival rose from 13% in 2017 to 18% in 2023 (Tjelmeland et al., 2024[160]). In the Netherlands, a citizen alert system dispatches two ambulances and notifies nearby certified volunteers to provide CPR in suspected cardiac arrests within their vicinity. Delivery of AED via equipped drones present the potential to reduce time to defibrillation in people suffering an OHCA (Schierbeck et al., 2021[161]). Recent studies in Sweden and Demark showed positive results regarding its feasibility, safety and time gains when compared to ambulance arrival (Jakobsen LK, 2025[162]; Schierbeck et al., 2023[163]). At the supra-national level, the EU has co-funded various projects to improve early detection and integrated care of heart rhythm disorders and sudden cardiac death (see Annex 6.A).
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Population training: Mandatory resuscitation training in schools (Denmark), at workplace (e.g. hospitality, education, industry, corporate offices), when acquiring a driver’s licence (Denmark) and Voluntary Cardiopulmonary Resuscitation (CPR) courses and distribution of CPR training kits.
Implementation of community response systems: Organisation of citizen assistance platforms (community first responders) (Netherlands, Norway, Ireland).
Support to people witnessing a cardiac arrest: Telephone guidance from emergency lines to bystanders witnessing a cardiac arrest, including remote instructions and real-time verbal encouragement (Denmark).
Availability of automated external defibrillators (AED) in public spaces and AED registry: Development of a network of AED in public spaces, including regular maintenance and documentation, namely at schools, commercial places and at workplaces (Denmark).
AED registry linked to emergency medical communication centre to guide bystanders to retrieve AED in the event of a cardiac arrest (Norway, Ireland).
Developing cardiac arrest registries could support improving care provided to people suffering an out-of-hospital cardiac arrest
The European Registry of Cardiac Arrest (EuReCa), led by the European Resuscitation Council and involving 28 countries, aims to improve understanding of OHCA incidence and outcomes. Despite progress, data collection remains inconsistent and lacking standardisation across Europe (Gräsner et al., 2020[148]). National OHCA registries in Denmark, Ireland, and Sweden support more accurate tracking and promote standardised data collection across countries and regions. These efforts enable better international comparisons to inform evidence‑based improvements in emergency response systems.
Effective pre‑hospital care relies on well-equipped and co‑ordinated Emergency Medical Services and optimising patient flows
Enhancing health literacy is a critical lever for improving early recognition and timely response to cardiovascular emergencies. Community-based training and the strategic deployment of AEDs are cost-effective and scalable interventions that empower the population to act. However, their impact depends on a well-equipped and co‑ordinated EMS to ensure rapid, seamless care. Strengthening these connections is essential to improving cardiovascular outcomes (see Chapter 4).
Emergency medical services (EMS) are often the first point of care for life‑threatening cardiovascular events, providing early diagnosis, triage, transport, and treatment. For ACS, EMS should activate the catheterisation laboratory after a STEMI diagnosis and bypass the ED (ESC Guidelines, 2023[164]) (see Chapter 4). In hyper-acute stroke, timely dispatch, pre‑notification, and transport to stroke‑capable centres are critical, especially for patients eligible for thrombolysis and thrombectomy, both highly time‑sensitive procedures (AHA, 2019[165]; Turc et al., 2019[166]) (see Chapter 4). Despite the potential, safety and communication challenges can arise during patient transfers that can have negative effects on patient outcomes and system effectiveness – so processes need to be implemented carefully. In addition, direct admission to specialised care often has better outcomes than patient transfers (Lomi et al., 2014[167]; Abdeldayem and Gunarathne, 2022[168]). In Italy, interhospital transfers have been shown to direct patient flows to hospitals with capacity to deliver higher quality of care and were associated with lower mortality (Lomi et al., 2014[167]; Berta, Vinciotti and Moscone, 2022[169]) Overall, this policy lever could be further adopted, with appropriate safeguards. In the United States, the American Heart Association Guidelines recommend that when patients with STEMI present to non – PCI‐capable hospitals that they receive an immediate emergency transfer to a STEMI receiving centre (Neumar et al., 2015[170]).To streamline care, eight countries implemented interhospital transfer agreements for ACS and stroke (Figure 6.7).
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
6.6.3. Measuring and improving equity is essential to tackle the burden of CVD
Groups living in vulnerable situations remain under-targeted in health literacy initiatives and under-treated, though emerging pilot initiatives show promise
Addressing inequalities in cardiovascular care requires a comprehensive approach, as disparities encompass various dimensions such as gender, ethnicity, and geography – each playing a distinct role in delaying diagnosis, treatment, and recovery. Likewise, the HiAP approach is considered crucial. Studies have shown that certain population groups are more likely to delay seeking care, highlighting the need for targeted interventions and inclusive policy responses. Delays in seeking care were linked to race, smoking, and diabetes (Frisch et al., 2019[171]). The EU-co-funded Joint Action on CVDs and diabetes, JACARDI (11/2023‑2010/27), applies the “4Cs” framework as a structured approach to integrate the principle of equity and diversity into the implementation of 142 national-level pilot projects, which entails “Critical reflection”, “Context and data”, “Co-design”, “inclusive and accessible Communications” (B Armocida, 2024[172]). Enhancing health systems ability to meet the needs of individuals from varied backgrounds requires ongoing self-reflection, recognising power imbalances, and ensuring commitment to respectful partnerships with diverse communities, to ensure that services are inclusive and equitable.
France launched a national pilot initiative in January 2024 to improve hypertension awareness and management in disadvantaged regions. Also, as part of JACARDI, a health literacy project in the region of Aragon, Spain, is addressing disparities in stroke care for people living in different geographical areas, including the most remote. The first phase involved surveying over 400 patients and caregivers to map health literacy profiles, followed by multi-stakeholder workshops to co-design tailored interventions. Two primary care centres are piloting these actions, with a view to integration into stroke care protocols. In Ireland, the Irish Heart Foundation’s “Her Heart Matters” campaign directly targets women’s awareness of MI symptoms. In the United Kingdom, high-risk cardiovascular conditions remain under-treated, particularly among Black and mixed ethnic groups, who face lower rates of monitoring, treatment, and appropriate prescriptions (CVDPREVENT, 2025[173]). The CVDPREVENT national primary care audit aims to support early identification and improved management of high-risk individuals in primary care (see Box 6.10).
CVDPREVENT is a national NHS audit using GP data to monitor and improve detection and management of high-risk CV conditions. As of September 2024, key measures and goals are in place:
Source: CVDPREVENT (2025[173]), Cardiovascular Disease Prevention (CVDP) CVDPREVENT Healthcare Quality Improvement (QI) Plan.
Coordinated actions to improve women’s cardiovascular care are not widespread
Across the care pathway, several factors are driving gender disparities in ACS care and outcomes (see Box 6.11). Addressing these gaps requires a comprehensive pathway approach, including inclusive representation in clinical trials to ensure evidence‑based, gender-sensitive care (Haupt, Carcel and Norton, 2024[174]). Women are less likely to accurately assess their cardiovascular risk and take longer to call emergency services when suffering from a myocardial infarction (see Chapter 4) (Moser et al., 2006[141]; Lachkhem, Rican and Minvielle, 2018[142]). Furthermore, certain CVD risk factors and conditions are unique to women, while others disproportionately affect them (Garcia et al., 2016[175]). Sex-specific differences also influence how CVD presents and how women respond to treatment (Vogel et al., 2021[176]).
Age gap at first event and higher comorbidity burden: Women typically experience their first ACS episode about 7 years later than men and present with more coexisting health conditions;
Higher mortality rates: Women have higher mortality rates – 10% vs. 7% in-hospital, 16% vs. 12% at 30 days, and 44% vs. 34% for death or cardiovascular readmission at 2 years;
Elevated risk in younger women: Women under 65 face particularly high risks, influenced by a mix of age, health status, ethnicity, and socio-economic background;
Adverse pregnancy outcomes (e.g. gestational diabetes, hypertensive disorders, pregnancy loss), increase women’s risk of presenting CVD risk factors and of developing CVD (Nisha I. Parikh, 2021[177]).
Under-recognised conditions: Women are more likely to experience conditions like myocardial infarction with non-obstructive coronary artery disease (MINOCA) and spontaneous coronary artery dissection (SCAD) – both associated with severe complications and mortality.
SCAD an increasingly recognised cause of acute coronary syndromes, especially in women under 50 and those during the peripartum period. (Ciliberti et al., 2023[178])
Gaps in care: Despite facing higher ischemic risk, women are less likely to receive guideline‑directed care, including invasive diagnostic, such as invasive angiography.
Source: Vranckx, Valgimigli and Aleksic (2024[179]), “Shaping the future of acute coronary syndrome management: a look back at 2024”, https://doi.org/10.1093/ehjacc/zuae143.
The integration of sex-specific strategies into national health policies and clinical guidelines has been proposed to ensure equitable access to high-quality care (see Box 6.12) (Lundberg et al., 2018[180]; Gulati et al., 2021[181]). Specialised women’s heart centres are emerging as a response to persistent sex disparities in cardiovascular care, supported by growing evidence that specialised care improves women’s outcomes. These centres adopt a team-based, multidisciplinary approach tailored to the unique biological and clinical characteristics of heart disease in women (Gulati et al., 2021[182]; Parvand et al., 2022[183]). Globally, around 50 women’s heart programmes have been established, including six in Canada and others across the United States and Europe, such as the Women’s Heart Center at the Cardiologico Monzino in Italy (Parvand et al., 2024[184]; Cardiologico Monzino[185]). In Ireland, a Women’s Health Research Network was established in March 2025, including patient representatives, healthcare professionals, researchers, and policymakers. It aims to promote integrated approaches to women’s cardiovascular health, particularly focussing on heart failure.
I was prescribed four medications, but they caused strong side effects and were not tested on women in menopause. Some also interacted with each other, making my condition worse. Over time, I stopped three of them, and I’m now reducing the last one (a beta-blocker). One of the medications – a diuretic – led to the development of osteoporosis, which was not identified early. This shows how important it is for doctors to monitor how medications affect the body over time and to adjust treatment quickly when it’s not working or causing harm. It also shows the need for more personalized and gender-aware care.
Angela, 53, mother, in menopause and living with multiple chronic conditions.
Investment in cross-sectoral prevention policies to improve health environments for girls and women (see sub-section Prevention) (Vervoort et al., 2024[186])
Improvement of women’s awareness to cardiovascular health needs, notably to adjust their perception of CVD risk factors and symptoms (Manzo-Silberman et al., 2024[187]).
Raising professionals’ awareness about women’s unique risk factors, symptoms diseases, and the importance of evidence‑based care.
Assessing cardiovascular health routinely among young women, including traditional CVD risk factors, sex-specific and gender-related CVD risk factors (Roeters van Lennep et al., 2023[188]).
