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Treatment of Patients With Coronary Heart Disease Fails to Meet Standards of European Guidelines: Results of EUROASPIRE Surveys
... A wealth of scientific evidence shows that lifestyle interventions, control of risk factors and use of cardioprotective drug therapies can reduce the risk of recurrent nonfatal and fatal disease and improve the chances of survival [2]. Despite this, Kotseva et al. has during three cross-European surveys (EUROASPIRE I-III) showed that secondary prevention of CHD is alarmingly inadequate with persistent smoking habits, high prevalence of obesity, inadequate control of blood pressure, lipids and blood glucose, with most patients not achieving therapy guideline defined targets [3]. In the wake of the EUROASPIRE surveys, a nurse-coordinated follow-up program for patients with CHD (EUROACTION) was initiated and rolled out as a randomized controlled trial (RCT) in eight European countries. ...
... "If I would have to write a diary, journal or remember anything in particular, like sending in reports or whatever… I doubt that I would have joined-I'm so bad in keeping track of such things". (Bryan) [3] All four informants said that they felt safe when being part of the follow-up program. The feeling of safety seemed to be related to both the pharmacist's professional skills as well as the predictability of the follow-up program. ...
Coronary heart disease (CHD) is one of the leading causes of death worldwide. Scientific literature shows that prevention of CHD is inadequate. The clinical pharmacist's role in patient-centred care has been shown favourable in a large amount of studies, also in relation to reduction of risk factors related to CHD. We developed and piloted a pharmacist-led follow-up program for patients with established CHD after hospital discharge from a hospital in North Norway. The aim of the present study was to explore how participants in the follow-up program experienced the program with regard to four main topics; medication knowledge, feeling of safety and comfort with medications, the functionality of the program and the clinical pharmacist's role in the interdisciplinary team.
We performed semi-structured thematic interviews with four patients included in the program. After verbatim transcribing, we analysed the interviews using "qualitative content analyses" by Graneheim and Lundman. Trial registration www.clinicaltrials.gov: NCT01131715.
All participants appreciated the follow-up program because their medication knowledge had increased, participation had made them feel safe, they were reassured about the appropriateness of their medications, and they had become more involved in their own medication. The participants reported that the program was well structured and the clinical pharmacist was said to be an important caretaker in the health-care system. The importance of collaboration between pharmacists and physicians, both in hospital and primary care, was emphasized.
Our results indicate that the follow-up program was highly appreciated among the four participants included in this study. The results must be interpreted in the context of the health care system in Norway today. Here, few pharmacists are working in hospitals or in close relation to the general practitioners. In addition, physicians are short of time in order to supply appropriate medication information, both in hospital and primary care. Involving pharmacists in follow-up of patients with CHD seems to be highly appreciated among patients and may be a step towards improving patient care. The study is limited by the low number of participants.
... The medical data concerning the effect of the prevention policies on Romanian CVD-patients were recorded during the EuroAspire III Romania Follow Up [16][17][18]. All the patients participating at this study were voluntary. ...
... The EuroAspire III Romania Follow Up study started in November 2007 as a continuation of EuroAspire III Primary Care [16][17][18] in Romania and its primary goal was the implementation of the European prevention recommendations for individuals with high cardiovascular risk in a geographic region where the incidence of CVD is very high largely because of unhealthy lifestyle. The aims of this study included the following: ...
Background:
Cardiovascular disease (CVD) is the main cause of morbidity and mortality worldwide, but it also is highly preventable. The prevention rate mainly depends on the patients' readiness to follow recommendations and the state's capacity to support patients. Our study aims to show that proper primary care can decrease the CVD-related morbidity rate and increase the economic efficiency of the healthcare system. Since their admission to the European Union (EU), the Eastern European countries have been in a quest to achieve the Western European standards of living. As a representative Eastern European country, Romania implemented the same strategies as the rest of Eastern Europe, reflected in the health status and lifestyle of its inhabitants. Thus, a valid health policy implemented in Romania should be valid for the rest of the Eastern European countries.
Methods:
Based on the data collected during the EUROASPIRE III Romania Follow Up study, the potential costs of healthcare were estimated for various cases over a 10-year time period. The total costs were split into patient-supported costs and state-supported costs. The state-supported costs were used to deduce the rate of patients with severe CVD that can be treated yearly. A statistical model for the evolution of this rate was computed based on the readiness of the patients to comply with proper primary care treatment.
Results:
We demonstrate that for patients ignoring the risks, a severe CVD has disadvantageous economic consequences, leading to increased healthcare expenses and even poverty. In contrast, performing appropriate prevention activities result in a decrease of the expenses allocated to a (eventual) CVD. In the long-term, the number of patients with severe CVD that can be treated increases as the number of patients receiving proper primary care increases.
Conclusions:
Proper primary care can not only decrease the risk of major CVD but also decrease the healthcare costs and increase the number of patients that can be treated. Most importantly, the health standards of the EU can be achieved more rapidly when primary care is delivered appropriately. JEL: I18, H51.
