In The Lancet today, the EUROASPIRE study group reports on cardiovascular prevention guidelines in daily practice, comparing EUROASPIRE I, II, and III surveys in eight European countries.2 This study collates data from 1995—96, 1999—2000, and 2006—07 on medical treatment and risk factor status roughly 1 year after a cardiac event in men and women 70 years or younger. Overall, the results are discouraging. Even if drug treatment according to guidelines and blood lipid status substantially improved, the attainment of therapeutic targets for blood pressure in general and glycaemic control in patients with diabetes mellitus in general did not. About a fifth of patients continued to smoke, with no reduction over the 12 years. Furthermore, of great concern is the substantial rise in obesity and diabetes mellitus—in the 2006—07 survey, almost 40% of patients were obese (body-mass index 30 kg/m2 or higher) and close to 30% reported diabetes mellitus.

The study thus shows a continuing gap between the standards set in guidelines on secondary cardiovascular risk prevention and results achieved in clinical practice. Only a third of patients with coronary heart disease in Europe are able to join a cardiac rehabilitation programme,2 and the authors claim that this service should be made accessible to all. Cardiac rehabilitation is characterised by comprehensive, multidisciplinary long-term programmes that involve medical assessment, prescribed exercise, risk-factor modification, education, and counselling—resource demanding in terms of costs and effort from patients and health personnel.3 Still, comprehensive cardiac rehabilitation has not been definitely proven to be more efficient in relation to hard endpoints than exercise alone.4 Its effect on lifestyle might be of modest clinical significance; in a study from a Norwegian inpatient institution that specialises in cardiac rehabilitation the highly motivated patients increased intake of fruit by 0·6 units daily and fish dinners by only 0·1 meals a week when assessed 6 months after a 3-week course.5

By studying patients' medical treatment and risk factor status, the EUROASPIRE investigators indirectly measure physicians' ability to adhere to guidelines on secondary cardiovascular risk prevention. We would expect doctors to more easily follow prescription guidelines than patients change dietary habits or stop smoking. But even if more prescriptions are being made than were previously, therapeutic targets are still out of reach. Are doctors reluctant to add yet another expensive drug with potential side-effects to compensate for a persistent lifestyle problem? Do they find the guidelines' targets too ambitious? Or are they not sufficiently updated on the latest guidelines? A positive step is that the European Society of Cardiology through the EUROACTION model has developed and assessed an intervention for patients with coronary heart disease that involves improving physicians' achievement of guideline targets—with promising results.6 General practitioners should indeed focus on optimum treatment of patients that are high risk instead of medicalising low-risk people in the name of primary prevention.7

Patients in the present study have had a cardiac event before the age of 70 years. They comprise a select high-risk group but also show trends in the general population. The increase of obesity and prevalence of diabetes mellitus during the study period gives serious cause for concern and indicates the adverse dietary habits and sedentary lifestyle of people in general, although with a socioeconomic gradient.8 Trends for smoking in western European countries might seem encouraging—the latest census data in Norway show that only one person of seven younger than 24 years is a daily smoker.9 The ban on indoor smoking in public areas has probably contributed substantially to this trend.

The results from the EUROASPIRE study give three messages. First, to help patients with coronary heart disease achieve a healthy lifestyle should be mandatory and have high priority for doctors and health authorities. Second, therapeutic targets in guidelines need to be continually discussed. Blood pressure and lipid targets that are too ambitious might take focus away from important lifestyle issues. Finally, secondary risk prevention is not enough. Political action is needed to reverse the negative trends of obesity and sedentary habits, ranging from fighting against the fast food and sugar industries to safe bicycle paths and healthy school meals.

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 Practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil 2007; 28: 2375-2424.
2 Kotseva K, Wood D, De Backer G, De Bacquer D, Pyörälä K, Keil Ufor the EUROASPIRE Study. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009; 373: 929-940.
3 Balady GJ, Ades PA, Comoss P, et al. Core components of cardiac rehabilitation/secondary prevention programs: a statement for healthcare professionals from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Circulation 2000; 102: 1069-1073.
4 Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116: 682-692.
5 Mildestvedt T, Meland E, Eide G. No difference in lifestyle changes by adding individual counselling to group-based rehabilitation RCT among coronary heart disease patients. Scand J Public Health 2007; 35: 591-598.
6 Wood DA, Kotseva K, Connolly S, et alon behalf of the EUROACTION Study. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008; 371: 1999-2012.
7 Getz L, Kirkengen AL, Hetlevik I, Romundstad S, Sigurdsson JA. Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. Scand J Prim Health Care 2004; 22: 202-208.
8 Avendano M, Kunst AE, Huisman M, et al. Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s. Heart 2006; 92: 461-467.
9 Steady decline in number of daily Statistics Norway. http://www.ssb.no/english/subjects/03/01/royk_en/ (accessed Feb 12, 2009).