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Background: Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice., Objectives: Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management., Methods: A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper., Results: Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab., Conclusions: Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention., Competing Interests: Fernando Lanas has received speaker honoraria and has served as an advisory board member for Pfizer, Novartis, Bayer, BMS, Boehringer, Astrazeneca, Novo Nordisk. Lale Tokgözoğlu has received honoraria or has been part of advisory boards from Abbott, Amgen, AstraZeneca, Bayer, Daiichi Sankyo, Eli Lilly, MSD, Novartis, Novo Nordisk Pfizer, Recordati, and Sanofi., (Copyright: © 2024 The Author(s).)

Background: Atherosclerotic cardiovascular diseases (ASCVD) including myocardial infarction, stroke and peripheral arterial disease continue to be major causes of premature death, disability and healthcare expenditure globally. Preventing the accumulation of cholesterol-containing atherogenic lipoproteins in the vessel wall is central to any healthcare strategy to prevent ASCVD. Advances in current concepts about reducing cumulative exposure to apolipoprotein B (apo B) cholesterol-containing lipoproteins and the emergence of novel therapies provide new opportunities to better prevent ASCVD. The present update of the World Heart Federation Cholesterol Roadmap provides a conceptual framework for the development of national policies and health systems approaches, so that potential roadblocks to cholesterol management and thus ASCVD prevention can be overcome., Methods: Through a review of published guidelines and research papers since 2017, and consultation with a committee composed of experts in clinical management of dyslipidaemias and health systems research in low-and-middle income countries (LMICs), this Roadmap identifies (1) key principles to effective ASCVD prevention (2) gaps in implementation of these interventions (knowledge-practice gaps); (3) health system roadblocks to treatment of elevated cholesterol in LMICs; and (4) potential strategies for overcoming these., Results: Reducing the future burden of ASCVD will require diverse approaches throughout the life-course. These include: a greater focus on primordial prevention; availability of affordable cholesterol testing; availability of universal cholesterol screening for inherited dyslipidaemias; risk stratification moving beyond 10-year risk to look at lifetime risk with adequate risk estimators; wider availability of affordable cholesterol-lowering therapies which should include statins as essential medications globally; use of adequate doses of potent statin regimens; and combination therapies with ezetimibe or other therapies in order to attain and maintain robust reductions in LDL-C in those at highest risk. Continuing efforts are needed on health literacy for both the public and healthcare providers, utilising multi-disciplinary teams in healthcare and applications that quantify both ASCVD risk and benefits of treatment as well as increased adherence to therapies., Conclusions: The adverse effects of LDL-cholesterol and apo B containing lipoprotein exposure are cumulative and result in ASCVD. These are preventable by implementation of different strategies, aimed at efficiently tackling atherosclerosis at different stages throughout the human life-course. Preventive strategies should therefore be updated to implement health policy, lifestyle changes and when needed pharmacotherapies earlier with investment in, and a shift in focus towards, early preventive strategies that preserve cardiovascular health rather than treat the consequences of ASCVD., Competing Interests: Kausik K. Ray has received honoraria for consulting, lectures from Kowa, Amgen, Regeneron Pharmaceuticals, Sanofi, Daiichi Sankyo, Pfizer, Viatris, AstraZeneca, Eli Lilly, Esperion, New Amsterdam Pharma, Novartis, Silence Therapeutics, Bayer, Boehringer Ingelheim, Novo Nordisk, SCRIBE, CRISPR, Cargene, Vaxxinity, Abbott, Resverlogix. In addition, he has received research grant support to his institution from Sanofi, Daiichi Sankyo, Amgen, Pfizer and MSD and support from the NIHR Imperial Biomedical Research Centre. Brian A. Ference has received research grants from Novartis, Amgen, Pfizer, Merck, and Esperion Therapeutics. In addition, the author has received personal fees for consulting, advisory board participation and lectures from Novartis, Amgen, Regeneron, Sanofi, Merck, Pfizer, Eli Lilly, Novo Nordisk, AstraZeneca, Viatris, The Medicines Co, Mylan, Daiichi Sankyo, dalCOR, CiVi Pharma, KrKa Phamaceuticals, the American College of Cardiology, the European Society of Cardiology, and the European Atherosclerosis Society. Dirk J. Blom has received research grants from Amgen, Amryt, AstraZeneca, IONIS, LIB Therapeutics, Novartis, Regeneron, Sanofi; Lecture fees and personal fees from Amgen, Novartis, Organon, Sandoz, Sanofi and has participated in advisory board for Amgen, Amryt (Chair of the LOWER study steering committee), and Sanofi. Stephen J. Nicolls has benefitted from research support from AstraZeneca, New Amsterdam Pharma, Amgen, Anthera, Eli Lilly, Esperion, Novartis, Cerenis, The Medicines Company, Resverlogix, InfraReDx, Roche, Sanofi-Regeneron and