Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries

Summary

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 ≤ 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 ≥ 30 kg/m²) increased substantially from 25·3% to 32·8%. The proportion with high blood pressure (≥ 140/90 mm Hg) was virtually the same (55·4% vs 53·9%), whereas the prevalence of high total cholesterol concentrations (≥ 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 β-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.

Introduction

The objective for patients with coronary heart disease (CHD) is to reduce their risk of further coronary and other atherosclerotic events, to improve quality of life, and to increase the chances of survival. Such patients are defined as the highest priority for prevention in the recommendations drawn up by the European Society of Cardiology, the European Atherosclerosis Society, and the European Society of Hypertension (collectively known as the Joint European Societies).1, 2 The aim of these recommendations is to raise the standard of preventive cardiology by stimulating the development and revision of national guidelines by multidisciplinary alliances of professional societies, and their dissemination, implementation, and audit by cardiologists and other physicians in hospitals and the community. The European recommendations define goals with regard to lifestyle, risk factors, and therapy. These goals are to stop smoking, make healthy food choices, and become physically active; to achieve a body-mass index (BMI) of less than 25 kg/m², a blood pressure of lower than 140/90 mm Hg, a total cholesterol concentration of less than 5·0 mmol/L, and an LDL-cholesterol concentration of less than 3·0 mmol/L; and to use appropriate prophylactic drugs such as aspirin or other platelet-modifying drugs, β-blockers, angiotensin-converting-enzyme (ACE) inhibitors, and anticoagulants.

After the publication of the Joint European Societies' recommendations on coronary prevention in 1994, the European Society of Cardiology did a survey called EUROASPIRE I (European Action on Secondary Prevention by Intervention to Reduce Events) in nine countries: the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia, and Spain during 1995–96.³ This study focused on patients with CHD, and was based on a survey in the UK called ASPIRE.⁴ Both surveys showed a high prevalence of modifiable risk factors, and therefore substantial potential to reduce the risk of recurrent non-fatal coronary disease and death. After the publication of the 1998 Joint European Societies' recommendations on coronary prevention, another survey (EUROASPIRE II) was done in 15 European countries under the auspices of the European Society of Cardiology, Euro Heart Survey Programme, including the same countries, and almost identical centres, that participated in the first survey. The main results of EUROASPIRE II have now been published.⁵ One of the objectives of this second survey was to see whether the practice of preventive cardiology in patients with CHD has improved in the centres that took part in EUROASPIRE I. Here we fulfil this objective by comparing the results of EUROASPIRE I and EUROASPIRE II.