... и 2000. го ди не у 15 европ ских зе ма ља [21]. Код 61% бо ле сни ка уве де на је ста тин ска тера пи ја, а код све га 51% вред но сти укуп ног хо ле сте ро ла до ве де не су у оп сег пре по ру че них, циљ них вред но сти. ...
Lipid and lipoprotein disorders are well known risk factors for atherosclerosis and its complications. The level of atherogenic LDL-cholesterol (LDL-C) is directly related to an increased risk of occurrence and progression of ischemic heart disease. Epidemiological and clinical studies have shown that the use of statin therapy to decrease LDL-C can significantly reduce the incidence of mortality, major coronary events and the need for revascularization procedures in the different groups of patients. The findings of a large meta-analysis conducted by the Cholesterol Treatment Trialists' (CTT) collaborators showed that every 1.0 mmol/lreduction of atherogenic LDL-C is associated with a 22% reduction in cardiovascular diseases mortality and I morbidity. However, despite the impressive results of the benefits of statin therapy, the EUROASPIRE study showed that about 50% of patients with ischemic heart disease did not achieve target LDL-C levels. According to the new ESC/EAS Guidelines for the Management of Dyslipidaemias in patients with a very high cardiovascular risk, treatment goal should be to decrease LDL-C below 1.8 mmol/l or >= 50% of initial values. In the majority of patients that can be achieved by statin therapy. For this reason an adequate choice of statins is of crucial importance, whereby the needed reduction in atherogenic LDL-C, after the identification of its target level based on the assessment of total cardiovascular risk, can be achieved.
... This strategy is also aligned with the current guidelines, which recommend coronary artery revascularization with coronary stents for the patients presented with a minimum stenosis diameter of <20% (as visually assessed by angiography). [26,27] Further, patients with noncritical lesion were managed conservatively and were put on medical management from both diabetic and non-diabetic patients in present study cohort. ...
To evaluate and compare clinical and epidemiological characteristics, treatment strategies, and utilization of evidence-based medicine (EBM) among coronary artery disease (CAD) patients with or without diabetes.
Prospective observational cohort study from a tertiary care hospital in India among patients with CAD (myocardial infarction, unstable angina, or chronic stable angina). Data included demographic information, vital signs, personal particulars, risk factors for CAD, treatment strategies, and discharge medications. We evaluated epidemiologic characteristics and treatment strategies for diabetic and non-diabetic patients.
Of 1,073 patients who underwent angiography, 960 patients (30% diabetic) had CAD. Proportion of hypertensive patients was higher among diabetic patients (58 vs 35% non-diabetic, P < 0.001). Similar proportion of patients received medical management in diabetic vs non-diabetic CAD patients (35 vs 34%, P = 0.091); in diabetics the use of surgical procedure was higher (22 vs 17%, P = 0.0230) than interventional strategy (percutaneous transluminal coronary angioplasty, 43 vs 49%, P = 0.0445). Key medications (antiplatelet agents, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), beta-blockers, and ahtihyperlipidemic agents) were prescribed in 95, 53/12, 67, and 91% diabetic (n = 252) and 96, 51/8, 67, and 94% non-diabetic (n = 673) patients, respectively on discharge.
Clustering of several risk factors at presentation, typically diabetes and hypertension, is common in CAD patients. Though diabetic patients are managed more conservatively, utilization of EBM for diabetic and non-diabetic patients is consistent with the recommendations.
... Instructions to the next care level on how to follow-up on the issues were not present in these cases. The low adherence to follow-up criteria shown in our study confirms results from other studies that follow-up of these patients is inadequate and that this is an area of improvement [26]. Our results may reflect the fact that hospital physicians consider this a task for the primary care level. ...
Purpose:
Numerous studies have documented suboptimal adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD(SP)). Clinical practice guidelines (CPGs) are continuously developed to define appropriate patient care, aiming to reduce risk of morbidity and death. The Medication Assessment Tool for CHD(SP) (MAT-CHD(SP)) was developed to assess adherence to CPGs concerning medication therapy and follow-up of patients with CHD(SP). The aim of this study was to explore whether the MAT-CHD(SP) could be applied retrospectively to assess guideline adherence and therapy goal achievement in secondary prevention of CHD.
Methods:
We collected data from electronic medical records of all patients who underwent percutaneous coronary intervention with stent implantation from January to March 2008 (n = 300) and applied the MAT-CHD(SP). We measured time for data collection and MAT application and tested reproducibility by calculating Cohen's kappa (κ) value for inter and intraobserver agreement.
Results:
A total of 247 MAT applications were analyzed, showing overall applicability of 66 % of the 4,446 MAT-CHD(SP) criteria and a high reproducibility of MAT-CHD(SP) application (κ values 0.93 and 0.95 for intra- and interobserver agreement, respectively). Mean time for data collection and MAT-CHD(SP) application was 11 min. Adherence to criteria concerning prescription was high (>75 %), but achievement of therapy goals for cholesterol and blood pressure was low (<50 %). Documentation of lifestyle advice achieved intermediate (50-75 %) or low adherence, as did therapy amendments in patients in whom therapy goals were unachieved at hospital admission.
