Presenter Report :
Wood, David A (United Kingdom)
Three EUROASPIRE surveys of coronary patients have been conducted over 12 years in 8 countries – Czech Republic, Finland, France, Germany, Hungary, Italy, The Netherlands, Slovenia - to monitor the practice of preventive cardiology. A total of 8547 patients with coronary artery disease – coronary artery surgery (CABG), angioplasty (PTCA), myocardial infarction or ischaemia – have been interviewed and examined over this period. Time trends in the management of lifestyle, other risk factors such as blood pressure, lipids and diabetes, and drugs in the prevention of cardiovascular disease are described.
These three surveys of coronary patients, uniquely spanning 12 years of European clinical practice, show that lifestyle management is a growing cause for concern. There has been 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 whom 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 CCBs, 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.
Discussant report: Poole-Wilson, Philip Alexander (UK)
The EuroASPIRE III study is critical to the management of patients with known coronary heart disease in the European community. The study describes current management, in 2006/2007, but also shows what changes have occurred over the last twelve years by comparison with two earlier studies (EuroASPIRE 1 and II).
In June 2007 the European Heart Health Charter was signed by many bodies in Europe concerned with coronary heart disease including representatives of the EU, WHO, EHN and ESC. This charter outlined a commitment to lifestyle changes and to appropriate medical management.
EuroASPIRE III was at the same time a disappointment, encouraging, and revealing.
The increase in the number of patients with obesity, overweight, diabetes and uncontrolled high blood pressure is a clear failure of preventive strategies. Smoking diminished but only by a small amount that might be the consequence of slight changes in patient selection between the three studies.
The increased use of drugs known to be of value in the prevention or delay of events in patients with coronary heart disease is commendable and indicates real progress. These drugs include anti-platelet drugs (eg aspirin), Angiotensin Converting Enzyme (ACE inhibitors, and beta-blockers. Of particular note is the huge increase in the use of statins resulting in a marked reduction in the number of patients with a total cholesterol below 5 mmol/L as recommended in guidelines.
What emerges from EuroASPIRE III is that much has been achieved in the use of drugs but lifestyle changes, currently the primary policy of national health systems and emphasised in the European Heart Health Charter, are not effectively implemented by doctors and patients.
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