Clinical reality of coronary prevention in Europe : A comparison of Euroaspire I, II and III surveys Time trends in cardiovascular disease prevention in clinical practice September 1994 - March 2007
Smoking has not changed over the three surveys. About one fifth of coronary patients still continue to smoke cigarettes, despite increasing availability of new and effective treatments to help patients stop. Body weight continues to increase dramatically; 4.9 kg between the first and third survey, and now four out of five patients are overweight (BMI ≥ 25 kg/m2) and over a third are obese (BMI ≥ 30 kg/m2); an increase from one quarter in the first survey to a third of all patients now. Waist lines are also increasing with more than half of all patients being centrally obese (waist circumference ≥ 102 cm men and ≥ 88 cm women). 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.
Professor Guy De Backer, National Coordinator for EUROASPIRE surveys in Belgium, commented «The results regarding the time trends in lifestyles are very disappointing. They illustrate how difficult it is to change behaviour in adult life but they also reflect the limited attention given to prevention even in patients with established heart disease. The health care systems in Europe are mainly driven by medical technology, devices and pharmacological care; lifestyles are considered as "private issues"; they should be an integral part of health insurance plans. A more professional and multidisciplinary approach is needed involving both primary care and specialised centres for preventive cardiology.»
Risk factor trends
(i) Blood pressure
Blood pressure management has shown no improvement over the three surveys. One half of all patients still have blood pressures above the recommended target (BP < 140/90 mmHg) which increases their risk of recurrent coronary disease, stroke, kidney and heart failure. Therapeutic control in patients using blood pressure lowering medication remains unchanged across the three surveys. Only 41% of such patients had achieved the BP target of < 140/90 mmHg (< 130/80 mmHg in diabetes) in the first survey compared to 39% in the third survey. This failure to improve management of blood pressure more effectively is despite large increases in prescriptions for all classes of anti-hypertensive medications: diuretics (15% to 31%), beta-blockers (56% to 86%), ACE/ARB"s (31% to 75%). The only exception to this trend is CCB"s for which prescriptions have fallen from 35% to 25%. So the explanation is probably the rising prevalence of overweight and obesity in these patients.
(ii) Blood cholesterol
In contrast the management of blood lipids has dramatically improved across the three surveys driven by the widespread use of statins, an increase from 18% to 87%; more than fourfold. Consequently, the proportions achieving the total and LDL-cholesterol targets have increased from 13% to 72% for total cholesterol < 5.0 mmol/l [190 mg/dL], and from 11% to 75% for LDL-cholesterol < 3.0 mmol/l [115 mg/dL] over this period. For the new lipid targets of < 4.5 mmol/l [170 mg/dL] for total cholesterol and < 2.5 mmol/l [96 mg/dL] for LDL-cholesterol set in 2003 the proportions achieving target are now 54% for total cholesterol and 53% for LDL-cholesterol. Therapeutic control in relation to these lower targets in those using lipid lowering medication has improved seven fold; from 8% to 57% achieving the total cholesterol target of < 4.5mmol/l. However, this still leaves a substantial proportion of patients who have yet to achieve these current lipid targets. The new Joint European Societies Guidelines (2007) have set lower cholesterol targets of < 4.0 mmol/l [154 mg/dL] for total cholesterol and < 2.0 mmol/l [77 mg/dL] for LDL-cholesterol where feasible and these will be an even tougher challenge.
(iii) Diabetes mellitus
The prevalence of diabetes continues to increase, from 17% to 28%, reflecting the rise in obesity. It is of great concern that 15% of the rest of the patients have undetected diabetes, making a total of 43% of all patients with known or unknown diabetes. Therapeutic control of self reported diabetes remains poor.
Cardioprotective medication trends
Prescriptions for cardioprotective medications have continued to increase across the three surveys for antiplatelet therapies (81% to 93%), beta-blockers (56% to 86%), ACE/ARB"s (31% to 75%), statins (18% to 87%) and diuretics (15% to 31%). The use of CCB"s has decreased (35% to 25%) compared to the first survey. Anticoagulants remain the same.