Investing in multidisciplinary´, personalised care to women- before, during and after pregnancy. Women heart centres and pregnancy heart teams can support guideline‑based care and improve clinical trial participation. (Rakisheva et al., 2024[189]).
Increase women’s representation in clinical trials, notably from minority groups, who face a higher burden of CVD risk factors (Manzo-Silberman et al., 2024[187]).
Investment in sex-specific CV research and research on non-traditional risk factors, such as autoimmune diseases and reproductive health factors (Manzo-Silberman et al., 2024[187]).
Regional networks for STEMI can reduce inequalities in emergency care access by improving co‑ordination with PCI centres
Regional networks play a critical role in improving equity in care delivery. By standardising access to life‑saving interventions regardless of geographic location, they contribute to bridge the gap between urban and rural healthcare facilities, reduce treatment delays, ensuring that all patients – regardless of where they live – receive guideline‑directed, evidence‑based care. Establishing a regional reperfusion strategy is, therefore, recommended to ensure timely and high-quality care for patients with suspected STEMI, connected to an efficient Emergency Medical Service. This can be achieved through the development of STEMI networks with explicit definitions of geographic areas of responsibility and pre‑established transfer protocols from community hospitals to percutaneous coronary intervention (PCI) capable centres. Randomised trials have consistently shown that transferring STEMI patients to PCI centres for primary PCI results in better outcomes than administering reperfusion therapy at non-PCI-capable hospitals (Dalby et al., 2003[190]). STEMI networks between hospitals have also been associated with a higher adherence to reperfusion guidelines (Claeys et al., 2012[191]). In centres where the expected transfer time to primary PCI is expected to exceed the timeframe recommended, tailored protocols are recommended to established. These protocols should ensure treatment initiation within ten minutes after first medical contact and immediate transfer for a PCI-capable centre (ESC, 2023[151]).
Integrated care aims to deliver co‑ordinated, high-quality services for individuals with complex health needs by addressing fragmented care. It involves connecting services of providers across the care continuum to improve patient outcomes (European Commission, 2017[192]). As highlighted by the PaRIS survey, gaps in care co‑ordination persist for people living with chronic conditions (OECD, 2025[3]).
Care coordination was one of the most challenging aspects of my journey. The transition between different healthcare providers, especially during my transfer to Budapest, was stressful and disjointed. A dedicated care coordinator could have alleviated much of this burden, ensuring a smoother pathway and better communication between teams.
Caius, artist, researcher, patient advocate, and heart attack survivor.
The “Gesundes Kinzigtal” programme in southwest Germany is a leading example of population-based integrated care in Europe. Launched in 2005, it brings together health insurers, physicians, and care managers to co‑ordinate services across sectors, focussing on prevention, self-management, patient-centred care, and electronic networking system (Struckmann, Boerma and Van Ginneken[193]). The model has demonstrated improved health outcomes compared to usual care (Busse and Stahl, 2014[194]; Hildebrandt, Schulte and Stunder, 2012[195]).
For patients living with CVD, integrated care models support continuity across care settings and facilitate early intervention through multidisciplinary collaboration. While early care models focussed on single diseases, a shift toward population-based models focussed on chronic diseases, such as the Chronic Care Model (Table 6.4), have shown to improve outcomes for patients with multiple chronic conditions in some settings through co‑ordinated, patient-centred care (Box 6.13).
Source: Rodriguez-Blazquez, C. et al. (2020[196])., “Assessing the Pilot Implementation of the Integrated Multimorbidity Care Model in Five European Settings: Results from the Joint Action CHRODIS-PLUS”, International Journal of Environmental Research and Public Health, Vol. 17/15, p. 5268, https://doi.org/10.3390/ijerph17155268; Bodenheimer, T., E. Wagner and K. Grumbach (2002[197])., “Improving Primary Care for Patients With Chronic Illness”, JAMA, Vol. 288/15, p. 1909, https://doi.org/10.1001/jama.288.15.1909; Vat et al. (2016[198]), “The Development of Integrated Stroke Care in the Netherlands a Benchmark Study”, https://doi.org/10.5334/ijic.2444.
Overall, the cost-effectiveness of integrated care remains inconclusive, largely due to limited system-level data, inconsistent definitions, and varying evaluation methods that hinder comparability. However, emerging evidence suggests that well-designed integrated care models – particularly those targeting people with multimorbidity in primary and community settings – can reduce unplanned hospital admissions and potentially save costs (Schiøtz et al., 2011[199]). The design and implementation of integrated care appear to be critical factors in achieving both clinical and economic benefits.
6.7.1. Further investment is needed to advance integrated care delivery
Several policy levers were previously identified as key to design and implement integrated care frameworks (Table 6.5). Strengthening governance structures by breaking down silos across administrative systems in health and social care is one key aspect. Financial incentives to healthcare providers have been associated with measures of enhanced access and increased quality of care (Flodgren et al., 2011[200]; Heider and Mang, 2020[201]). Furthermore, primary care‑oriented health systems, with GPs as gatekeepers, stronger financial incentives directed to GPs and better care continuity, have been associated with lower avoidable hospitalisations in a previous OECD analysis (OECD/The Health Foundation, 2025[202]). Various European countries are strengthening governance models, changing legal frameworks and piloting the systematic collection of integrated cardiovascular care indicators to enhance cardiovascular care integration (Table 6.6).
Source: The column on the left is adapted from European Commission (2017[192]), “Blocks – Tools and methodologies to assess integrated care in Europe – Report by the Expert Group on Health Systems Performance Assessment”, https://doi.org/10.2875/69305. The column on the right is based on OECD (2023[203]), Integrating Care to Prevent and Manage Chronic Diseases: Best Practices in Public Health, https://doi.org/10.1787/9acc1b1d-en.
Health information systems with data linkages also need to be strengthened, to monitor longer care trajectories, patient trajectories between health and social care, and home‑based care. Findings from the PaRIS survey showed that only half of primary care participating centres were able to exchange electronic health records with other centres (OECD, 2025[3]). The first OECD pilot on the collection of Integrated Care indicators to support international comparisons, undertaken in 2020-2021 with 15 countries demonstrated feasibility, nonetheless, data linkage remained a challenge (Barrenho et al., 2022[204]).
|
Country |
Strengthening governance models |
Changes in legal framework |
Systematic collection of integrated CV care indicators |
|---|---|---|---|
|
Austria |
In development |
In development |
In development |
|
Croatia |
N/A |
N/A |
N/A |
|
Czechia |
N/A |
N/A |
N/A |
|
Estonia |
In development |
In development |
In development |
|
Finland |
N/A |
N/A |
N/A |
|
France |
In development |
In development |
Fully implemented |
|
Germany |
N/A |
N/A |
Fully implemented |
|
Ireland |
In development |
N/A |
In development |
|
Latvia |
In development |
In development |
In development |
|
Luxembourg |
In development |
In development |
In development |
|
Netherlands |
In development |
In development |
In development |
|
Slovenia |
N/A |
N/A |
N/A |
|
Sweden |
In development |
Fully implemented |
N/A |
|
Iceland |
N/A |
N/A |
N/A |
|
Norway |
In development |
In development |
In development |
|
Canada |
N/A |
N/A |
N/A |
|
Japan |
Not implemented |
Not implemented |
Not implemented |
|
Türkiye |
N/A |
N/A |
N/A |
|
United Kingdom |
In development |
Fully implemented |
In development |
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey. N/A: information not available.
Atrial fibrillation (AF): AF poses a growing burden on health systems due increased risk of stroke, bleeding, and mortality. Integrated care models – centred on the ABC pathway (Anticoagulation, Better symptom control, and Cardiovascular risk management) (Lip, 2017[205])–have shown to reduce adverse events, improve outcomes, and lower costs (Camacho and Lip, 2023[206]) by co‑ordinating care across all settings, leveraging multidisciplinary teams, technology, and self-management (Bhat et al., 2021[207]; Machado, Leite and Pereira, 2025[208]).
Cardiomyopathies: Cardiomyopathies, often inherited and affecting up to 1 in 250 people, can lead to severe complications such as heart failure, stroke, and sudden cardiac death, and are a leading cause of heart transplantation in young patients. Effective care requires a multidisciplinary approach, including smooth transition from paediatric to adult care and a shared approach between cardiomyopathy specialists and general cardiology centres. Networks like European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart) and national expert networks in Spain and France enable professionals to share expertise and improve care (ESC Guidelines, 2023[209]). Key policy actions include promoting screening programmes, accrediting expert centres and developing co‑ordinated networks, implementing care guidelines, and supporting data-sharing infrastructures for inherited cardiac diseases.
Diabetes: Integrated care models involving diabetes specialists collaborating with primary care teams have shown clinical benefits, including improvements in blood glucose and blood pressure, although further research is needed to better characterise specific intervention types leading to successful outcomes (Zarora et al., 2022[210]). A meta‑analysis found that multidisciplinary collaborative care – including closer follow-ups, self-monitoring, and lifestyle support – improved outcomes in patients with uncontrolled diabetes. It also maintained or improved patient-reported outcomes, with healthcare costs comparable to usual care, highlighting the value of co‑ordinated approaches in diabetes management (Siaw and Lee, 2018[211]).
Ischemic heart disease (IHD): The “Lancet Commission on Rethinking Coronary Artery Disease” (April 2025), calls for a fundamental shift in how coronary artery disease (CAD) is understood and managed (Zaman et al., 2025[212]). Key goals include reclassifying CAD as atherosclerotic coronary artery disease (ACAD), promoting early detection and prevention, supporting lifelong risk factor management, and realigning healthcare systems and research to focus on the root causes of atherosclerosis rather than late‑stage ischaemic events, namely acute coronary syndromes. Multidisciplinary intervention is key to successful preventive measures (ESC, 2017[213]).
Structural heart disease, congenital or acquired, including:
Heart valve disease (HVD): HVD, a complex and often overlooked part of cardiovascular care, can lead to serious complications like heart failure. As structural heart programmes grow – driven by ageing populations and innovations like transcatheter aortic valve replacement – success depends on multidisciplinary services (Almanfi, 2018[214]) and targeted policies across the care pathway, including symptom awareness, primary care training, improved referrals, access to diagnostics and new treatments, and co‑ordinated follow-up care (Global Heart Hub, 2020[215]).
Adult congenital heart disease (ACHD): Adults with ACHD now live longer thanks to advances in care, but face long-term complications requiring specialised, multidisciplinary management to manage the complex trajectory of ACHD (Liu et al., 2022[216]; Marshall V. et al., 2025[217]). All ACHD patients should be assessed at least once in a specialist centre, with close co‑ordination between general cardiologists and ACHD teams, especially in complex or acute cases (ESC Guidelines, 2020[218]).
