London, UK - Results from the latest European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) surveys are so discouraging that investigators say they should be a cause for concern to all health policy makers, physicians, and other health-care professionals responsible for the care of patients with coronary heart disease [1].

In examining cardiovascular prevention guidelines in daily practice in eight European countries, investigators observed many adverse lifestyle trends, including increases in obesity, diabetes mellitus, and smoking in younger female subjects, as well as no improvements in blood-pressure management.

The findings, published in the March 14, 2009 issue of the Lancet, highlight a continuing gap between standards set in cardiovascular disease prevention guidelines and clinical practice, according to investigators.

"The European healthcare systems are dominated by acute care, medical technology, devices, and pharmacological treatments," write lead investigator Dr Kornelia Kotseva (Imperial College London, UK) and colleagues. "Lifestyles are judged as private issues. However, lifestyle programs could be an integral part of healthcare provision and health insurance plans. All patients with coronary heart disease would benefit from access to a comprehensive cardiovascular prevention and rehabilitation program. To salvage the acutely ischemic myocardium without addressing the underlying lifestyle causes of the disease is futile; we need to invest in prevention."

In an editorial accompanying the published study [2], Drs Mette Brekke and Bjørn Gjelsvik (both from University of Oslo, Norway) called the results of the EUROASPIRE studies "discouraging." They note that recommendations for lifestyle changes are increasingly emphasized in cardiac rehabilitation and secondary risk prevention, including advice to stop smoking, make healthy food choices, and become physically active.

"Is this advice not worth the paper it is written on?" ask Brekke and Gjelsvik.

The first EUROASPIRE survey by the European Society of Cardiology (ESC) was performed in 1995-1996 in nine countries, and the second survey was performed in 1999-2000. Both of these showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey, performed in 2006-2007 in 22 countries, was conducted to determine whether preventive cardiology had improved and whether prevention guidelines were being followed.

The analysis, first presented at the ESC Congress in 2007 and reported by heartwire at that time, examined trends in the eight countries that have participated in all three surveys, including the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia.

Overall, about 20% of patients continue to smoke, and this rate is almost unchanged over the 12-year period. However, the data suggest worrisome trends within these data, such as an increase in number of women smokers, as well as an increase in smoking in men and women younger than 50 years.

Obesity is also more rampant, with more than 80% of all coronary heart disease patients considered overweight or obese. With this, there is also more self-reported diabetes among these patients. The number of patients with hypertension is unchanged from 1995, although the proportion of patients with elevated total-cholesterol levels is down. Despite this, roughly half of all patients still had cholesterol levels considered too high by current guidelines.

a. Elevated blood pressure is defined as 140 mm Hg or more systolic or 90 mm Hg or more diastolic for those without diabetes and 130 or mm Hg or more systolic or 80 mm Hg or more diastolic for those with diabetes

b. Elevated serum total cholesterol was defined as >4.5 mmol/L (>175 mg/dL)

The investigators note that these results occurred despite increases in the use of medical therapy, including blood-pressure-lowering drugs. In 2006-2007, 97% of patients were prescribed an antihypertensive medication, while 89% were prescribed cholesterol-lowering therapy, namely statins.

In their editorial, Brekke and Gjelsvik suggest that physicians should be able to follow guidelines on secondary prevention more easily than patients are able to alter lifestyle habits. Yet these therapeutic targets are still out of reach. Whether the reason is that doctors are reluctant to add another expensive drug with potential side effects to a problem perceived as lifestyle-based, that the targets are too ambitious, or simply that doctors are unaware of the latest guidelines is unknown, they write.

Brekke and Gjelsvik point out that cardiac rehabilitation, characterized by multidisciplinary, long-term programs that include dietary counseling and exercise prescription alongside medical therapy, is expensive and has not definitively been proven to be more effective at reducing hard clinical end points when compared with exercise alone. Still, helping coronary heart disease patients achieve a healthy lifestyle "should be mandatory" and a high priority for physicians and health authorities.

Political action is also needed to reverse the negative trends of obesity and unhealthy lifestyle, and this includes fighting against the fast-food and sugar industries as well as creating safe bicycle paths and healthy school meals, write the editorialists.