Conclusions:
The MAT-CHD(SP) offers a means to identify both adherence and nonadherence to CPGs concerning CHD(SP) is applicable in retrospective assessment of CHD(SP), and identifies potentials for improved patient care.
Coronary Artery Disease: Epidemiology and Management in a Tertiary Hospital in South Trinidad Mandreker Bahall Coronary artery disease (CAD) care is enhanced by improving the epidemiological profile and minimising the evidence-practice gaps (EPGs) in the management of patients. This thesis includes separate studies that targeted CAD patients hospitalised at the only public health care institution in south Trinidad. Recruited patients comprised suspected acute myocardial infarction (AMI) or confirmed AMI cases. Data were collected using questionnaires, by face-to-face and telephone interviews, and from patients' medical records. Questionnaires on epidemiology, mortality, pre-hospital care, hospital care and quality of life were used. Statistical analyses were performed on data sets entered in SPSS with secure password to determine epidemiological variations and evidence practice gaps (EPGs) in CAD care. The age of presentation of AMI in Trinidad was about a decade earlier than in high income or industrialised countries. The overall mean age (standard deviation) of AMI presentation was 58.6 (± 13.43) years. The mean age of AMI mortality was 70.5 (range: 40 to 93) years. The prevalence of traditional risks such as diabetes, hypertension, hypercholesterolaemia, ischaemic heart disease (IHD), and a family history of IHD was nearly twice that of developed countries. The mean pre-hospital delay (PHD) was 7.5 hours (evidence-based guidelines EBG: 90 minutes) with a patient delay of 3.5 hours (EBG: 5 minutes). No primary angioplasty was performed. Emergency thrombolysis occurred in 70.5% of eligible patients with 57.5% of thrombolysis occurring within 30 minutes. Prescribed EBG medication (aspirin, beta blockers, statins and an ACE inhibitor) for AMI exceeded 80%. Cardiovascular risk evaluation and surgical and non-pharmacological treatment (counselling, cardiac rehabilitation) were virtually absent. About 43.9% of patients failed to obtain echocardiograms. Discharge medication included an ACE inhibitor (64.6%), beta blockers (70.6%), simvastatin (75.3%), clopidogrel (79.0%) and aspirin (79.8%). There was little documented information on advice on lifestyle, activity, cardiac rehabilitation, and follow-up care. In-patient mortality was 6.5%; about 3 times higher than that of high-income countries. Physical, social and emotional quality of life (QOL) improved over time and was better in males and the young. In conclusion, ages for presentation with AMI, or AMI deaths, were about a decade earlier than in high-income or industrialised countries. Evidence practice gaps in CAD management, except for pharmacological treatment, were quite high. ii Keywords: acute myocardial infarction; coronary artery disease; epidemiology of CAD; evidence practice gaps; primary care; public health; secondary care; tertiary care; Trinidad (Trinidad and Tobago). iii ACKNOWLEDGEMENTS
This paper summarizes the results of the PAPEETE study (Population-based Analysis of PErsistence with treatment and Economics of TElmisartan) that assessed trends in prescriptions, determinants and timing of treatment discontinuation and/or changes in antihypertensive drug therapy in a cohort of hypertensive patients living in Pavia. In the study were included all new users 18 years old or over receiving a first prescription for diuretics, beta-blockers, calcium channel-blockers, ACE inhibitors (ACEi) or angiotensin receptor blockers (ARBs) between 1 January 2003 and 31 December 2006. The follow-up period for each patient was 12 months starting from enrolment date. Based in the presence of continuous therapy, patients were defined as persistent and non-persistent users. A total of 61,493 patients was included in the study of whom 11.2% were persistent. Persistence with the treatment seems to be associated with patient-related factors and with the class of anti-hypertensive drug initially prescribed with the lowest persistence to antihypertensive treatment with diuretics (3.0%) and the highest with ARBs (18.8%).
Resumen
En prevención secundaria cardiovascular, el grado de control de los factores de riesgo cardiovascular es deficiente en los países europeos y la falta de adherencia terapéutica parece ser uno de los factores causales. La buena adherencia se asocia a un 20% de disminución del riesgo de enfermedad cardiovascular y un 38% de disminución de mortalidad por cualquier causa. Los pacientes con mala adherencia multiplican por 3 el riesgo de mortalidad. Sin embargo, la adherencia a los fármacos preventivos (ácido acetilsalicílico, bloqueadores beta, inhibidores de la enzima de conversión de la angiotensina, estatinas, etc.) ronda el 50% 1 año después del alta hospitalaria. La Organización Mundial de la Salud define adherencia terapéutica como el grado en que el comportamiento de una persona, con respecto a tomar la medicación o seguir una recomendación dietética o de cambio de estilo de vida, concuerda con las prescripciones del profesional sanitario consensuadas con el paciente. No existe un método ideal para medir la adherencia, pero se recomienda para la práctica clínica la pregunta de Haynes-Sackett y el cuestionario de Morisky-Green de ocho ítems. No obstante, el patrón de referencia sigue siendo el recuento de comprimidos, y se considera buena adherencia el consumo de más del 80% de la prescripción. Mejorar la comunicación entre médicos y pacientes, facilitar la continuidad asistencial mediante la colaboración con atención primaria, involucrar a otros profesionales sanitarios (farmacéuticos) y el desarrollo de terapias combinadas a dosis fijas, como la polypill, son estrategias que pueden mejorar la adherencia terapéutica y el grado de control y reducir los costes sanitarios.