Improving integrated cardiovascular care delivery in Europe will require continued attention to the challenges countries face and further investment in key policy areas, including governance models, cross-sector health information systems, financing approaches, workforce training and the scale‑up of innovation (Figure 6.8 and Figure 6.9). Sweden is investing in integrated care through regional and municipal initiatives in the last decade. Legislative changes have been introduced, particularly by clarifying procedures for care transitions, namely after hospital discharge. Norway has long-standing policies addressing cardiovascular care integration, with ongoing development to refine these measures. Germany has implemented mandatory follow-up outcome indicators for acute coronary syndrome and stroke in hospitals. The United Kingdom has enacted the Health and Care Act 2022, which defines 42 Integrated Care Systems in England, which plan health and care services at the local level. Ireland has established integrated care hubs including cardiology specialist teams to deliver care in the community in an integrated manner.
Singapore is currently expanding its national Stroke and CHF National Value Base Care programme beyond acute care to encompass prevention, diagnosis, acute interventions, chronic care, and end-to‑end care pathways. This expansion will ensure better integration across care settings and reflect real-life patient journeys, supported by internal reporting systems, provider education, and decision-support mechanisms. Beyond Value‑Driven Care, Singapore has also included CHF, one of the ambulatory care sensitive conditions, under the list of Medisave claimable complication of selected Chronic Disease Management Programme conditions, like Diabetes, Hypertension and Lipid disorders (DHL) and Chronic Obstructive Pulmonary Disease (COPD). This hence functions as a financial leverage to improve CHF integrated care. Colombia has strengthened integrated care by implementing regulations that promote prospective payment models based on health outcomes, improving contractual relationships between providers and payers. These reforms aim to reduce information asymmetries, enhance transparency, and build trust among stakeholders to improve care co‑ordination and population health.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
6.7.2. Chronic heart failure care – Strengthening integrated care from early diagnosis to rehabilitation
Improving early recognition and referral of heart failure patients is essential to improve outcomes
Timely diagnosis of heart failure in primary care remains a challenge, with significant delays in referral and investigation (Hayhoe et al., 2018[219]). This is partly due to the gradual onset and non-specific nature of symptoms, often misattributed to other conditions by both patients and clinicians (Taylor et al., 2017[220]). The ESC recommends natriuretic peptide testing for early diagnosis (ESC Guidelines, 2021[221]), yet access in primary care is limited – only 20% of surveyed healthcare professionals reported availability in community settings (Bayes‐Genis et al., 2024[222]). Access also varies widely across Europe due to differing reimbursement policies, highlighting the need for broader implementation to reduce diagnostic delays (Box 6.14). In the “STOP-HF Screening Programme”, launched in Ireland as a research study in 2004, natriuretic peptide testing is conducted to identify people at high risk of developing heart failure. The frequency of medical visits is then tailored to each person’s risk status.
Improving early diagnosis and referral of heart failure requires a multifaceted approach, including:
Public education campaigns, such as the BEAT campaign – Breathlessness, Exhaustion, Ankle swelling, and Time to act – implemented across the United Kingdom to educate the public (BeatHF[223]).
Raising healthcare professionals’ awareness, particularly in primary care. The adoption of natriuretic peptide testing in primary care settings is a key step forward (NICE, 2023[224])
Integrating heart failure diagnostic strategies into national cardiovascular care plans and developing clear referral pathways to streamline patient journeys.
The most relevant components of heart failure management programmes include:
Multidisciplinary management: evidence‑based recommendation (class IA), recommended to reduce heart failure (HF) mortality and the risk of hospitalisation (ESC Guidelines, 2021[221])
Self-management strategies: evidence‑based recommendation (class IA), recommended to reduce HF mortality and the risk of hospitalisation (ESC Guidelines, 2021[221])
Home‑based and/or clinic-based programmes: recommended to reduce HF mortality and the risk of hospitalisation (ESC Guidelines, 2021[221]) for follow-up after hospital discharge and to monitor and treat of new signs/symptoms of HF.
Source: Adapted from ESC Guidelines (2021[225]), 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, https://doi.org/10.1093/eurheartj/ehab368.
Multidisciplinary heart failure programmes and care networks could harness integrated care, with stronger primary care involvement
Multidisciplinary heart failure management programmes have shown to reduce healthcare costs and improve clinical outcomes, being recommended in the ESC HF clinical guidelines (ESC Guidelines, 2021[221]). This model of care ensures co‑ordinated care transitions and may result in the establishment of networks of care pathways (ESC, 2011[226]). National clinical networks connect providers with HF centres to manage heart failure patients, improving access and promoting evidence‑based care. (Luedike et al., 2022[227]). In Germany, the programme HF-NET (Heart Failure Network) links hospital and outpatient services within regional networks through standard operating procedures and care pathways (Heart Failure Policy Network, 2020[228]). A systematic review assessing the effectiveness of transitional care services following hospitalisation for heart failure showed that nurse home visits and disease management clinics significantly reduced all-cause mortality of heart failure patients, when compared with usual care (Van Spall et al., 2017[229]).3 Nurse home visits and disease management clinics have also shown to decrease all-cause readmission and to save costs (Van Spall et al., 2017[229]).
I think after a diagnosis of a heart disease, especially for young people, there should be a team helping out, not just a cardiologist. I am thinking of a psychologist, a movement expert, a dietician. Because we work as a full body, and if we have a strong and healthy one, it benefits the heart as well.
Francesca, 34, female living with hypertrophic cardiomyopathy and an implantable cardioverter-defibrillator.
Implementation of HF management programmes require multidisciplinary collaboration across the entire care pathway, from diagnosis, through acute events, and terminal phases (ESC, 2011[226]) (ESC Guidelines, 2021[221]) and should apply a holistic approach, addressing comorbidities, such as diabetes, renal dysfunction, and mental conditions (ESC, 2011[226]) (Box 6.14). Continuous quality improvement initiatives can play a role in assessing and refining these programs. In France, the French Hospitals Federation (Fédération Hospitalière de France, FHF) launched a pilot project in five territorial hospital groups to implement an integrated model of heart failure care to enhance care quality and promote more efficient resource use (Heart Failure Policy Network, 2020[228]). In Ireland, a HF referral pathway is being implemented nationally, including an electronic referral system and virtual consultations between cardiologists and GPs (Heart Failure Policy Network, 2020[228]).
Primary care plays a critical role in improving outcomes for people living with heart failure, particularly when integrated into multidisciplinary care models. Observational studies from Spain, Sweden and France have shown that strong collaboration between hospitals and primary care can reduce heart failure readmissions by up to 20% (Raat et al., 2021[230]). However, only a minority of multidisciplinary heart failure programmes actively involved primary care professionals, highlighting a missed opportunity for more co‑ordinated care (Raat et al., 2021[230]) (Figure 6.10).
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Implementation of heart teams varies widely across Europe
The heart team approach, well established in European and other international clinical guidelines, enables a patient-centred and tailored therapeutical approach and long-term management for patients with complex cardiac conditions, while fostering multidisciplinary collaboration and promoting research and innovation (Scott-Herridge et al., 2022[231]). Dedicated heart teams, which are specialised on specific cardiac conditions, are recommended for various cardiac diseases, given the increasingly clinical complexity of patients and the development of new treatment approaches and devices. Previous studies have shown improved outcomes when patients with specific cardiac pathologies were evaluated by dedicated heart teams, such as mitral valve disease (Sardari Nia et al., 2021[232]), while further research is needed to define best practices and document their impact on efficiency of care delivery and patient experiences and outcomes (Batchelor et al., 2023[233]).
An European survey assessing the execution of heart teams across 26 countries showed wide variability in the composition and adoption of heart teams across Europe (Imran Hamid et al., 2023[234]). The existence of a regional referral system was reported by 50% of the respondents, 77% reported lack of re‑imbursement for the heart teams meetings, and 67% acknowledged a lack of auditing process for heart team decisions (Imran Hamid et al., 2023[234]). In the 2025 OECD Cardiovascular Policy and Data Survey, nine countries reported the use of heart teams to manage specific cardiac pathologies (Figure 6.11).
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
6.7.3. Stroke care – Improving patient care across the stroke care pathway, with timely, standardised and co‑ordinated care
Ensuring the provision of dedicated stroke teams and stroke units promotes acute stroke care standardisation
Evidence‑based pathways guide national stroke care, ensuring equal access irrespective of region, time of hospitalisation, and patient characteristics. Stroke units are defined by the European Stroke Initiative as organised in-hospital facility that is mostly or entirely devoted to care for patients with stroke, staffed by a multidisciplinary team knowledgeable in stroke care (see Chapter 4). Dedicated “stroke units” (SU) are the first level of care for both types of strokes, ischemic and haemorrhagic. Irrespective of age and stroke severity, treatment in dedicated stroke units significantly reduces the risk of death, institutional care and disability (Stroke Unit Trialists' Collaboration, 2013[235]). Comprehensive or primary “stroke centres” (SC) are “fully equipped institution providing the same service as an stroke unit, and in addition offering thrombectomy and other neuro-radiological and surgical interventions” (Waje-Andreassen et al., 2018[236]). Involvement of stroke teams reduces delays, particularly when the team is pre‑notified that the patient will arrive.
Improving the performance of local stroke centres and the referral pathway can play a part in developing efficient and effective ischemic stroke care. Current care pathways for patients with suspected large vessel occlusion strokes often include pre‑hospital triage decisions that either send patients directly to a facility equipped for mechanical thrombectomy (usually comprehensive stroke centres) or to a closer hospital that lacks endovascular treatment capabilities but can administer intravenous thrombolysis (acute/primary stroke centres or telestroke centres). Studies assessing the difference in outcomes of these strategies have showed mixed results. Some showed lower mortality and better functional outcomes of patients directly admitted to Comprehensive Stroke Centres (Venema E, 2019[237]). The Rapid Arterial Occlusion Evaluation Trial (RACECAT), conducted in Spain (LINNC, 2023[238]) showed similar outcomes for people triaged direct to the Comprehensive Stroke Centre when compared to those who were initially treated at an acute stroke unit, although the door in-door out times in this trial were remarkably short. A randomised clinical trial assessing the influence of the characteristics of the local stroke centres on the optimal initial transport strategy concluded that the centre characteristics and performance may influence patients outcomes (Olive‐Gadea et al., 2024[239]). The decision on whether direct transport to a thrombectomy-capable stroke centre is superior to transport a closer local stroke centre remains a subject of intense research. Hospital characteristics, such as the level of care of the local stroke centre and the delay to systematic thrombolysis, are important factors, thus improving the performance of stroke centres remains an avenue to help improve overall outcomes.
Unfortunately, when I arrived at the stroke unit (after being misdiagnosed), I was already outside the window of time to perform thrombolysis or thrombectomy. My survival is a miracle! Despite having lasting aftereffects for the rest of my life, if today I am able to walk unassisted, drive, and take care of my children, it is thanks to family support and intensive rehabilitation for months after the stroke.
Diana, 48, stroke survivor.
