Author + information
- Kornelia Kotseva, MD, PhD,
- Dirk De Bacquer, PhD,
- Catriona Jennings, PhD,
- Viveca Gyberg, MD, PhD,
- Guy De Backer, MD, PhD,
- Lars Rydén, MD, PhD,
- Philippe Amouyel, MD, PhD,
- Jan Bruthans, MD, PhD,
- Renata Cifkova, MD, PhD,
- Jaap W. Deckers, MD, PhD,
- Johan De Sutter, MD, PhD,
- Zlatko Fraz, MD, PhD,
- Ian Graham, MD,
- Irena Keber, MD, PhD,
- Seppo Lehto, MD, PhD,
- David Moore, MD,
- Andrzej Pajak, MD, PhD,
- David Wood, MD, MSc∗ (, )
- on behalf of the EUROASPIRE Investigators
- ↵∗International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, United Kingdom
Three EUROASPIRE (EUROpean Action on Secondary and Primary prevention In order to Reduce Events) surveys, conducted between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and United Kingdom, sought to describe in coronary patients time trends in lifestyle, risk factor control including management of diabetes, and cardioprotective medications (1,2). They were undertaken in the same geographic areas and hospitals including ≥1 hospital, offering interventional cardiology and cardiac surgery. Consecutive patients with coronary disease (≥18 to <70 years of age) were identified from hospital discharge lists: 1) coronary artery bypass grafting; 2) percutaneous coronary intervention; 3) acute myocardial infarction; and 4) unstable angina were interviewed and examined ≥6 months later. A centralized training base of data collectors and standardized methodologies, including central laboratory measurements, ensured data quality.
Of 12,775 identified patients, 8,456 were interviewed (66.2%): 3,320 patients in EUROASPIRE II (1999 to 2000), 2,632 in EUROASPIRE III (2006 to 2007), and 2,513 in EUROASPIRE IV (2012 to 2013). Interview rates were 67.5%, 63.6%, and 51.4%, respectively. A comparison of those attending with those who did not showed lower participation in women, in younger patients (except EUROASPIRE II), and those not revascularized. The time trends in lifestyle, medical risk factors, and prescriptions for cardioprotective medications are presented in Figures 1A and 1B. The proportion of persistent smokers was similar (52%, 55%, 53%; p = 0.67), whereas obesity (32%, 33%, 39%; p = 0.007) and self-reported diabetes (19%, 24%, 27%; p = 0.004) increased. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes; 54%, 52%, 45%; p = 0.01) and raised low-density lipoprotein (LDL)-cholesterol (≥1.8 mmol/l) decreased (96%, 80%, 75%; p <0.0001). The use of high-intensity statins (atorvastatin, 40 to 80 mg, or rosuvastatin, 20 to 40 mg, or simvastatin, 80 mg) increased (in EUROASPIRE III to IV 23.0% to 45.1%).
The comparison among 3 surveys over 14 years provides a unique description of time trends for secondary prevention. They reveal stagnation in the prevalence of persistent smokers and increases in obesity and diabetes. Despite improvements in blood pressure and LDL-cholesterol control, the adverse lifestyle trends with a concomitant increase in the prevalence of diabetes will counteract some of these gains.
The prevalence of persistent smokers did not change but most smokers attempted to quit after their coronary event; however, use of pharmacotherapies was low. The rising prevalence of obesity brings, together with an absolute increase in diabetes of 9%, an increased risk of recurrent macrovascular disease, microvascular disease, and reduction in life expectancy. Despite an increase in the proportions of patients achieving the blood pressure and lipid targets there is further potential to reduce cardiovascular risk through more effective control. The 2012 Joint European guidelines on cardiovascular prevention propose a more conservative blood pressure target of <140/90 mm Hg, which is still not being achieved, and an even more rigorous LDL-cholesterol target of <1.8 mmol/l requiring more intensive management of both blood pressure and lipids. The risk of recurrent disease could be further reduced by optimizing the dose of cardioprotective medications and improving patient adherence.