Objective: To evaluate prescription adequacy, after myocardial infarction, to the established recommendations by the Andalusian Public Health System, and analyze those factors that deviate from their compliance. Method: Analysis of prescriptions in discharge reports from the cardiology department to patients undergoing percutaneous transluminal angioplasty after myocardial infarction, from August 2005 to July 2007. Calculation of the global adequacy indicator, and analysis of factors that contribute to the deviation. Results: The average degree of adequacy was 63.6% ± 16.5%. The results for each recommendation were: acetylsalicylic acid prescription (98.5%), beta blockers (89.5%), ACE inhibitors (74.6%), Clopidogrel in the established duration (62%), sublingual nitroglycerin (60.3%), non-transdermal nitroglycerin (63.1%), recommended statins (3.8%), diet type (84.7%) and exercise recommendation (39%). Conclusions: Global adequacy is low. The selected statin, duration of double antiaggregation, conditional indication for sublingual nitroglycerin and lack of exercise recommendation contribute to deviation.
Resumen
La práctica clínica cardiológica requiere una organización compleja que influya en los resultados globales y puede diferir sustancialmente entre distintos hospitales y comunidades. El objetivo de este documento de consenso es definir indicadores de calidad en cardiología, incluidos los indicadores para medir la calidad de los resultados (indicadores de resultados) y los parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). El documento está destinado principalmente al sistema de asistencia sanitaria de España y puede servir de base para documentos similares en otros países.
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
Objective: This research describes self-care means for people living with heart disease in the city of Ibague during the month of June 2011. Materials and methods: A qualitative approach for convenience random sampling, taking the address of the database of people consulting Federico Lleras Acosta Hospital. Inclusion criteria were: Having a medical diagnosis of coronary heart disease more than five years ago, has institutional endorsement of the University of Tolima and Federico Lleras Hospital. By appointment and informed consent for participation in research, were interviewed 8 people. Results: highlighted that the meaning of self-care in people with coronary heart disease falls into five dimensions: change in lifestyle, spiritual and family support, pharmacological, nutritional, household activity and exercise. Conclusions:We found that all patients do not learn in the same way, the above depends really have a change of attitude and specifically that people understand that they are each responsible and improve their health status through actions self-care.
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.
Background: In 2005, acute myocardial infarction (AMI) was included in a universal health plan (GES) to reduce inequity in care and optimize its diagnosis and treatment. Aim: To evaluate the effect of GES in risk factor control and therapeutic management among patients with AMI. Material and Methods: A survey was conducted in 2008-2009 in six public hospitals. Patients were identified from a hospital based registry of AMI and evaluated one year later with laboratory tests and an interview. Results: The registry enrolled 534 patients with ST and non ST segment elevation myocardial infarction. Of these, 416 patients aged 63 ± 12 years (25% women) were evaluated one year later. Eighty three percent were evaluated by a cardiologist and 37% by a general practitioner. Twenty two percent were evaluated by a nurse and 22% by a nutritionist. At the moment of the interview, 9% smoked, 78% were overweight or obese, 24% performed moderate or vigorous physical activity ≥ 150 min/week, 60% had systolic pressure > 130 mmHg and 63% a diastolic pressure > 80 mmHg. In 30%, LDL cholesterol was > 100 mg/dl and in 43%, triglycerides were > 150 mm/dl. Twenty two percent were diabetic and among them, 52% had a glycosilated hemoglobin > 7%. Forty five percent of non-diabetic patients had a fasting glucose > 100 mg/dl. Ninety three percent were in treatment with aspirin, 86% with statins, 66% with β-blockers, and 73% with angiotensin converting enzyme inhibitors or angiotensin receptor blockers and 20% with clopidogrel. Conclusions: Despite the high proportion of patients in treatment with evidence-based therapy, many do not achieve the targets for risk factor control with the new health care model. (Rev Med Chile 2013; 141: 977-986).