To optimise the stroke pathway, formal mechanical thrombectomy networks have been established in the UK to streamline patient transfer, minimise treatment times and optimise outcomes (Halvorsrud et al., 2018[240]). Mechanical thrombectomy networks include the ambulance services, professionals from the referring Acute Stroke Centres and professionals from the comprehensive stroke centres performing the mechanical thrombectomy. Furthermore, effective networks include monitoring of quality standards, allowing for a regular review of protocols to improve quality (Mortimer et al., 2021[241]).
Designing stroke care networks based on the level of the expertise and performance in each centre helps reduce regional inequalities
Stroke care networks help reduce regional inequalities in access to thrombolysis and thrombectomy in patients with acute ischemic stroke. Stroke care networks allow lower-care‑level hospitals located in remote areas to be associated to hospitals equipped with specialised stroke units and stroke centres (Schoenfelder et al., 2021[242]). These specialised hospitals may also provide additional assistance such as continued training and quality management. Stroke care networks are being implemented in several EU+2 countries (Figure 6.12).
Since the 1990s, the Netherlands has promoted integrated stroke care through regional networks linking hospitals, rehabilitation centres, and primary care. This approach has improved outcomes, with more patients returning home and less reliance on home care. A study assessing the performance of the design of stroke care networks in Bavaria, Germany, proposed improvements in the stroke network design in Bavaria to reduce average travel distances (Schoenfelder et al., 2021[242]). In Ireland, the National Clinical Programme for Stroke is developing a two‑centre model to meet the country’s needs for endovascular treatment of stroke. Plans for expanding services will be guided by national data collected by the Irish National Audit of Stroke and the National Thrombectomy Service.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Telemedicine can be a useful tool in stroke. In particular, in connecting local centres to hospitals with strong neurological expertise, helping to reduce regional and rural disparities in care (see also Chapters 4 and 5). Through telemedicine, local physicians can consult with expert stroke physicians, transmit digital brain images and decide next steps. If needed a real-time clinical examination of the patient can also be performed via videoconferencing. Telemedicine enables the coverage of large areas, not densely populated, increasing the use of evidence‑based care across all European regions and countries where there is no onsite expertise (Hubert et al., 2018[243]). When compared to traditional models of care, telestroke networks have been shown to be cost-effective and carry the potential to reduce regional inequalities of acute stroke care (Schoenfelder et al., 2021[242]). A German study evaluating a 10‑year experience of telestroke units as a model of care in rural areas showed a substantial increase in the number of stroke patients treated in telestroke units (from 19% to 78%), in the proportion of intravenous thrombolysis (from 3% to 16% of patients with ischemic stroke) and shorter treatment times (Müller-Barna et al., 2014[244]). Estonia, Ireland, Germany, Norway and Slovenia are using of telemedicine to connect remote regions with stroke teams (Figure 6.12).
Mobile Stroke Units (MSUs) are specialised ambulances equipped with CT scanner, lab testing, and telemedicine, staffed by stroke‑trained teams. MSUs improve prehospital care of people with suspected stroke, with relevant reductions in time to thrombolysis, and may facilitate prehospital triage directly to comprehensive stroke centres (Walter et al., 2022[245]). European guidelines recommend MSUs over conventional care for suspected stroke cases, with evidence supporting their cost-effectiveness in densely populated regions (Oliveira Gonçalves et al., 2023[246]). France, Germany, Norway have implemented MSUs (Figure 6.12). A Norwegian study found that optimising the base location of a MSU in the Oslo area could improve patient coverage by 17% compared to the current site and shorten treatment times (Markhorst et al., 2025[247]). This study highlighted the importance of careful site selection for the MSUs to maximise timely treatment and improve outcomes.
Standardising post-acute stroke care delivery is crucial to improve outcomes
A systematic review assessing integrated care in stroke, showed that it improved quality of life, reduced the risk of recurrent strokes, and reduced anxiety and depression, with some favourable effect on certain cardiovascular risk factors (Eustace et al., 2025[248]). Nonetheless, a standardised definition of the components of integrated care in stroke lacks consensus, in both acute and post-acute settings, and additional research is needed to identify which specific components offer the greatest benefits. A post-stroke ABC pathway was proposed as a holistic approach to integrated stroke care, including three components: A) Appropriate antithrombotic therapy; B) Better functional and psychological status; C) Cardiovascular risk factors and comorbidity optimisation. Full adherence to the ABC stroke pathway showed a significant reduction in stroke recurrence (Sagris et al., 2024[249]) and a reduction in the risk of adverse outcomes (Tsang et al., 2024[250]).
Managing medications has been a challenge, especially given the side effects and the need for frequent adjustments. For example, blood-thinning medication may have contributed to my electrical storm episodes. Clearer communication about medication risks and benefits, as well as regular follow-ups, are essential for effective management.
Caius, artist, researcher, patient advocate, and heart attack survivor.
Although the importance of standardised and co‑ordinated post-stroke care and follow-up after rehabilitation is clear, the availability of these services remains limited. These structured programmes can enhance the overall quality of care through reducing the inconsistencies in patients care pathways. They also play a key role in informing quality standards, enabling benchmarking of services against standards. In Italy, the Friuli-Venezia Giulia region has developed a comprehensive care pathway for stroke spanning the pre‑hospital, hospital, and post-hospital care (The Health Policy Partnership, 2021[251]). The post-acute phase includes services delivered in community settings, outpatient clinics, residential facilities, and rehabilitation centres. The discharge process includes patient and caregiver education, co‑ordinated multidisciplinary medication management, standardised discharge documentation, and a clear overview of community-based follow-up care.
6.8.1. People‑centred care entails co-production and shared decision making
People‑centred care acknowledges that medical care is integrated within individual context and preferences (Ekman et al., 2011[252]), promoting shared decision making (NEMJ, 2017[253]), and prioritising physical and emotional well-being. It entails key elements: voice, choice, co-production, respectfulness and integration. People centredness is positioned at the core of health system in the OECD’s Health System Performance Assessment Framework, recognised as both a health system objective and an instrument to achieve other policy objectives (OECD, 2024[1]).
The first European standard on person-centred care, initiated by the University of Gothenburg’s Centre for Person-centred Care, was in 2020 by the European Committee for Standardization (CEN) (GPCC, 2024[254]). It outlines minimum requirements for patient involvement for patient involvement across care delivery, research, and in the design and implementation of quality indicators. It focus on patient narratives, partnerships, care planning, and public engagement. Ongoing research is essential to evaluate its practical and policy impact (Stjernswärd and Glasdam, 2022[255]).
In the 2025 OECD Cardiovascular Policy and Data Survey, eight of the EU27+2 countries reported that citizen or patient representatives were involved in developing policies related to access and quality of CV care. However, only four European countries reported citizen or patient representatives participating as co-designers (Figure 6.13). Estonia promotes participatory practices by involving patient representatives in policymaking and through patient advisory boards in public hospitals. In France, patient representatives contribute to national health policy through various committees. Norway also involves patients in the development of national guidelines, though not always in clinical guideline creation. In Slovenia, patient organisations are generally engaged in working groups that design healthcare regulations and policies. In Canada, people with lived experience contribute to the development of the Canadian Stroke Best Practice recommendations and participate in provincial planning and hospital advisory committees.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom).
Source: 2025 OECD Cardiovascular Policy and Data Survey.
6.8.2. People‑centred cardiovascular care improves patient experiences and outcomes, yet lacks widespread adoption
The operationalisation of people‑centred care across the entire CV care pathway includes various components across healthcare settings. According to the Gothenburg Centre for Person-Centred Care, three main routines should be considered, namely: 1) to establish a person-provider partnership, where the person’s personal description of symptoms and impact on quality of life is the starting point; 2) to maintain the partnership, ensuring shared decision making throughout the care pathway, and jointly agreed goals are set and monitored, 3) to safeguard the partnership, by documenting patient values, preferences and involvement in decision making in patient records (Britten et al., 2020[256]).
Ensuring people‑centred care in the management of people suffering from CVD improves patient outcomes and quality of life. A study assessing the outcomes of patients hospitalised with worsening chronic heart failure treated according to principles of person-centredness care, showed shorter length of hospital stay and improved functional performance, when compared to usual care (Ekman et al., 2011[257]). Person-centred care approach after an acute coronary syndrome improved patient-reported outcomes in a previous trial, such as return to work (Fors et al., 2017[258]), as well patient experiences regarding the information received (Wolf, Vella and Fors, 2019[259]). In this Swedish clinical trial (Wolf, Vella and Fors, 2019[259]), the person-centred care approach developed by the Gothenburg Centre for Person-Centred Care showed positive effects on patient experiences, which were more marked among lower educated individuals (Wolf, Vella and Fors, 2019[259]).
Despite its benefits and the broad acknowledgement of person-centred care as a relevant component of care, this practice is not systematically practiced nor documented (Ekman et al., 2011[252]). Healthcare professionals’ perception of person-centred care has been described as an extremely complex innovation and as an abstract notion (Fridberg, Wallin and Tistad, 2021[260]). In Sweden, laws and policies supporting the patient as a central actor in the communication with healthcare professionals have been put in place to help ensure the patient is viewed as a co-producer of health and care (Hedberg et al., 2022[261]).
Guidance to patients and providers may support people‑centred care. The Gothenburg Centre for Person-Centred Care has developed tools for person-centred care, such as online courses, conversation guides to support professionals interacting with adults with heart failure and fragile elderly patients, and health planning documents and tools for evaluation and measurement (GPCC[262]). A Dutch half-year pilot study in primary care, showed that a programme offering professionals training and tools to organise integrated and person-centred care for chronically ill patients was feasible and acceptable (Smeets et al., 2023[263]). Team commitment and strong network ties were found crucial for effective implementation.
6.8.3. Shared decision making is key for people‑centred care and could be further prioritised
Shared decision making (SDM) is a cornerstone of patient-centred care, particularly in the management of CV diseases such as heart failure, atrial fibrillation, and coronary artery disease. It entails professionals and patients working jointly to make informed choices tailored to personal preferences. Evidence shows that shared decision making improves treatment adherence, patient satisfaction, and health outcomes. The American Heart Association’s guidelines emphasise SDM as a way to ensure the communication with patients allows to make healthcare decisions tailored to each individual (AHA, 2023[264]).
I have appreciated healthcare professionals who engage in clear communication and involve me in decisions about my care. Education classes and patient training programs have been valuable but are not always widely available. Having a care plan co-developed with my care team helped me manage medications and lifestyle changes better, though such plans are not standard everywhere.
Antonis, 58, congenital heart disease patient and advocate for digital health and patient empowerment.
Germany’s SHARE TO CARE program, implemented in one of the ten largest university medical centres in Germany, across 22 departments supports shared decision making through physician and nurse training, patient activation, and decision aids (SHARE TO CARE[265]). It proved feasible within a period of four years (2018-2021) and effective hospital-wide, with improved patient-reported involvement in care. As a result, SDM is now reimbursed by major insurers, and a national rollout has been recommended by the German Federal Joint Committee (Scheibler et al., 2023[266]). In England, the NHS has developed decision support tools tailored to specific conditions, aiming to embed SDM into routine practice.