Dr Kornelia Kotseva, Consultant Cardiologist and the Project
Manager for the EUROASPIRE III survey commented «despite the
increase in prophylactic drug therapy, the majority of coronary
patients in Europe have still not achieved the blood pressure
target and two out of five are not achieving the total cholesterol
goal. Medical treatment by cardiologists in coronary patients is
not sufficient. Drug therapy without addressing the underlying
causes of the disease can never achieve the overall benefits of
prevention. Drug therapy should always go hand in hand with a
professional lifestyle intervention.»
So these three surveys of coronary patients, uniquely spanning 12 years of European clinical practice, show that lifestyle management is a growing cause for concern. No change in the prevalence of smoking, and alarming increases in both obesity and central obesity. These lifestyle trends are adversely impacting the management of other major risk factors for recurrent coronary disease, stroke, kidney and heart failure. Blood pressure management remains unchanged, despite a substantial increase in the use of anti-hypertensive medications. Only a third of patients on drugs are being therapeutically controlled to target. Lipid management shows enormous improvement, almost entirely due to the widespread use of statins. However, a substantial proportion of patients still remain above the recommended lipid targets. The challenge of achieving these targets will be even greater with the new lower total and LDL-cholesterol targets being announced at the 2007 ESC Congress. The rising prevalence of diabetes is a growing concern, with almost half of all coronary patients with this diagnosis, about a third of who are undetected. Therapeutic management of diabetes remains poor and consequently there is an increased risk of both recurrent coronary disease and stroke, and also microvascular complications. The use of cardioprotective medications has increased across all classes, with the exception of CCB"s, and the greatest increase is seen for statins. Yet it is clear from these time trends that drug therapies are simply not sufficient and need to be combined with a professional lifestyle and risk factor intervention.
Professor David Wood, the Principal Investigator for the EUROASPIRE surveys said «patients need professional support to make lifestyle changes and also manage their risk factors more effectively. Simply giving a prescription is not enough. Patients need to understand the nature of their disease and how to mange it through lifestyle and drugs. This can only be achieved by a comprehensive prevention and rehabilitation programme."
In EUROASPIRE III only one third of patients accessed any form of cardiac rehabilitation in Europe because, despite compelling scientific evidence that such programmes reduce total mortality, there is completely inadequate provision in many countries. All coronary patients are entitled to a comprehensive ambulatory multidisciplinary cardiovascular prevention and rehabilitation programme to help them reduce their risk of recurrent disease and improve their quality of life and life expectancy. With continuing adverse lifestyle trends coupled with inadequate risk factor management there is a compelling need for "Prevention Centres" providing a full range of preventive cardiology services.
Professor Hugo Saner, President of the European Association for Cardiovascular Prevention and Rehabilitation commented "Although most European Hospitals could provide services for prevention and rehabilitation, coordinated lifestyle intervention programmes are rarely offered. There is an urgent need to offer secondary prevention programmes through comprehensive cardiac rehabilitation to all patients with established cardiovascular disease, and also to those at high risk of developing the disease. The European Association for Cardiovascular Prevention and Rehabilitation has taken the initiative to promote the establishment of effective and comprehensive "Prevention Centres" in most European Hospitals within the next few years".
This study was presented at the ESC Annual Congress in Vienna.
Notes to editors:
Declaration of interest: The European Society of Cardiology received unrestricted educational grants from the following pharmaceutical companies to support the costs of this survey: AstraZeneca, Bristol-Myers Squibb, Glaxo Smith Kline, Merck/Schering-Plough, Novartis, Pfizer, Sanofi-Aventis, Servier.
The European Society of Cardiology (ESC):
The ESC represents nearly 53,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
The ESC achieves this through a variety of scientific and educational activities including the coordination of: clinical practice guidelines, education courses and initiatives, pan-European surveys on specific disease areas and the ESC Annual Congress, the largest medical meeting in Europe. The ESC also works closely with the European Commission and WHO to improve health policy in the EU.
The ESC comprises 3 Councils, 5 Associations, 19 Working Groups, 50 National Cardiac Societies and an ESC Fellowship Community (Fellow, FESC; Nurse Fellow, NFESC). For more information on ESC Initiatives, Congresses and Constituent Bodies see www.escardio.org.
European Society of Cardiology, The European Heart House 2035 Route des Colles, B.P. 179 - Les Templiers, Sophia Antipolis F-06903 France
About the Author(s)
Professor David Wood
National Heart & Lung Institute, Imperial College London, United Kingdom
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