Despite the prognostic importance of achieving target cholesterol levels, the majority of patients with hypercholesterolemia do not achieve them. Statins remain the drugs of choice for the treatment of hypercholesterolemia due to their efficacy and their beneficial effects on morbidity and mortality. Nevertheless, there is a progressive loss of efficacy at high doses, which makes it difficult to achieve target levels in high-risk patients. Ezetimibe is a selective cholesterol absorption inhibitor that has been shown to be effective and well tolerated in clinical trials in which the drug was given in combination with various statins. Its use enabled therapeutic targets to be achieved in a large number of patients. In addition, there is also evidence that ezetimibe is effective in patients with renal failure. This article reviews the efficacy and clinical benefits of ezetimibe and considers questions raised about the drug's possible effects on morbidity and mortality.
This article contains a review of major new developments in drug treatment and the impact they could have for the general cardiologist. New treatments for arrhythmias, chronic ischemic heart disease, and secondary prevention are changing the practice of clinical cardiology. In addition, recent publications on treatment adherence and therapeutic inertia are discussed. Finally, the work of the Clinical Cardiology and Outpatient Section of the Spanish Society of Cardiology during the last year is described.
Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.
This is the third edition of European cardiovascular disease statistics. The first edition was published in 2000 when the European Union (EU) consisted of 15 Member States. After enlargement in 2004 and then again in 2007, there are now 27 Member States. Much has changed in the last seven years, but cardiovascular disease (CVD) remains the main cause of death in the EU. The European cardiovascular disease statistics was the first publication to bring together all the available sources of information about the burden of CVD in Europe, including data on death and illness, treatment, the prevalence of behavioural risk factors for CVD (smoking, diet, physical inactivity and alcohol consumption), and the prevalence of medical conditions associated with CVD (raised cholesterol, raised blood pressure, overweight and obesity, and diabetes). It
has become an indispensable resource for anybody working on reducing the burden of CVD in Europe or in public health generally.<br /
Aims The principal aim of the second EUROASPIRE survey was to determine in patients with established coronary heart disease whether the Joint European Societies' recommendations on coronary prevention are being followed in clinical practice.
Methods This survey was undertaken in 1999–2000 in 15 European countries: Belgium, Czech Republic, Finland, France, Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Poland, Slovenia, Sweden, Spain and the U.K., in selected geographical areas and 47 centres. Consecutive patients, men and women ≤70 years were identified retrospectively with the following diagnoses: coronary artery bypass graft, percutaneous transluminal coronary angioplasty, acute myocardial infarction and myocardial ischaemia. Data collection was based on a review of medical records and interview and risk assessment at least 6 months after hospital admission.
Results 8181 medical records (25% women) were reviewed and 5556 patients (adjusted participation rate 76%) interviewed. Recording of risk factor history and risk factor measurement in hospital notes was incomplete, particularly for discharge documents. At interview (median time 1·4 years after hospital discharge), 21% of patients smoked cigarettes, 31% were obese, 50% had raised blood pressure (systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg), 58% had elevated serum total cholesterol (total cholesterol ≥5mmol.l⁻¹) and 20% reported a medical history of diabetes. Glucose control in these diabetic patients was poor with 87% having plasma glucose >6·0mmol.l⁻¹and 72% ≥7·0mmol.l⁻¹. Among the patients interviewed the use of prophylactic drug therapies on admission, at discharge and at interview was as follows: aspirin or other antiplatelets drugs 47%, 90% and 86%; beta-blockers 44%, 66% and 63%; ACE inhibitors 24%, 38% and 38%; and lipid-lowering drugs 26%, 43% and 61%, respectively. With the exception of antiplatelet drugs, wide variations in the use of prophylactic drug therapies exist between countries.
Conclusions This European survey of coronary patients shows a high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of drug therapies to achieve blood pressure and lipid goals. There is considerable potential throughout Europe to raise the standard of preventive cardiology through more effective lifestyle intervention, control of other risk factors and optimal use of prophylactic drug therapies in order to reduce coronary morbidity and mortality.
Background:
The three major European scientific societies in cardiovascular medicine--the European Society of Cardiology (ESC), the European Atherosclerosis Society and the European Society of Hypertension--published in October 1994 joint recommendations on prevention of coronary heart disease in clinical practice. Patients with established coronary heart disease, or other major atherosclerotic disease, were deemed to be the top priority for prevention. A European survey (EUROASPIRE) was therefore conducted under the auspices of the ESC to describe current clinical practice in relation to secondary prevention of coronary heart disease.
Aims:
The aims of EUROASPIRE were (i) to determine whether the major risk factors for coronary heart disease are recorded in patients medical records; (ii) to measure the modifiable risk factors and describe their current management following hospitalization, and (ii) to determine whether first degree blood relatives have been screened.
Methods:
The survey was conducted in selected geographical areas and hospitals in nine European countries. Consecutive patients (< or = 70 years) were identified retrospectively with the following diagnoses: coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute myocardial infarction and acute myocardial ischaemia without infarction. Data collection was based on a retrospective review of hospital medical records and a prospective interview and examination of the patients.