6.8.4. Innovative self-management interventions may improve long-term outcomes in a cost-effective manner
Self-care can be defined as a “process of maintaining health through health promoting practices and managing illness” (Riegel, Jaarsma and Strömberg, 2012[267]) and it is a key component to improve health and quality of life (AHA, 2017[268]). The Theory of Self‐care of Chronic Illness has evolved from clinical practice with heart failure patients and addresses the prevention and management of chronic conditions, including three core elements: self‐care maintenance, self‐care monitoring, and self‐care management (Riegel, Jaarsma and Strömberg, 2012[267]) (Figure 6.14). Self-care implies individuals, families and communities to maintain health through health-promoting behaviours and to be able to manage illness.
Source: Adapted from AHA: (2017[268]), “Self‐Care for the Prevention and Management of Cardiovascular Disease and Stroke”, https://doi.org/10.1161/jaha.117.006997 and Riegel, Jaarsma and Strömberg (2012[267]), “A Middle-Range Theory of Self-Care of Chronic Illness”, https://doi.org/10.1097/ans.0b013e318261b1ba.
Evidence shows that self‐care interventions focussed on lifestyle changes may improve outcomes in coronary heart disease (AHA, 2017[268]). A meta‑analysis to evaluate stroke self-care programmes showed improvements in quality of life and self-efficacy when compared with usual care (Heneghan et al., 2012[269]). Regarding hypertension, studies also show that self-care monitoring is an effective mean to improve treatment adherence and reduce blood pressure.
Patients diagnosed with HF need to perform lifestyle adjustments to be able to monitor symptom changes, adhere to daily medication and prevent deterioration (ESC, 2011[226]) and frequently have multiple comorbidities. A literature review assessing the effectiveness of self-management strategies in heart failure patients has shown a significant effect on mortality at half- and one‑year follow-up, as well as the cost-effectiveness of these strategies (Koikai and Khan, 2023[270]).
Some studies have showed the feasibility and cost-effectiveness of innovative methods to increase adherence to self-management, such as home‑based interventions, telemonitoring and the use of mobile telephone applications. An intervention including home‑based care and support to caregivers was considered feasible and contributing to enhance symptom perception in people with heart failure (Santos et al., 2023[271]). A Dutch randomised controlled trial assessing the impact of personalised telemonitoring on heart failure patients, found that it was feasible to educate patients and improve their ability to self-care (TEHAF, 2013[272]).
Only Ireland has reported implementing health literacy initiatives aimed at promoting self-care and shared decision making, while five European countries have indicated that such initiatives are under development (Figure 6.15). Ireland has established a Decision Support Service to aid individuals in making or sharing health-related decisions, with over 3 000 agreements in place as of March 2025. France introduced ”Mon bilan prévention”, a personalised prevention programme encouraging proactive health management in key phases of life, where individuals meet with a healthcare professional to identify risk factors, assess lifestyle habits, and receive tailored advice related to self-care. The United Kingdom promotes self-care through NHS initiatives and British Heart Foundation resources available online. In Latvia, the Cardiovascular Health Action Plan adopted in mid-2025 (2025‑2027) includes incentives to support self-care practices. Sweden incorporates self-care into its national, regional, and local strategies on integrated care delivery.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom), only 11 countries provided responses to this item.
Source: 2025 OECD Cardiovascular Policy and Data Survey.
6.8.5. Enhancing patient experiences and quality of life requires strong investments in discharge planning, self-management and rehabilitation
Implementation of early supported discharge and community rehabilitation programmes varies greatly across Europe, though evidence suggests their safety and cost-effectiveness
Primary care‑oriented systems contribute to improve population health by preventing acute deterioration in people living with three chronic conditions, including congestive heart failure (OECD/The Health Foundation, 2025[202]). Cardiovascular conditions comprise a relevant burden to primary care patients aged 45 years or older: In the PaRIS survey, cardiovascular conditions were the third most frequent diagnosis among men (27%) and women (17%), followed by diabetes (23% and 15%) (OECD, 2025[3]).
My healthcare journey has been a rollercoaster. While I am grateful for the expertise of the doctors who treated me, I often felt like a passive participant in my care. There was a lack of communication and shared decision-making, which left me feeling disconnected at times. I believe that involving patients in their care plans and providing tailored education can significantly enhance the healthcare experience.
Caius, artist, researcher, patient advocate, and heart attack survivor.
Early supported discharge aims to accelerate the discharge of stroke patients from hospital by offering specialised rehabilitation and social care at home, with a multidisciplinary team support (Waje-Andreassen et al., 2018[236]). Several countries are implementing early discharge protocols across Europe (Figure 6.16). For stroke, this practice is established in only a few countries, such as Sweden, Ireland and the United Kingdom, despite local variations (SAFE[273]). Early discharge after ST-segment-elevation myocardial infarction (STEMI), 24‑48 hours after treatment, may offer benefits both for patients and the healthcare system, however it has not yet gained widespread adoption. Various studies showed that an early discharge strategy after STEMI after primary PCI was safe 30 days after discharge among selected low-risk patients (Piris et al., 2024[274]; Rathod et al., 2021[275]; Yndigegn et al., 2022[276]) and cost-effective (Rathod et al., 2025[277]). Nonetheless, it is crucial to ensure follow-up support from a cardiac rehabilitation team, and ensure that patients or caregivers have clear understanding of treatment and ongoing management.
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom), only 12 countries responded to this item.
Note: In response to the question ‘Since 2020, has your country implemented any of the following policies (…)? Regulatory frameworks of new models of CV care delivery: (specifically) Early discharge protocols after stroke, acute coronary syndrome, heart procedures”. The disaggregate data per country, specifying which conditions these protocols apply to is not available.
Source: 2025 OECD Cardiovascular Policy and Data Survey.
Rehabilitation and lifelong management are essential and cost-effective components of tertiary prevention for people with cardiac diseases and stroke (Anderson and Taylor, 2014[278]). Cardiac rehabilitation is a multidisciplinary supervised programme involving tailored exercise and education focussed on improving lifestyle habits and reducing health risks for individuals with heart conditions (Khadanga et al., 2024[279]). Cardiac rehabilitation can improve the quality of life of patients diagnosed with HF, relieving symptoms and improving exercise capacity, as well as reducing both all-cause and HF specific hospitalisations (ESC Guidelines, 2021[221]). While exercise is recommended for all patients who are able to in order to improve their quality of life and reduce HF hospitalisations, the ESC recommend “supervised, exercise-based cardiac rehabilitation programmes should be considered in patients with more severe disease, frailty or other comorbidities” (ESC Guidelines, 2021[221]).
The availability of cardiac rehabilitation is not widely available across Europe (see Chapter 4) and lack of referral to cardiac rehabilitation has been identified as a key barrier hindering participation of eligible patients (Khadanga et al., 2024[279]). Ireland has implemented a Model of Care for Integrated Cardiac Rehabilitation for people living with CVD (Box 6.15).
Post-stroke disability is a key contributor to long-term healthcare resource use, thereby strengthening rehabilitation services may reduce healthcare costs. Nonetheless, access to rehabilitation services after stroke varies greatly across Europe. Stroke survivors frequently face problems with speech, mobility or speech, and require multi-disciplinary support. Few countries monitor rehabilitation provision at hospital level and even less monitor this service at the community level (SAFE[273]).
Ireland’s Model of Care for Integrated Cardiac Rehabilitation sets out an evidence‑based approach for the delivery of a high-quality, equitable and person-centred cardiac rehabilitation service for those living with CVD (HSE, 2023[280]).
A person-centred approach
To optimise recruitment and retention and enhance participant experience, the model promotes a person-centred approach (BACPR, 2023[281]; ESC, 2022[282]).The model also places a focus on enhancing referral to, and attendance at, cardiac rehabilitation for those who are traditionally under-referred, such as women, older patients and marginalised groups (ESC, 2018[283]; Castellanos, 2019[284]; Ruano-Ravina A, 2016[285]; Resurrección DM, 2017[286]).
leveraging Ireland’s national health policy
The Model of Care aligns with Sláintecare – Ireland’s roadmap to deliver a sustainable universal health and social care service – and constitutes a foundational component of the National Framework for the Integrated Prevention and Management of Chronic Disease, which describes a continuum of care from health promotion and disease prevention through to proactive disease management, rehabilitation and palliative care (Department of Health, 2023[287]; HSE, 2020[288]). The National Framework aims to shift care from a reactive, hospital-centric approach to a more integrated, population-based approach for the prevention and management of chronic disease (HSE, 2020[288]).
Implementation
The Model of Care for Integrated Cardiac Rehabilitation was developed by a multi-disciplinary expert group with representation from cardiologists, nurses, health and social care professionals, psychologists and patient groups. To drive implementation, a national needs assessment for cardiac rehabilitation was undertaken to understand the resources required to meet population needs and to identify the barriers and facilitators to implementation. Funding has been provided to implement and evaluate the full end-to‑end Model of Care for Integrated Cardiac Rehabilitation in the West of Ireland in 2025 and 2026, with a view to supporting national scale‑up of the service thereafter.
Embedding rehabilitation in national guidelines, standardised care pathways and innovative delivery models may foster rehabilitation provision across Europe
Alternative solutions and interventions to enhance cardiac rehabilitation (CR) delivery can enhance attendance, such as hybrid CR (includes in-facility and at-home or community-based CR), home‑based CR, automatic referral at time of discharge, patient education and financial incentives (Khadanga et al., 2024[279]). Home‑based cardiac rehabilitation may provide an effective and more affordable alternative to centre‑based rehabilitation (Claes et al., 2016[289]). In a multicentre randomised clinical trial in England, a home‑based cardiac rehabilitation intervention tailored to people with HF and their caregivers was evaluated as an alternative to traditional hospital-based programmes (Dalal et al., 2018[290]). This study showed better outcomes in quality of life and self-management when compared with usual care. The possibility to provide tele‑supervised rehabilitation for heart failure patients is also promising, with some studies reporting favourable effects of its implementation (Piotrowicz et al., 2016[291]). Home‑based point-of-care technologies and wearable devices may enhance the quality and accuracy of follow-up data (Norrving et al., 2018[292]) (see Chapter 5).
Only a handful of countries are systematically developing regulatory frameworks for the systemic use of home‑based care (Figure 6.17). Estonia’s national policy mandates that care homes provide 24/7 support for individuals unable to live independently. Local governments are responsible for assessing care needs and co-financing care home services. The CardiacCare@Home project, led by Radboudumc in the Netherlands, aims to improve heart failure care at home through technology development and AI-driven monitoring. Its main goals are to reduce hospital admissions by enabling early detection of heart failure worsening, support home‑based rehabilitation, and ultimately enhance patients’ quality of life, while lowering workload at the hospital (Radbound UMC, 2024[293]).
