Secondary prevention of cardiovascular disease in Europe: Prescribing pills is not sufficient

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By Kornelia Kotseva

Cardiovascular disease, of which coronary heart disease is the most common, is the major cause of death in adults in most European countries1. However, risk factor management in patients with coronary heart disease in Europe is far from optimal. The results of EUROASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events) surveys, carried out by the European Society of Cardiology in 1995–1996, 1999–2000 and 2006–2007, showed that integration of cardiovascular disease prevention into daily clinical practice is inadequate2. EUROASPIRE I, II, and III surveys were conducted in the same geographical areas and hospitals in eight European countries – Czech Republic, Finland, France, Germany, Hungary, Italy, The Netherlands and Slovenia. A total of 8,547 patients with coronary heart disease were interviewed and examined at least six months after their coronary event or procedure.


The EUROASPIRE surveys give a unique European picture of preventive cardiology as practiced by cardiologists, other specialists and primary care physicians looking after patients with coronary disease. The comparison between the three surveys demonstrates a compelling need for more effective lifestyle management of coronary patients. Adverse trends in smoking prevalence in younger women and the alarming increase in obesity, central obesity and diabetes are an increasing cause for concern. The overall prevalence of smoking was virtually unchanged over the three surveys (20%, 21% and 18%, respectively) despite increasing availability of new and effective treatments to help patients stop smoking. The prevalence of obesity (BMI≥30kg/m2) continued to increase dramatically between the first and third survey (25%, 33% and 38% respectively), with a corresponding increase in central obesity. These adverse trends in body weight and distribution, reflecting the same trends in the general population, contribute to a worsening of other risk factors such as raised blood pressure, dyslipidaemia and diabetes.


Blood pressure management showed no improvement with nearly three fifths (58%, 58% and 61%) of patients still having blood pressure above the recommended target (<140/90mmHg, <130/80mmHg in patients with diabetes). This failure to improve management of blood pressure is despite the large increase in prescriptions for anti-hypertensive medications. Therapeutic control of blood pressure remained unchanged, with only two fifths of patients on blood pressure lowering medication achieving the blood pressure goal in the third survey.


In contrast, the management of total cholesterol improved dramatically driven by the widespread use of statins. The prevalence of elevated total cholesterol (≥4.5mmol/l) had decreased substantially: 95%, 77% and 46%. However, nearly two fifths of patients on lipid-lowering medication in the third survey had not reached the total cholesterol goal.


The prevalence of self reported diabetes mellitus increased across the surveys, 17.4%, 20.1% and 28%. The use of cardioprotective medication increased across all classes: aspirin or platelet-active drugs 81%, 84%, and 93%; betablockers 56%, 69% and 86% ; ACE inhibitors/AT2 receptor blockers 31%, 49% and 74 %, and lipid-lowering drugs 32%, 63% and 89%.


Yet it is clear from these time trends that drug therapies are simply not sufficient. Preventive cardiology care needs a systematic, comprehensive, multidisciplinary approach, which addresses lifestyle and risk factor management by cardiologists, other specialists, general practitioners, nurses and other allied health professionals, and a health care system which invests in prevention. Saving people’s lives from acute heart attacks is not sufficient, and an urgent investment in prevention is needed to address the lifestyle causes of heart disease. “To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.”2


References

[1] Graham I, Atar D, Borch-Johnsen K, et al. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice: Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Prevention in Clinical Practice. Eur J Cardiovasc Prev Rehabil 2007; 14 (Suppl 2): S1-S113.

[2] Kotseva K, Wood D, De Backer G, De Bacquer D,Pyorala K, Keil U, on behalf of EUROASPIRE study Group Cardiovascular prevention guidelines – the clinical reality: a comparison of EUROASPIRE I, II and III surveys in 8 European countries. Lancet 2009; 372: 929-40


Kornelia Kotseva is a senior clinical research fellow, consultant cardiologist, Cardiovascular Medicine, National Heart & Lung Institute, Imperial College London, UK.