Results:
4863 medical records were reviewed of whom 25% were women, and 3569 patients were interviewed (adjusted response rate 85%) with an average age of 61 years. Nineteen percent of patients smoked cigarettes, 25% were overweight (BMI > or = 30 kg.m-2), 53% had raised blood pressure (systolic BP > or = 140 and/or diastolic BP > or = 90 mmHg), 44% had raised total plasma cholesterol (total cholesterol > or = 5.5 mmol.l-1) and 18% were diabetic. Reported medication at interview was: antiplatelet drugs 81%, beta-blockers, 54% (58% in post-infarction patients). ACE inhibitors 30% (38% in post infarction patients) and lipid lowering drugs 32%. Of the patients receiving blood pressure lowering drugs (not always prescribed for the treatment of hypertension) 50% had a systolic BP > 140 mmHg and 21% > 160 mmHg, and of those receiving lipid lowering drugs, 49% had plasma total cholesterol > 5.5 mmol.l-1 and 13% > 6.5 mmol.l-1. Thirty-seven percent of patients had a family history of premature coronary heart disease in a first-degree blood relative, but only 21% of patients reported being advised to have their relatives screened for coronary risk factors.
Conclusions:
This European survey has demonstrated a high prevalence of modifiable risk factors in coronary heart disease patients. There is considerable potential for cardiologists and physicians to further reduce coronary heart disease morbidity and mortality and improve patients chances of survival.
Background:
Patients with coronary heart disease (CHD) are the top priority for preventive cardiology. The first EUROASPIRE survey among patients with established CHD in nine countries in 1995-96 showed substantial potential for risk reduction. A second survey (EUROASPIRE II) was done in 1999-2000 in the same countries to see whether preventive cardiology had improved since the first. We compared the proportion of patients in both studies who achieved the lifestyle, risk-factor, and therapeutic goals recommended by the Joint European Societies report on coronary prevention.
Methods:
The surveys were undertaken in the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia, and Spain. Consecutive patients (men and women < or = 70 years of age) were identified after coronary-artery bypass graft or percutaneous transluminal coronary angioplasty, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later.
Findings:
3569 and 3379 patients were interviewed in the first and second surveys, respectively. The prevalence of smoking remained almost unchanged at 19.4% vs 20.8%. The prevalence of obesity (body-mass index > or = 30 kg/m2) increased substantially from 25.3% to 32.8%. The proportion with high blood pressure (> or = 140/90 mm Hg) was virtually the same (55.4% vs 53.9%), whereas the prevalence of high total cholesterol concentrations (> or = 5.0 mmol/L) decreased substantially from 86.2% to 58.8%. Aspirin or other antiplatelet therapy was as widely used in the second survey as the first (83.9% overall), and reported use of beta-blockers, angiotensin-converting-enzyme inhibitors, and especially lipid-lowering drugs increased.
Interpretation:
The adverse lifestyle trends among European CHD patients are a cause for concern, as is the lack of any improvement in blood-pressure management, and the fact that most CHD patients are still not achieving the cholesterol goal of less than 5 mmol/L. There is a collective failure of medical practice in Europe to achieve the substantial potential among patients with CHD to reduce the risk of recurrent disease and death.
The aim of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey was to determine whether the Joint European Societies' guidelines on cardiovascular prevention are being followed in everyday clinical practice and to describe the lifestyle, risk factor and therapeutic management in patients with coronary heart disease (CHD) in Europe.
The EUROASPIRE III survey was carried out in 2006-2007 in 76 centres from selected geographical areas in 22 countries in Europe. Consecutive patients, with a clinical diagnosis of CHD, were identified retrospectively and then followed up, interviewed and examined at least 6 months after their coronary event.
Thirteen thousand nine hundred and thirty-five medical records (27% women) were reviewed and 8966 patients were interviewed. At interview, 17% of patients smoked cigarettes, 35% were obese and 53% centrally obese, 56% had a blood pressure >or=140/90 mmHg (>or=130/80 in people with diabetes mellitus), 51% had a serum total cholesterol >or=4.5 mmol/l and 25% reported a history of diabetes of whom 10% had a fasting plasma glucose less than 6.1 mmol/l and 35% a glycated haemoglobin A1c less than 6.5%. The use of cardioprotective medication was: antiplatelets 91%; beta-blockers 80%; angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 71%; calcium channel blockers 25% and statins 78%.
The EUROASPIRE III survey shows that large proportions of coronary patients do not achieve the lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention. Wide variations in risk factor prevalences and the use of cardioprotective drug therapies exist between countries. There is still considerable potential throughout Europe to raise standards of preventive care in order to reduce the risk of recurrent disease and death in patients with CHD.
The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006-07 in 22 countries to see whether preventive cardiology had improved and if the joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice.