Note: N=19 EU+2 and OECD G20 countries (Austria, Canada, Croatia, Czechia, Estonia, Finland, France, Germany, Iceland, Ireland, Japan, Latvia, Luxembourg, the Netherlands, Norway, Slovenia, Sweden, Türkiye, the United Kingdom), only 10 countries responded to this item.
Source: 2025 OECD Cardiovascular Policy and Data Survey.
In Denmark, a national clinical guideline for cardiac rehabilitation was launched in 2013 as a result of a national political agreement, alongside a national clinical quality database for CR (Lindström Egholm et al., 2018[294]). Improvements in adherence at hospital level were noted, while no general improvement was observed at the community level, suggesting that tailored initiatives to specific settings may be needed to support implementation. In Ireland, cardiac rehabilitation is a key component of the Model of Care for the Integrated Prevention and Management of Chronic Disease, implemented in Ireland (2020-2025). Specialist ambulatory care hubs have been established since 2020 in Ireland, which includes hospital and community-based staff, collaborating to provide rehabilitation services (HSE, 2023[280]).
Return-to-work programs can be better integrated into national policies
CVD frequently impact work ability, with return-to-work rates varying across countries and patient groups (Sadeghi et al., 2022[295]; Rørth et al., 2016[296]). A study suggested that returning may be harder for people suffering from with heart valve disease or heart failure than for people diagnosed with atrial fibrillation or ischemic heart disease (Bernt Jørgensen et al., 2022[297]). A Danish nation-wide study reported that among working-age patients, employed before admission, who experience a first‐time myocardial infarction, 91% had returned to work within one year (Smedegaard et al., 2017[298]). However, after their return, 24% were detached from employment and receiving social benefits. Factors associated with detachment from employment included heart failure, diabetes, and depression. Individuals with higher levels of education and income were more likely to remain in the workforce. A multicentre prospective cohort study between 2013 and 2021 reported that, among young individuals who experienced a first ischemic stroke, significant vascular cognitive deficits and slower processing speed during the subacute phase were independently linked to being unemployed. However, these factors did not appear to affect the ability to maintain employment (Schellekens et al., 2025[299]).
Cardiac rehabilitation has a relevant role in facilitating returning to work (Sadeghi et al., 2022[295]) and international guidelines recommend including vocational counselling as part of rehabilitation programmes. Nonetheless, research on long-term return-to-work effectiveness remains limited, notably the effectiveness of workplace‑focussed interventions. Combined cardiac rehabilitation programmes interventions (including physical and psychological aspects) may improve return to work within six months among individuals diagnosed with coronary heart disease (Hegewald et al., 2019[300]). A clinical trial assessing the effect of an extended case‑management rehabilitation intervention showed a relevant positive impact on the return-to-work of myocardial infarction (MI) patients and in increased probability of maintaining employment at one and two years of follow-up (Zack et al., 2022[301]).
Most European countries lack clear guidelines (Reibis et al., 2019[302]) and there is a wide variety of rehabilitation and return-to-work policies, due to heterogeneous legal, institutional, and cultural frameworks (EAPC, 2019[303]). A comparative review of rehabilitation laws, policies and national action plans in Sweden, Italy, Germany, the Netherlands, and the United Kingdom revealed that disease‑specific policies across these countries consistently state rehabilitation as a core component of healthcare. However, a gap between legal entitlements to universal rehabilitation coverage and policy implementation was identified (Garg, Skempes and Bickenbach, 2020[304]). Germany’s Operational Integration Management is legally mandated since 2004 and supports employees returning to work after extended illness (more than six weeks) (Box 6.16). In the Netherlands, return-to-work programmes are embedded within a structured legal framework that emphasises early intervention and co‑ordinated reintegration. Under the Eligibility for Permanent Incapacity Benefit (Restrictions) Act (“Wet verbetering poortwachter”), employers are legally required to initiate a reintegration process if an employee is ill for more than six weeks. This includes creating a reintegration dossier, conducting regular progress meetings, and developing a tailored action plan in collaboration with occupational health professionals (RVO[305]).
In Germany, return-to-work policies are embedded within a comprehensive social insurance framework, primarily managed by the German statutory pension insurance (GPI). Individuals are legally entitled to medical and vocational rehabilitation if certain conditions are met, with rehabilitation being prioritised over early retirement (Hetzel et al., 2023[306]). Most interventions are delivered through 3‑ to 4‑week inpatient, outpatient or semi‑inpatient options. During rehabilitation, employees receive continued wage payments for up to six weeks, after which the GPI provides transitional benefits.
Germany’s Operational Integration Management (OIM) targets employees absent for more than six weeks within a year. Employers are required to offer OIM, but participation is voluntary. The reintegration process includes a systematic assessment of health-related limitations and corresponding workplace adjustments. It is co‑ordinated by the company’s case manager and carried out in collaboration with staff and works council representatives, as well as treating physicians, therapists and occupational health service, where appropriate. Its implementation varies, with limited uptake in smaller enterprises (BAuA[307]) .
Germany’s four‑phase reintegration model is a stepwise approach promoting sustainable work reintegration through continuous and tailored support. Initially developed to tackle mental health problems, it has broader applicability, and entails: 1) co‑orientation, fostering trust and identifying necessary resources, 2) co‑ordination, focussing on organising interventions, 3) co‑operation, supporting the actual return to work and 4) renewed co‑orientation, to sustain performance and work ability.
Source: (BAuA[307]; Hetzel et al., 2023[306]).
Occupational safety and health strategies and systems policies from 32 European countries were analysed in the context of the European Parliament’s pilot project “Safer and healthier work at any age – occupational safety and health in the context of an ageing workforce”, launched in 2012 (EU-OSHA, 2022[308]). Effective return-to-work policies share several characteristics, according to this analysis, including legal frameworks covering all aspects of the process, effective co‑ordination mechanisms, and incentives for employers and workers (Box 6.17).
An analysis across 32 European countries under the European Parliament’s pilot project “Safer and healthier work at any age – occupational safety and health in the context of an ageing workforce”, identified essential prerequisites for establishing an effective national return-to-work system:
Holistic systems targeting all workers: Expanding support to all workers, enabling early, tailored interventions for those returning from medium- or long-term sickness.
Embedding within the broader policy framework: Embedding return-to-work within broader policy frameworks to ensure cross-sectoral co‑ordination including employment, health, safety, social protection, and education sectors. Joint budgeting may enhance co‑ordination and efficiency.
Co‑ordinated systems with workplace at core: Strengthening co‑ordination among healthcare providers, rehabilitation services, and the workplace as a central actor.
Financial and technical support for workplaces: Providing financial and technical assistance, especially for small enterprises, to implement effective reintegration strategies.
Awareness: Promoting understanding of return-to-work strategies through company culture and intermediary actors.
Research gaps: Addressing gaps in implementation, small business practices, groups living in vulnerable situations, and EU-level data harmonisation on sickness absence and return-to-work rates.
Source: EU-OSHA (2022[308]), Rehabilitation and return-to-work polices and systems in European Countries - OSHwiki | European Agency for Safety and Health at Work, https://oshwiki.osha.europa.eu/en/themes/rehabilitation-and-return-work-polices-and-systems-european-countries#_edn1.
6.8.6. Measuring what matters for people with CVD may accelerate people‑centred improvements across the care pathway
Condition-specific PROMs for CVD have the potential to improve clinical practice
CVD symptoms frequently have a negative impact on health-related quality of life and are associated with reduced physical competence, as well as emotional stress (de Leon et al., 2009[309]). Patient-reported outcome measures (PROMs) are a key component of people‑centred clinical practice and evaluate health domains such as symptoms, health-related quality of life, and health behaviours, allowing to tailor treatment to patient needs. PROMs are frequently administered longitudinally at different moments in time to monitor outcomes trends. The International Consortium for Health Outcomes Measurement (ICHOM), established in 2012, gathers research, clinical and patients experts from around the world to standardise and promote patient-centred outcomes measurement (Bright et al., 2025[310]). It has published 46 standards, covering 60% of the global burden of disease (Bright et al., 2025[310]).
While generic tools allow comparison across clinical conditions, disease‑specific tools present greater face validity to guide improvements at the disease level. Various studies recommend using generic and condition-specific instruments simultaneously to assess PROMs (Rumsfeld et al., 2013[311]; Abdalla et al., 2022[312]). A literature review aiming to identify heart-disease‑specific PROMS, identified several PROMs instruments for various heart diseases, namely coronary artery disease, valvular and structural heart interventions, percutaneous coronary intervention, congestive heart failure, adult congenital heart disease, peripheral vascular and arterial disease, and one related to arrhythmia management, which present a relevant potential to tailor cardiovascular care to each patient needs and expectations (Kornowski, 2021[313]) (Box 6.18).
Stable coronary heart disease: PROMs may contribute to better define the patients’ expectations from the available treatment strategies, to improve physicians reliability to grade PCI appropriateness, and potentially predict long-term cardiac prognosis of patients who underwent PCI. A study that collected PROMs pre‑percutaneous coronary intervention and at 30‑days after the procedure, showed similar symptom improvements regardless of the appropriateness defined by physician assessments (Yang et al., 2019[314]), signalling the potential value of PROMS to improve the evaluation of PCI appropriateness made by physicians.
Valvular and structural heart interventions: PROMs may contribute to individualise outcome predictions in high-risk patients. Studies have shown a misalignment between the measured benefits of transcatheter aortic valve implantation (TAVI) and the perceived benefits by the patients who underwent the procedure, underscoring the value of TAVI even for patients to whom the heart team deemed the treatment futile.
Atrial fibrillation: The inclusion of PROMs as endpoints in clinical trials and their routine collection in practice may contribute to enhance care experiences and monitor outcomes. Intervention studies have shown an association between improvement in PROM scores and a decrease in the burden of AF and related symptoms (Steinberg and Piccini, 2019[315]; RATE-AF, 2020[316]). AF-specific questionnaires still lack sufficient validation of their measurement properties (Kotecha et al., 2016[317]; Ogendo et al., 2025[318]). A recent study has developed and validated the Atrial Fibrillation Patient-Reported Outcome Measures (AF-PROMs) Questionnaire in the United Kingdom, to measure the quality-of-life of AF patients (Kanthasamy et al., 2025[319]), which may be tested in clinical practice and research.
Congestive heart failure: The NYHA (New York Heart Association) classification, commonly used in heart failure (HF) care, offers a limited clinician-based view of patient health. Researchers have developed the PROMIS-Plus-HF tool, a PROM that captures physical, mental, and social health dimensions and allows customisation based on clinical or research needs (Ahmad et al., 2019[320]). The first randomised clinical trial assessing the impact of routine PRO evaluation in heart failure care found no impact on patient-reported health status at one year compared with usual care, underscoring the importance of continue evaluating the implementation of PROM in practice to monitor its impact on patient-reported data (Sandhu et al., 2024[321]).