LipoScience and consulting and honoraria fees from AstraZeneca, Amarin, Akcea, Eli Lilly, Anthera, Omthera, Merck, Takeda, Resverlogix, Sanofi-Regeneron, CSL Behring, Esperion, Boehringer Ingelheim, Sequirus. Rodrigo Alonso has received honorary fees and participation in pharma symposia or advisory boards in the last five years from Amgen, Tecnofarma, SAVAL, ABBOTT, NovoNordisk, Boehringer-Ingelheim and Teva. Piotr Jankowski has received Honoraria and travel grants from Amgen, Sanofi, Servier. Roopa Mehta has been part of the speakers’ bureau for Amgen. Nathan D. Wong has received Research support through his institution from Novartis and Novo Nordisk and has been a consultant to Novartis. As Co-Principal Investigator of INTERASPIRE, David A. Wood’s Institute is in receipt of Independent Investigator Initiated grants from Abbott, Novartis, Pfizer, Sanofi, Viatris. Samuel S. Gidding has been a consultant on paediatric clinical trials of bempedoic acid for Esperion. Fausto J. Pinto has participated in Advisory Board, Speaker’s bureau, and clinical trials with Astra-Zeneca, Daichii Sankyo, Amgen, Sanofi. Raul D. Santos has received honoraria related to speaker activities, consulting or research from: Abbott, Ache, Abbott, Amgen, Astra Zeneca, Biolab, EMS, Hypera, Libbs, Esperion, Kowa, Getz pharma, Novo-Nordisk, Novartis, Merck, PTC therapeutics, Pfizer, and Sanofi., (Copyright: © 2022 The Author(s).)

More than 500 million people worldwide live with cardiovascular disease (CVD). Health systems today face fundamental challenges in delivering optimal care due to ageing populations, healthcare workforce constraints, financing, availability and affordability of CVD medicine, and service delivery. Digital health technologies can help address these challenges. They may be a tool to reach Sustainable Development Goal 3.4 and reduce premature mortality from non-communicable diseases (NCDs) by a third by 2030. Yet, a range of fundamental barriers prevents implementation and access to such technologies. Health system governance, health provider, patient and technological factors can prevent or distort their implementation. World Heart Federation (WHF) roadmaps aim to identify essential roadblocks on the pathway to effective prevention, detection, and treatment of CVD. Further, they aim to provide actionable solutions and implementation frameworks for local adaptation. This WHF Roadmap for digital health in cardiology identifies barriers to implementing digital health technologies for CVD and provides recommendations for overcoming them., Competing Interests: Dr Jasper Tromp is supported by the National University of Singapore Start-up grant, the tier 1 grant from the ministry of education and the CS-IRG New Investigator Grant from the National Medical Research Council; has received consulting or speaker fees from Daiichi-Sankyo, Boehringer Ingelheim, Roche diagnostics and Us2.ai, owns patent US-10702247-B2 related to artificial intelligence and echocardiography. Dr Devraj Jindal holds a copyright for the CARDIOMETCARE-M software which is a clinical decision support system. Dr Julie Redfern owns a portion of the IP for the TEXTCARE software that was developed following the TEXTME study. She is also funded by a NHMRC Investigator Grant Leadership Level 2 [GNT2007946]. Dr Khung Keong Yeo has received research funding from Amgen, Astra Zeneca, Abbott Vascular, Bayer, Boston Scientific, Shockwave Medical, Nestle, Novartis (all significant, via institution); Consulting or honoraria feeds (all modest) from Abbott Vascular, Boston Scientific, Medtronic, Amgen, Bayer, Novartis, Astra Zeneca, Peijia Medical; Speaker or Proctor fees from Shockwave Medical, Abbott Vascular, Boston Scientific, Medtronic, Philips, Alvimedica, Bayer, Biotronik, Orbus Neich, Shockwave Medical, Amgen, Novartis, Astra Zeneca, Microport, Terumo. Dr. Lopez-Jimenez is co-inventor of several AI algorithms that have been licensed to digital health companies and may receive financial compensation in the future. He is member of the advisory board for Anumana, an AI-based technology company. He has co-developed digital health technology to use 3D volumes to assess cardiometabolic risk with Selected Research Inc, and may receive financial benefit in the future. Dr Dorairaj Prabhakaran holds a copyright for the CARDIOMETCARE-M software which is a clinical decision support system. Prof Carolyn SP Lam is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research support from Bayer and Roche Diagnostics; has served as consultant or on the Advisory Board/Steering Committee/Executive Committee for Abbott, Actelion, Alleviant Medical, Allysta Pharma, Amgen, AnaCardio AB, Applied Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Cytokinetics, Darma Inc., EchoNous Inc, Impulse Dynamics, Ionis Pharmaceutical, Janssen Research & Development LLC, Medscape/WebMD Global LLC, Merck, Novartis, Novo Nordisk, Prosciento Inc, Radcliffe Group Ltd., Roche Diagnostics, Sanofi, Siemens Healthcare Diagnostics and Us2.ai; and serves as co-founder & non-executive director of Us2.ai. Dr Martin R Cowie has provided consultancy advice to Medtronic, Boston Scientific, Abbott and AstraZeneca, related to aspects of digital health. As from 1 August 2022 he has been employed by AstraZeneca as Clinical Vice-President in Late Stage Research (Biopharmaceuticals)., (Copyright: © 2022 The Author(s).)