Methods EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women = 30 kg/m(2)) increased from 25.0% in EUROASPIRE I, to 32.6% in 11, and 38.0% in III (p=0.0006). The proportion of patients with raised blood pressure (>= 140/90 mm Hg in patients without diabetes or >= 130/80 mm Hg in patients with diabetes) was similar (58.1% in EUROASPIRE 1, 58.3% in II, and 60.9% in III; p=0.49), whereas the proportion with raised total cholesterol (>= 4.5 mmol/L) decreased, from 94.5% in EUROASPIRE I to 76.7% in II, and 46.2% in III (p
This summary is taken from the Second Joint Task Force of European and other Societies Recommendations on Prevention of Coronary Heart Disease in Clinical Practice. The second Task Force was convened by the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS) and the European Society of Hypertension (ESH), the societies responsible for the original 1994 Task Force recommendations on coronary prevention (Chairman Professor K Pyorala) and consisted of a writing group, other invited members and specialists, together with representatives of other European societies and organisations as listed in the appendix. The full Task Force first met in November 1997 to review the original recommendations and agree on the principles for revision. The Writing Group then prepared a new draft of the recommendations and the specialist contributions of Professor Daan Kromhout (diet), Professor Kristina Orth-Gomer (socioeconomic, psychosocial factors and behavioural change), Professor Francois Cambi...
This summary is taken from the Second Joint Task Force of European and other Societies Recommendations on Prevention of Coronary Heart Disease in Clinical Practice. The second Task Force was convened by the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS) and the European Society of Hypertension (ESH), the societies responsible for the original 1994 Task Force recommendations on coronary prevention (Chairman Professor K Pyörälä) and consisted of a writing group, other invited members and specialists, together with representatives of other European societies and organisations as listed in the appendix. The full Task Force first met in November 1997 to review the original recommendations and agree on the principles for revision. The Writing Group then prepared a new draft of the recommendations and the specialist contributions of Professor Daan Kromhout (diet), Professor Kristina Orth-Gomér (socioeconomic, psychosocial factors and behavioural change), Professor Francois Cambien (genetics) and Dr Carlos Brotons (opportunities and barriers for coronary prevention) are gratefully acknowledged. This was submitted to a second Task Force meeting in April 1998 for approval. After this meeting the Writing Group prepared the final version of the recommendations and this was approved by the full Task Force in June. The expert advice of Professor Philip Home and Professor George Alberti on diabetes mellitus is gratefully acknowledged. The document was then approved by the ESC, EAS and ESH. The Task Force recommendations have been published in the European Heart Journal, Atherosclerosis and the Journal of Hypertension (summary only).
Guidelines aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making. A great number of guidelines have been issued in recent years by different organisations--European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and other related societies. By means of links to web sites of National Societies several hundred guidelines are available. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing guidelines. In spite of the fact that standards for issuing good quality guidelines are well defined, recent surveys of guidelines published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilisation of health resources. In addition, the legal implications of medical guidelines have been discussed and examined, resulting in position documents, which have been published by a specific task force. The ESC Committee for practice guidelines (CPG) supervises and coordinates the preparation of new guidelines and expert consensus documents produced by task forces, expert groups or consensus panels. The Committee is also responsible for the endorsement of these guidelines or statements.
Our aim was to calculate the global burden of disease and risk factors for 2001, to examine regional trends from 1990 to 2001, and to provide a starting point for the analysis of the Disease Control Priorities Project (DCPP).
We calculated mortality, incidence, prevalence, and disability adjusted life years (DALYs) for 136 diseases and injuries, for seven income/geographic country groups. To assess trends, we re-estimated all-cause mortality for 1990 with the same methods as for 2001. We estimated mortality and disease burden attributable to 19 risk factors.
About 56 million people died in 2001. Of these, 10.6 million were children, 99% of whom lived in low-and-middle-income countries. More than half of child deaths in 2001 were attributable to acute respiratory infections, measles, diarrhoea, malaria, and HIV/AIDS. The ten leading diseases for global disease burden were perinatal conditions, lower respiratory infections, ischaemic heart disease, cerebrovascular disease, HIV/AIDS, diarrhoeal diseases, unipolar major depression, malaria, chronic obstructive pulmonary disease, and tuberculosis. There was a 20% reduction in global disease burden per head due to communicable, maternal, perinatal, and nutritional conditions between 1990 and 2001. Almost half the disease burden in low-and-middle-income countries is now from non-communicable diseases (disease burden per head in Sub-Saharan Africa and the low-and-middle-income countries of Europe and Central Asia increased between 1990 and 2001). Undernutrition remains the leading risk factor for health loss. An estimated 45% of global mortality and 36% of global disease burden are attributable to the joint hazardous effects of the 19 risk factors studied. Uncertainty in all-cause mortality estimates ranged from around 1% in high-income countries to 15-20% in Sub-Saharan Africa. Uncertainty was larger for mortality from specific diseases, and for incidence and prevalence of non-fatal outcomes.
Despite uncertainties about mortality and burden of disease estimates, our findings suggest that substantial gains in health have been achieved in most populations, countered by the HIV/AIDS epidemic in Sub-Saharan Africa and setbacks in adult mortality in countries of the former Soviet Union. Our results on major disease, injury, and risk factor causes of loss of health, together with information on the cost-effectiveness of interventions, can assist in accelerating progress towards better health and reducing the persistent differentials in health between poor and rich countries.