Adult congenital heart disease: There is lack of disease‑specific PROMs for adults with congenital heart disease, due to the population’s clinical diversity and complexity. Researchers developed and validated the Adult Congenital Heart Disease – Patient-Reported Outcome (ACHD-PRO), a 33‑item tool covering physical, psychological, and quality-of-life domains. Further validation is needed to confirm its broader applicability in this patient group.
Diabetes: A Delphi study developed an outcome set for routine diabetes care, which was agreed by international key stakeholders and was tested and implemented in Europe in the context of the H2O project (Porth et al., 2023[322]; Kornowski, 2021[313]).
Some European countries are implementing PROMs to monitor cardiovascular care, yet challenges persist
The systematic collection and use of PROMs data can be facilitated by the integration of PROMs into data infrastructures such as patient portals and electronic health records, which is being implemented in some countries. This integration provides various advantages, namely the integration into clinical flows and real-time data collection. An OECD survey assessing the systematic collection and use of PROMs among OECD countries showed that about from the 55 programmes of PROMs data collection identified, eight programmes targeted people with CVD (Kendir et al., 2025[323])(Figure 6.18). Most of the programmes identified reported using both generic and condition-specific tools to measure patient outcomes. Estonia integrates PROMs into the clinical pathway for stroke. Germany has introduced a paper-based patient survey under the Federal Joint Committee’s directive for quality assurance in percutaneous coronary intervention and coronary angiography, launched in July 2022. In Canada, PROMs are used in cardiac rehabilitation to capture the experiences of people living with heart conditions. England employs the Long-Term Conditions Questionnaire to assess outcomes across various health conditions, including diabetes and heart disease.
In Austria, the “Therapie Aktiv: Diabetes Disease Management” programme collects PROMs electronically to support diabetes care. Sweden has developed a condition-specific questionnaire to evaluate PROM and PREM in patients with diabetes, a measure that was lacking in the Swedish National Diabetes Register (Svedbo Engström et al., 2018[324]). Denmark has also developed a national core set of diabetes outcome measures for routine use in clinical practice and has various sets of PROMs implemented to monitor various chronic conditions (Skovlund et al., 2021[325]; Skovlund et al., 2021[326]) (Box 6.19).
Note: The category “people with cardiovascular diseases” includes seven reported target populations, including people with valvular diseases, heart failure and coronary artery diseases. The category “people with cancer” includes nine reported target populations: people with breast, lung, colorectal, ovarian, cervical, head and neck, vulvar, uterine, oesophagus, stomach cancers). Some initiatives have multiple target populations.
Note: Programmes targeting individuals with other conditions represented by n ≤ 2 have been excluded from this figure for clarity. These account for a total of 53 programmes.
Source: Kendir et al. (2025[323]), “PROMoting quality of care through patient reported outcome measures (PROMs): Systematic collection of PROMs for quality improvement and assurance in 38 countries”, https://doi.org/10.1787/c17bb968-en.
Denmark is systematically monitoring condition-specific PROMs and is expanding to other conditions
Danish regions and municipalities collaborate to deliver integrated and preventive care services in a decentralised healthcare system. Denmark has taken a structured and progressive approach to implementing patient-reported outcome measures (PROMs) across its healthcare system. PROMs are currently used nationally in areas such as diabetes and cardiac rehabilitation. The “Interface PRO Diabetes” tool is designed to capture people‑centred outcomes that reflect the lived experience of managing diabetes, assessing patients’ daily life experiences, symptom burden, medication management, and blood sugar control. PROMs are also being piloted to monitor heart failure care, indicating a growing interest in expanding their use to other chronic conditions.
In addition to routine care, Denmark is exploring PROMs through research initiatives, such as a project focussed on developing stroke‑specific PROMs for patients with cognitive impairments.
Heart failure PROMs are monitored in Wales, as part of the broader “Value in Health” programme
In Wales, the implementation of patient-reported outcome measures (PROMs) for heart failure is a key component of the country’s “Value in Health” programme. The Heart Failure Service captures patients’ perspectives on their symptoms, quality of life, and treatment impact throughout their care journey. PROMs are collected at multiple points, including at referral, during treatment, and at follow-up, using digital platforms that integrate with clinical systems. This enables clinicians to monitor changes over time and tailor care to individual needs, while also generating data for service evaluation and improvement.
The PROMs Standard Operating Model (PSOM) in Wales provides a structured framework for collecting, managing, and using PROMs data across health services. In the heart failure context, this includes validated tools such as the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EQ‑5D, which assess both disease‑specific and general health outcomes. The data collected supports shared decision making, enhances communication between patients and providers, and informs resource allocation and policy decisions.
Source: Welsh Value in Health Centre (n.d.[327]), Case Illustration - Heart Failure Service - Value in Health, https://vbhc.nhs.wales/delivering-value/toolkits/education/patient-reported-outcome-measures-proms/case-illustration-heart-failure-service/?previewid=797FDA09-3623-4F99-8E6B1178E543EACD (accessed on 15 July 2025); Withers et al. (2020[328]), “First steps in PROMs and PREMs collection in Wales as part of the prudent and value-based healthcare agenda”, https://doi.org/10.1007/s11136-020-02711-2.; Welsh Value in Health Centre (n.d.[329]), PROMs Standard Operating Model (PSOM) - Value in Health, https://vbhc.nhs.wales/digital-health/data-products/proms-standard-operating-model-psom/ (accessed on 15 July 2025).
The Health Outcomes Observatory (H2O), co-funded by the European Commission, was conducted from October 2020 until September 2025. It aims to enhance the standardised collection of health outcomes and support their integration into healthcare decision making processes (Stamm et al., 2021[330]). This initiative established the first European scale network for health outcomes data, and the first H20 Observatories were Austria, Germany, the Netherlands, and Spain (H20[331]). Likewise, the OECD PaRIS survey is being used to examine the outcomes and experiences of patients with CVD who attend primary care (See Chapters 2, 3 and 4) (OECD, 2025[3]).
Improved patient experience has been associated with better cardiovascular health outcomes
Optimal patient experience has been associated with better health outcomes among patients with CVD Among patients with atherosclerotic CVD, an American study showed an association between optimal patient-centred care and various health outcomes, including quality of care processes and patient-reported outcomes (Okunrintemi et al., 2017[332]). Four key patient-centred domains to optimise patient-reported experiences among patients with CVD were identified in a previous review: 1): overall patient satisfaction, 2) access to a healthcare provider, 4) patient-provider communication, and 4) shared decision making (Okunrintemi and Nasir, 2020[333]). An Australian cross-sectional survey of patients who underwent elective cardiac catheterisation within the past six months found that fewer than 80% of those who rated certain aspects of care as “very important” or “essential” felt they actually received that level of care (Fakes et al., 2023[334])The identified gaps were related to the referral process, decision making process and prognosis information.
Patient-reported experience measures (PREMs) are collected through standardised instruments allowing to provide the patient’s perspective on care delivery, such as assessing information support, emotional support and patient involvement (Scholl et al., 2014[335]). A scoping review conducted to obtain an overview of PREMs used to capture patients’ experiences with digitally supported care processes in people suffering from heart failure (HF) (iCARE4CVD consortium, 2024[336]) showed that, in most cases, PREMs were assessed with self-developed and study-specific questionnaires which lacked standardisation and validity. To fill this gap in the field of catheterisation laboratory-based procedures, the European Association of Percutaneous Cardiovascular Interventions Patient Initiatives Committee from the ESC developed the “European Patient Experience in the Catheterisation Laboratory” PATCATH, a patient Reported Experience Measurements (PREM) questionnaire available in ten languages, aiming to characterise and improve these patients’ experience (ESC, 2024[337]). Further efforts are necessary to improve standardisation of questionnaires within and across countries to improve international comparability.
PREMs are being increasingly used to compare care providers and support accreditation, although standardising instruments could enhance comparability
In Sweden, the National Diabetes Register developed a diabetes-specific questionnaire to capture patient-reported outcomes and experiences – such as well-being, abilities, and perceptions of diabetes care (Borg et al., 2019[338]). Studies using registry data have shown that demographic characteristics have a significant influence on diabetic patients experiences and outcomes, which highlights the value of monitoring PROMs and PREMs to tailor care to specific populations (Sághy et al., 2025[339]). In France, since 2016, the e‑Satis survey by France’s “Haute Autorité de Santé” collects patient-reported experience measures across major hospital care pathways, including acute in-patient medicine, rehabilitation services, with some modules in development, such as home‑based care (HAS, 2025[340]). It generates a global satisfaction score out of 100 for each hospital and makes these results publicly available. These insights feed into national quality and safety indicators to help hospitals identify and address areas for improvement.
In Belgium, two large initiatives in the Flemish and French-speaking communities support hospitals in using PREMs (Desomer et al., 2018[341]). The French-speaking program, “Project ASPE: Attentes et Satisfaction des Patients et de leur Entourage”, has voluntary participation of hospitals and uses generic and domain-specific PREMs. It includes day hospitalisation and surgery and emergency department, among others. The programme provides several services to participants, such as regular benchmarking for some domains, an online platform closed to participant organisations to exchange experiences, board tables and scientific updates. These components promote cross-learning between participants and foster improvements in the quality of healthcare services. The Flemish initiative, “The Vlaamse Patiëntenpeiling”, covers the cardiology and stroke domains, besides other clinical areas. Feedback and benchmarking reports are provided to organisations and healthcare providers, while a selection of aggregate results is made public.
6.8.7. Resilience as a cross-cutting domain: Cardiovascular health services design need to be resilient to care for an ageing and diverse population
The COVID‑19 pandemic caused major disruptions in care delivery for people suffering from CVD, notably with delays in access to diagnosis and treatment, leading to worsening outcomes (de Lange et al., 2022[342]; CVD-COVID-UK Consortium, 2023[343]; Khan et al., 2023[344]). Geographical and socio‑economic variations in the detection and management of some conditions were reported in some studies (Castanon et al., 2023[345]), underscoring the importance of monitoring and tackling inequalities during crises. Considering the high burden of CVDs across Europe (see Chapter 2) and their life‑threatening, time‑sensitive nature, maintaining cardiovascular care priority during shocks that disrupt health systems is critical.
Resilience refers to the capacity of a health system to maintain its performance under extreme stress (OECD, 2023[346]). A resilience approach recognises that some shocks may overwhelm the entire health system, making it essential to prepare and absorb impacts, to recover and adapt for future challenges (Figure 6.19). In recent years, resilience has become a central concept in how countries assess and strengthen their health systems and several countries are integrating resilience into their health system performance assessment frameworks. Belgium has formally embedded resilience as a key dimension in its Health System Performance Assessment (KCE, 2024[347]; KCE, 2023[348]). Ireland is updating its Healthy Ireland framework to strengthen integrated care and adaptability (see Section 6.2).
