Dr Marie-Christine Iliou, MD, Cardiologist
National CVD Prevention Coordinator for France
Head of the Cardiac Rehabilitation and Secondary Prevention Department. Corentin Celton.
AP HP Centre-Université de Paris, France
Statistics and short report prepared by Marie-Christine Iliou in collaboration with Olie Valerie, PhD, Epidemiologist, Department of Non Transmissible Diseases. Santé Publique France.
The French health system combines a universal financial coverage for all (active and non–active) with a public–private mix of hospital and ambulatory care facilities mostly financed by the National Health Insurance (NHI) system. All residents automatically get health insurance coverage, funded by employers, workers or public funds depending on their occupational status. Cardiovascular diseases (CVD) management, including interventions and cardiac rehabilitation (CR), as well as prevention screening and chronic treatment with evidence-based medications are fully covered by the NHI, whichever the medical services used (public or private physicians or institutions). In addition, 90% of the population subscribe to a complementary health insurance to cover additional health expenses not covered by the NHI.
Statistics on risk factor status at population level:
Smokers (2019) 
Regular smoking (2018) 
34.7 % men 
33.5 % women 
26.8 % men 21.8 % women 
|Diabetes (2015) ||7.4 %||10.6 %||4.6 %|
Overweight (2015) Obesity (2015) 
31.8 %17.2 %
37.1 %16.8 %
26.8 %17.4 %
13.0 %3.9 %
|Sedentary* (2015) ||88.8 %||88.2 %||89.3 %||
65.1 % men57.0 % women
|Physical activity** (2015) ||
58.8 % men51.0 % women
|Hypertension (2015) ||31.3 %||38.1 %||25.0 %|
|Hypercholesterolemia (LDL>1.6 g/l) (2015) ||27 %||29.7 %||24.5 %|
* defined as a moderate or elevated level of sedentary according to the recommendations
** defined as a moderate or elevated level of physical activity according to the recommendations
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In France, numerous entities are involved in CVD prevention: institutional agencies ("Santé publique France", the French public health agency, Ministries of Health and Sports, National Health Authority, etc.) or organisations (French Federation of Cardiology, French Society of Cardiology, a patient association called "Alliance du Coeur", etc.). The main stakeholders are general practitioners (GPs), private or public cardiologists and allied professionals, and specialists working in preventive institutions.
A large number of initiatives for promoting CV health are developed in France, initiated by a vast array of institutions, organisations, private insurance and groups. Coordination is somehow lacking.
Two remarkable national plans may be cited: nutrition (PNNS) and tobacco (PNRT).
Important health promotion projects are implemented at the national and/or regional level. These projects are conducted and coordinated by numerous stakeholders. In 2017 a national decree was published specifying that GPs and specialists may prescribe physical exercise in chronic diseases.
Among the campaigns on health prevention and promotion, one should mention the initiatives of the French Federation of Cardiology, national regulations promoting health in all commercials for food and certain drinks (alcohol and sodas) on mass media, interventions in the workplace, implementation and diffusion of the ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice, etc.
A minimum level of training in primary and secondary prevention is currently proposed in medical education programmes, whereas educational training for CV prevention and rehabilitation, or for smoking cessation, are organised by universities, CV societies or foundations, but on a volunteer basis. Better education in these crucial issues is needed.
Similar to the organisation of the EAPC, the specific working group from the French Society of cardiology includes prevention, cardiac rehabilitation, exercise and sport (GERS-P) since 2018.
CR in France is based on phase II and III (maintenance) programmes.
Phase II programmes are delivered in one of the 140 dedicated public or private CR centres to both residential and outpatient facilities. Since 2008, according to a national regulation, all centres are regularly audited by a Regional Agency of Health, in order to be certified in multifaceted rehabilitation and patient education. Since 2012, a national degree for CV prevention and rehabilitation has been created to train high quality professionals; it has met striking success. The Cardiac Rehabilitation Working Group from the French Society of Cardiology (called GERS-P) brings together cardiologists and paramedics involved in CR and published national guidelines on CR in 2012. The French health organisation allows for early CR after any serious cardiovascular event. In fact, 36% of patients after myocardial infarction (MI) undergo CR among the ~ 50% prescribed (FAST MI 2015), around 50 to 60% after cardiac surgery and only 10 % of heart failure patients are referred to CR centres.
Phase III maintenance is delivered to around 14,500 patients every year in 206 patient clubs under the supervision of the French Federation of Cardiology. Its cost is however not covered by the NHI and is directly supported by the attendants (there are few initiatives from private insurance to help patients).
Although continuously increasing in recent years, the CR referral rate currently appears limited by an insufficient availability of beds and ambulatory facilities. Tele-rehabilitation is only provided through trials or protocols; but the reimbursement is not yet approved.
Aims for the future
- To implement European guidelines on preventive measures in the National Heart Action Plan for all ages
- To promote better cooperation and coordinated actions between all actors
- To reduce the burden of risk factors, especially smoking, inappropriate nutrition and physical inactivity
- To increase financial support for "sport-health" initiatives and for home-based CR programmes.
Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.