The World Heart Federation (WHF) Roadmap series covers a large range of cardiovascular conditions. These Roadmaps identify potential roadblocks and their solutions to improve the prevention, detection and management of cardiovascular diseases and provide a generic global framework available for local adaptation. A first Roadmap on raised blood pressure was published in 2015. Since then, advances in hypertension have included the publication of new clinical guidelines (AHA/ACC; ESC; ESH/ISH); the launch of the WHO Global HEARTS Initiative in 2016 and the associated Resolve to Save Lives (RTSL) initiative in 2017; the inclusion of single-pill combinations on the WHO Essential Medicines' list as well as various advances in technology, in particular telemedicine and mobile health. Given the substantial benefit accrued from effective interventions in the management of hypertension and their potential for scalability in low and middle-income countries (LMICs), the WHF has now revisited and updated the 'Roadmap for raised BP' as 'Roadmap for hypertension' by incorporating new developments in science and policy. Even though cost-effective lifestyle and medical interventions to prevent and manage hypertension exist, uptake is still low, particularly in resource-poor areas. This Roadmap examined the roadblocks pertaining to both the demand side (demographic and socio-economic factors, knowledge and beliefs, social relations, norms, and traditions) and the supply side (health systems resources and processes) along the patient pathway to propose a range of possible solutions to overcoming them. Those include the development of population-wide prevention and control programmes; the implementation of opportunistic screening and of out-of-office blood pressure measurements; the strengthening of primary care and a greater focus on task sharing and team-based care; the delivery of people-centred care and stronger patient and carer education; and the facilitation of adherence to treatment. All of the above are dependent upon the availability and effective distribution of good quality, evidence-based, inexpensive BP-lowering agents., Competing Interests: Panniyammakal Jeemon is supported by the Wellcome Trust through a Wellcome Trust/DBT India Alliance Clinical and Public Health Intermediate Fellowship [IA/CPHI/14/1/501497]. Neil Poulter has received financial support from several pharmaceutical companies which manufacture BP-lowering agents, for consultancy fees (Servier), research projects, and staff (Servier, Pfizer) and for arranging and speaking at educational meetings (AstraZeneca, Lri Therapharma, Napi, Servier, Sanofi, Eva Pharma and Pfizer). He holds no stocks and shares in any such companies. Norman Campbell reports personal fees from Resolve to Save Lives (RTSL) outside the submitted work and is an unpaid member of World Action on Salt, Sugar and Health and an unpaid consultant on dietary sodium and hypertension control to numerous governmental and non-governmental organizations. Kazuomi Kario received research grant from A &D Co., Omron Helthcare Co., Fukuda Denshi Co., MSD K.K., Astellas Pharma Inc., Eisai Co., Otsuka Pharmaceutical Co., Otsuka Holdings Co., Sanofi K.K., Shionogi & Co., Sanwa Kagaku Kenkyusho Co., Daiichi Sankyo Co., Taisho Pharmaceutical Co., Ltd, Sumitomo Dainippon Pharma Co., Takeda Pharmaceutical Co., Mitsubishi Tanabe Pharma Co., Teijin Pharma, Boehringer Ingelheim Japan Inc., Pfizer Japan Inc., Fukuda Lifetec Co., Fukuda Lifetec Kanto Co., Bristol-Myers Squibb K.K., Mylan Co., Mochida Pharmaceutical Co., Roche Diagnostics K.K. and honoraria from Idorsia Pharmaceuticals Japan, Omron Healthcare Co., Daiichi Sankyo Company, Limited, Takeda Pharmaceutical Co., Terumo Corporation, Mylan EPD. Taskeen Khan is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent those of the World Health Organization. Pedro Ordunez is a staff member of the Pan American Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent those of the Pan American Health Organization. Aletta E Schutte has received speaker honoraria from Omron Healthcare, Servier, Takeda, Novartis and advisory board fees from Abbott, outside the submitted work., (Copyright: © 2021 The Author(s).)