Researchers call for new approach to the secondary prevention of coronary disease

The large majority of coronary patients in Europe are failing to achieve their lifestyle, risk factor and therapeutic targets as set out in the latest prevention guidelines. Fewer than one half of all European patients following a heart attack are even receiving the benefits of cardiac rehabilitation and preventive care.

In the light of the findings, from EUROASPIRE IV, largest survey of coronary care in Europe, the investigators are now calling for "a new approach to cardiovascular prevention...  which integrates cardiac rehabilitation and secondary prevention into modern preventive cardiology programmes with appropriate adaptation to medical and cultural settings in each country". Such an approach, they add, requires multidisciplinary teams and should involve both patients and their families in a bid to achieve prevention targets and improve quality of life and survival.

EUROASPIRE IV is an ongoing survey run under the auspices of the European Society of Cardiology EURObservational Research Programme. This latest survey was undertaken at 78 centres in 24 European countries. A total of 16,426 medical records were reviewed and 7998 coronary patients identified and interviewed. The median time between index event and interview was 1.35 years. The results of the survey are reported today in the European Journal of Preventive Cardiology.

Throughout the two decades of EUROASPIRE surveys, results have reflected continuing adverse lifestyle trends, in particular an evident increase in obesity and a persistently high prevalence of smoking in younger patients. This latest survey, performed throughout 2012 and 2013, shows emphatically that these trends continue. For example:

• Almost one-half of those who smoked before their cardiac event were still smokers at follow-up; the prevalence of smoking among these persistent smokers was highest in younger patients (under 50 years), both men and women. Stopping smoking after a heart attack is an effective preventive action, shown in several important studies to reduce coronary mortality by at least 36%. Yet, say the investigators, despite this evidence fewer than one in five of those still smoking were advised to attend a smoking cessation clinic, and only a small minority did so.
• A majority of coronary patients did report increasing physical activity levels and changing diet since hospitalisation. However, only four out of 10 achieved a physical activity level of moderate or vigorous intensity during at least 20 minutes on one or more occasions a week.
• A majority of coronary patients were overweight or obese, many with central obesity, contributing to the high prevalence of diabetes. Many obese patients were uninformed about their weight and nearly half did not follow any dietary recommendations or increase their physical activity levels. Many had no plans to lose weight.
• Although information on hypertension was well recorded in discharge notes, less than one-third of coronary patients taking blood pressure medication had reached the recommended target (which at the time was 130/80 mmHg or below). A more conservative target of 140/90 mmHg was recommended in 2012 guidelines, but even this was not achieved by more than two-fifths of the patients.
• Less than two-thirds of coronary patients had reached the conservative LDL cholesterol target of <2.5 mmol/l (and only one-fifth the 2012 target of <1.8 mmol/l), despite lipid-lowering therapy. " Coronary patients require more intensive cholesterol management," say the investigators.
• Similarly, glucose control in previously diagnosed diabetes was poor, with just over one-third achieving the target levels for HbA1c of 6.5% (a measure of sugar in blood) - and still less than half using the new target level of 7.0 mmol/l.

In reviewing the results the investigators note considerable variation between European countries in lifestyle and risk factor management, the use of cardioprotective medication, and the provision of rehabilitations services. Indeed, despite the strength of evidence, cardiac prevention and rehabilitation in Europe continues to be widely underused, they say, with enormous heterogeneity in service provision between countries. Overall less than one-half of coronary patients access such services.

The study's first author and Chair of the EUROASPIRE Steering Committee, Dr Kornelia Kotseva from the National Heart and Lung Institute, Imperial College London, described the results as "very disappointing".

She said: "A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Despite the existence of clear, evidence-based guidelines, their integration into routine clinical care remains disappointing, and there is still much room to raise the standards of preventive cardiology throughout Europe."

EUROASPIRE's Principal Investigator, Professor David Wood, also from the National Heart and Lung Institute in London, added: "Acute intervention should always be followed by prevention. While the cardiology community is focussed on rescuing the acutely ischaemic myocardium, there is insufficient investment in protecting the heart and circulation."