Source: OECD (2023[346]), Ready for the Next Crisis? Investing in Health System Resilience, https://doi.org/10.1787/1e53cf80-en.
Several European initiatives are actively working to enhance health systems resilience (Table 6.7). The EU4Health Programme (2021‑2027) addresses cross-border health threats and overall system resilience. The Health Emergency Preparedness and Response Authority supports co‑ordinated EU responses to health emergencies. The RESIL-Card project (2023-2026) is developing a resilience assessment toolkit to strengthen European cardiovascular care pathways to face future crises.
Source: European Commission (n.d.[349]), EU4Health programme 2021-2027 – a vision for a healthier European Union, https://health.ec.europa.eu/funding/eu4health-programme-2021-2027-vision-healthier-european-union_en. We CARE (2025[350]), RESIL-Card marks major milestone with first cardiovascular resilience assessment tool - We CARE, https://www.wecareabouthearts.org/resil-card-marks-major-milestone-with-first-cardiovascular-resilience-assessment-tool/.
Key themes emerge as priorities for enhancing health systems resilience and cardiovascular care pathways in particular, enabling a comprehensive approach to support readiness for future crises (Box 6.20). These include strengthening workforce, clear governance, adaptable infrastructure, digital innovation, and supply chain resilience.
Strengthening cardiovascular care resilience requires focus on several key areas:
Promoting workforce recruitment, retention, flexibility and well-being,
Promoting infrastructure’s flexibility to accommodate more intensive care and to separate clean and dirty pathways during crises,
Prioritising the development of triage scales and prioritisation criteria for CVD patients to be applied during crises, ideally integrated into regularly tested simulation protocols, and as part of a broader, harmonised framework for minimum service provision,
Investing in the uptake of telemedicine and home‑based care,
Strengthening communication and co‑operation between primary and secondary care professionals and with patients and carers,
Harnessing data collection and use,
Investing on the resilience of the supply chain.
Source OECD (2023[346]), Ready for the Next Crisis? Investing in Health System Resilience, https://doi.org/10.1787/1e53cf80-en; We CARE (2025[350]), RESIL-Card marks major milestone with first cardiovascular resilience assessment tool - We CARE, https://www.wecareabouthearts.org/resil-card-marks-major-milestone-with-first-cardiovascular-resilience-assessment-tool/; European Commission (2020[351]), “Assessing the resilience of health systems in Europe – An overview of the theory, current practice and strategies for improvement”, https://doi.org/10.2875/191483.
6.8.8. Sustainability as a cross-cutting dimension to enhance health system performance and improve population health
Improvements in fiscal sustainability could be achieved by harnessing prevention policies
Sustainability is most commonly referred in relation to fiscal sustainability of health systems, i.e. governments’ ability to “manage public finances credibly” (OECD, 2015[352]). Fiscal sustainability can be attained by policymakers through three broad pillars: 1) improving the efficiency of health spending, 2) reevaluating the boundaries between private and public spending, and 3) raising more money for health (OECD, 2024[353]). While the three ways are applicable to cardiovascular care delivery, the first measure relates closely to prevention spending, which entails a cost-effective approach to foster financial sustainability of cardiovascular care delivery (see Section 6.4).
The economic pressure on healthcare systems by the cardiovascular system is considerable, and continues to stress already strained systems (see Chapter 2) (ESC-Oxford Burden of Disease, 2023, 2023[354]). The return on investment in preventing and managing CVD disease is large, and cross-sectoral action can reduce substantially the societal economic burden, particularly around tobacco, physical activity and diet (Masters et al., 2017[355]). Recent evidence suggests that financial incentives may contribute to positively change relevant lifestyle behaviours, such as smoking and diet improvements. Incentives like vouchers and cash payments, often linked to measurable outcomes, may support improvements in healthcare systems’ sustainability (Petracca et al., 2025[356]). Furthermore, CV risk is socially patterned, with worst cardiovascular health in the more deprived segments of the population. They also tend to have more risk factors at higher levels, often resulting in differential outcomes, such as strong social gradients in CVD mortality. Higher levels of social protection and access to healthcare seems not to explain all the disparities, so the social patterning of risk requires intervention. (Bugiardini, 2023[357]).
Tailored goals and regulations are lacking to enhance healthcare environmental sustainability
Health systems and the environment are deeply interconnected, however often neglected in policymaking. On one hand, health systems contribute to approximately 4.4% of global net emissions, on the other hand, citizen are exposed to climate‑related health risks driven by heatwaves or air pollution (see Chapter 3). Improving population health, driven by socio‑economic, environmental, and healthcare aspects, not only fosters resilience to environmental threats but also reduces the environmental footprint of health systems. Many countries currently lack mechanisms to monitor these impacts, and sector-specific decarbonisation policies are limited, with most efforts focussed on broad public and industrial strategies for reducing emissions (Gocke et al., 2023[358]).
A literature review aiming to identify services and care pathways assessing their carbon footprint identified six studies related to cardiac care, assessing atrial fibrillation catheter ablation, cardioversion care pathway, cardiac surgery, decompensated heart failure care pathway and elective coronary artery bypass graft surgery (Kouwenberg et al., 2024[359]). The carbon footprint ranged between 76.9 kg of Co2e in the AF ablation procedure and 505 kg Co2e per elective coronary artery bypass grafting (CABG). The main contributor to the impact of AF ablation were related to electrophysiology catheters and patches, which could be reduced, reused and recycled (Ditac et al., 2022[360]). In uncomplicated CABG surgery, emissions were mainly related to manufacturing and disposal of medical waste, which represented 436.7 kg of CO2−e per surgery (Hubert et al., 2022[361]).
Studies assessing waste reduction and enhanced circularity in healthcare organisations provided promising results, some of which are applicable or could be tested in cardiovascular care. For instance, the possibility to reprocess face masks with minimal reduction of filtration efficiency (van Straten et al., 2021[362]), recycle polypropylene wrapping paper, used to wrap sterile surgical instruments, into new medical devices (van Straten et al., 2021[363]), and recycle discarded stainless steel surgical instruments, while saving costs through a circular approach (van Straten et al., 2021[363]). A study in the Netherlands showed that heart surgeries and intensive care admissions may be performed more sustainably, by identifying opportunities to reduce the environmental footprint of coronary artery bypass surgeries (van Bree et al., 2025[364]). Potential gains can be achieved in the healthcare pathway through using washable drapes,4 optimising air handling units and using renewable energy – when balanced with infection prevention priorities, operational constraints, and environmental impacts (Doerstling et al., 2025[365]). Further research is warranted, for instance to reduce the heavy environmental burden of plastic materials contained in a disposable set for the heart-lung machine.
The European Society of Cardiology (ESC) has established the ESC Environmental Sustainability Task Force (2024-2026), aiming to raise awareness, expand research and advocacy, contributing to the implementation of sustainable practices (ESC Task Force Environmental Sustainability, 2025[366]). The subsequent Task Force (2026-2028) is envisioned to sustain and expand on these efforts. Some countries have introduced national strategies which include health sector responsibilities, particularly for large hospitals, however comprehensive policies are rare (Gocke et al., 2023[358]). In the Netherlands, some advanced healthcare sustainability policies have been implemented through a series of Green Deals. The third Green Deal was signed in 2022, setting out specific goals addressing a broad spectrum of environmental issues, including CO₂ emissions and pharmaceutical pollution in water. In Belgium, the Flemish Government established 13 climate commitments for healthcare facilities in 2017, targeting reductions in energy use and CO₂ emissions by 2030. Further embedding of climate resilience into health policy design may drive system-level adaptations, fostering greener and more sustainable health systems.
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AFFECT-EU (Apr 2021 to Mar 2024) (AFFECT-EU, 2020[377]) intends to develop and evaluate a risk-based screening approach to detect atrial fibrillation in the community
PROFID (PROFID EHRA, 2025[378]) (Jan 2020 to 31 March 2026) aims to develop a clinical decision support tool to identify which patients with history of coronary heart syndrome would benefit from an implantable cardioverter defibrillator (ICD). The project includes the PROFID EHRA trial, which aims to provide contemporary data on sudden cardiac death prevention after myocardial infarction, assessing the role of ICD under contemporary optimal medical therapy (OMT), https://profid-project.eu/profid-ehra-trial/.
Both projects are co-funded by Horizon 2020.
EuroHeartPath (EuroHeartPath, 2025[379]) “will simultaneously conduct 18 pathfinder studies to optimize the personalized early detection, diagnosis, monitoring, and treatment of heart failure, atrial fibrillation, ventricular fibrillation, and coronary disease, with a particular emphasis on prevention. These studies are categorized into four key areas: 1) novel artificial intelligence (AI) and machine learning applications, such as automated AI analysis of ECGs and Holters, and AI for predicting cardiomyopathies and cardiovascular events; 2) digital health integration, aimed at improving the diagnosis of aortic stenosis and enhancing secondary prevention measures; 3) point-of-care testing, including the use of point-of-care diagnostics in primary practice and ambulances to exclude heart failure; and 4) technology and robotics, encompassing robotic echocardiography and invasive diagnostics in obstructive epicardial coronary artery disease.”
AFFIRMO (AFFIRMO[380]): The AFFIRMO project is dedicated to enhancing the management of atrial fibrillation (AF) among Europe’s ageing population by addressing multimorbidity through a holistic, patient-centred approach. Recognising that AF often coexists with other chronic conditions, the project aims to transition from fragmented care to an integrated strategy based on the “Atrial Fibrillation Better Care” (ABC) model. This model emphasises three key components: Avoiding stroke through appropriate anticoagulation, Better symptom management by involving patients in their treatment plans, and Cardiovascular and comorbidity risk optimisation by addressing associated health issues. AFFIRMO seeks to identify clusters of multimorbidity in older AF patients, assess the needs of patients, caregivers, and healthcare professionals, and develop a digital platform to facilitate personalised care pathways and shared decision making.
← 1. There is currently not a global consensus on the definition of ultra-processed foods (UPFs), with most studies relying on the NOVA classification (Monteiro et al., 2017[381]). Growing evidence links high UPF consumption to increased risk of cardiovascular disease and related factors such as obesity, hypertension, and systemic inflammation (Lane et al., 2024[382]).
← 2. 56 risk assessment tools have been compiled by JACARDI, https://risktoolapp.shinyapps.io/Risk_Tool/.
← 3. Relative risk (RR) 0.78, 95% confidence intervals (CI) 0.62‑0.98 for nurse home visits and RR 0.80, 95% CI 0.67‑0.97 for disease management clinics.
← 4. APIC/WHO guidelines indicate that current evidence – rated moderate to very low quality – shows no clear advantage or disadvantage of disposable drapes and gowns compared to reusable ones in preventing surgical site infections (p.133). Further research is needed to confirm these findings and assess implications for patient safety.