Other experts who contributed to parts of the guidelines: Edmond Walma, Tony Fitzgerald, Marie Therese Cooney, Alexandra Dudina
European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson), John Camm, Raffaele De Caterina, Veronica Dean, Kenneth Dickstein, Christian Funck-Brentano, Gerasimos Filippatos, Irene Hellemans, Steen Dalby Kristensen, Keith McGregor, Udo Sechtem, Sigmund Silber, Michal Tendera, Petr Widimsky, Jose Luis Zamorano
Document reviewers: Irene Hellemans (CPG Review Co-ordinator), Attila Altiner, Enzo Bonora, Paul N. Durrington, Robert Fagard, Simona Giampaoli, Harry Hemingway, Jan Hakansson, Sverre Erik Kjeldsen, Mogens Lytken Larsen, Giuseppe Mancia, Athanasios J. Manolis, Kristina Orth-Gomer, Terje Pedersen, Mike Rayner, Lars Ryden, Mario Sammut, Neil Schneiderman, Anton F. Stalenhoef, Lale Tokgözoglu, Olov Wiklund, Antonis Zampelas
Our aim was to investigate whether a nurse-coordinated multidisciplinary, family-based preventive cardiology programme could improve standards of preventive care in routine clinical practice.
In a matched, cluster-randomised, controlled trial in eight European countries, six pairs of hospitals and six pairs of general practices were assigned to an intervention programme (INT) or usual care (UC) for patients with coronary heart disease or those at high risk of developing cardiovascular disease. The primary endpoints-measured at 1 year-were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescription of cardioprotective drugs. Analysis was by intention to treat. The trial is registered as ISRCTN 71715857.
1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC, respectively. In patients with coronary heart disease who smoked in the month before the event, 136 (58%) in the INT and 154 (47%) in the UC groups did not smoke 1 year afterwards (difference in change 10.4%, 95% CI -0.3 to 21.2, p=0.06). Reduced consumption of saturated fat (196 [55%] vs 168 [40%]; 17.3%, 6.4 to 28.2, p=0.009), and increased consumption of fruit and vegetables (680 [72%] vs 349 [35%]; 37.3%, 18.1 to 56.5, p=0.004), and oily fish (156 [17%] vs 81 [8%]; 8.9%, 0.3 to 17.5, p=0.04) at 1 year were greatest in the INT group. High-risk individuals and partners showed changes only for fruit and vegetables (p=0.005). Blood-pressure target of less than 140/90 mm Hg was attained by both coronary (615 [65%] vs 547 [55%]; 10.4%, 0.6 to 20.2, p=0.04) and high-risk (586 [58%] vs 407 [41%]; 16.9%, 2.0 to 31.8, p=0.03) patients in the INT groups. Achievement of total cholesterol of less than 5 mmol/L did not differ between groups, but in high-risk patients the difference in change from baseline to 1 year was 12.7% (2.4 to 23.0, p=0.02) in favour of INT. In the hospital group, prescriptions for statins were higher in the INT group (810 [86%] vs 794 [80%]; 6.0%, -0.5 to 11.5, p=0.04). In general practices in the intervention groups, angiotensin-converting enzyme inhibitors (297 [29%] INT vs 196 [20%] UC; 8.5%, 1.8 to 15.2, p=0.02) and statins (381 [37%] INT vs 232 [22%] UC; 14.6%, 2.5 to 26.7, p=0.03) were more frequently prescribed.
To achieve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to individual countries, which are accessible by all hospitals and general practices caring for coronary and high-risk patients.
et al on behalf of the EUROACTION Study Group EUROACTION: A European Society of Cardiology demonstration project in preventive cardiology
- Da Wood
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- A Mead
- J Jones
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Wood DA, Kotseva K, Jennings C, Mead A, Jones J, Holden A, et al on behalf of the EUROACTION Study Group. EUROACTION: A European Society of Cardiology demonstration project in preventive cardiology. Eur Heart J. 2004;6 Suppl J:J3-J15.
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
- K Kotseva
- D Wood
- G Backer
- D Bacquer
- K Pyorala
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.
European Cardiovascular disease statistics: 2008 edition. London: British Heart Foundation
- S Allender
- P Scharbotough
- Rayner V M Peto
- J R Leal
Allender S, Scharbotough P, Peto V, Rayner M, Leal J, Luengo-Fernández R, et al. European Cardiovascular disease statistics: 2008 edition. London: British Heart Foundation; 2008.
on behalf of EUROASPIRE study Group Cardiovascular prevention guidelines-the clinical reality: a comparison of EUROASPIRE I, II and III surveys in 8
- K Kotseva
- D Wood
- G De Backer
- D De Bacquer
- K Pyorala
- U Keil
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
European countries. Lancet. 2009;372:929-40.
Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II. Euro Heart Survey Programme
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EUROASPIRE Study Group. Lifestyle and risk factor
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