The trends in prevalence and control of cardiovascular risk factors in EUROASPIRE are in accordance with earlier multinational studies conducted in Europe and the United States. The results from 6 consecutive National Health and Nutrition Examination Surveys from 1999 to 2000, to 2009 to 2010 showed improvement of LDL-cholesterol but in 2009 to 2010 only 58% of individuals with CHD or risk equivalents had controlled LDL-cholesterol. The new American College of Cardiology/American Heart Association guidelines do not have an LDL-cholesterol target and recommend high-intensity statins for all patients with coronary heart disease and there has been a 2-fold increase in proportions of patients on high-intensity statins between EUROASPIRE III and IV.
The main strengths of the EUROASPIRE surveys are participation by the same countries, geographic regions, and hospitals, and maintaining standardized methodologies over 14 years, so time trends can be described with confidence. The geographic regions studied are not nationally representative and the standard of care in specialized centers is probably higher and therefore the reality of secondary prevention practice in general hospitals is likely to be poorer than described by EUROASPIRE.
In conclusion, time trends from the EUROASPIRE surveys show the enormous and continuing challenges in implementing evidence-based prevention guidelines in clinical practice for coronary patients. The life-saving treatments for acute coronary artery disease through angioplasty, stenting and surgery, and cardioprotective medications must be matched by modern preventive cardiology programs combining a professional lifestyle intervention with effective risk factor control to reduce total cardiovascular risk.
Please note: The three EUROASPIRE surveys were carried out under the auspices of the European Society of Cardiology, Euro Heart Survey and subsequently the EURObservational Research Programme. The European Society of Cardiology received unrestricted research grants from AstraZeneca, Bristol-Myers Squibb, Merck, Sharp & Dohme, and Pfizer (EUROASPIRE II); AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck/Schering-Plough, Novartis, Pfizer, Sanofi-Aventis, and Servier (EUROASPIRE III); and Amgen, AstraZeneca, Bristol-Myers Squibb, F. Hoffman-La Roche, GlaxoSmithKline, and Merck Sharp & Dohme (EUROASPIRE IV). The sponsors of the EUROASPIRE surveys had no role in the design, data collection, data analysis, data interpretation, decision to publish, or writing the manuscript. Drs. Kotseva, Jennings, Gyberg, Rydén, and Wood received grant support from the European Society of Cardiology for the submitted work. Dr. Gyberg was supported by a grant from the Swedish Heart and Lung Foundation. Dr. Pajak was supported by a grant from Polish Ministry of Science and Higher Education (Sources for Science 2006 to 2009) and National Science Centre (DEC-2011/03/B/N27/06101). Dr. Bruthans was supported by the grant No NT 13186 by the Internal Grant Agency, Ministry of Health, Czech Republic. Dr. Moore has received grants from Servier, MSD, Sanofi-Aventis, and Menarini. Dr. Amouyel has received a grant from AstraZeneca. The following had financial activities outside the submitted work within the past 2 years: Dr. Wood has received honoraria for invited lectures or advisory boards from Amgen and AstraZeneca. Dr. de Backer was a consultant to MSD and AstraZeneca. Dr. Rydén has received grants from Swedish Heart Lung Foundation, Swedish Diabetes Association, Roche AG, Bayer AG, and Karolinska Institute Funds; and personal fees from Roche, Sanofi-Aventis, and Bayer AG. Dr. Gyberg has received lecture fees from MSD Sweden. Dr. Amouyel has received grants and personal fees from Fondation Plan Alzheimer, Servier, Alzprotect, Total, Roche, Daiichi-Sankyo, and Genoscreen. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2015 American College of Cardiology Foundation
- Kotseva K.,
- Wood D.,
- De Bacquer D.,
- et al.,
- on behalf of the EUROASPIRE Investigators