Primary prevention of coronary heart disease: challenges and achievements

The European Society of Cardiology together with other partner Societies has engaged in a comprehensive programme of prevention of cardiovascular disease (CVD) since 1994. Guidelines on this important topic have been developed and updated at regular intervals over the last 13 years, most recently in 2007.

The implementation of these guidelines is facilitated by the Joint European Prevention Committee and the new European Association for Cardiovascular Prevention and Rehabilitation through a network of national coordinators all over Europe. Results are evaluated with audit surveys called EUROASPIRE starting in the mid-nineties with EUROASPIRE I, EUROASPIRE II at the turn of the millennium and EUROASPIRE III in 2006/07. This third EUROASPIRE survey has evaluated how effectively these recommendations have been implemented in daily practice in relation to the standards set in the Third Joint European Task Force guidelines on CVD prevention in 2003.

All three EUROASPIRE surveys have evaluated how patients with established CVD, who are the top clinical priority, are being managed, but in this third survey, the second priority group of asymptomatic individuals who are at high risk of developing CVD have been addressed. These apparently healthy individuals are at increased total CV risk because of markedly raised levels of blood pressure, cholesterol or the development of diabetes.

This "primary care arm" of EUROASPIRE III took place in 12 European countries in close collaboration with General Practitioners. Asymptomatic subjects, free of CVD, were identified and invited to participate if they fulfilled the following conditions:

• Men and women aged < 80 years;
• Free of clinical CVD;
• Either started on drug therapy for arterial hypertension;
• On lipid lowering drugs or treated with diet;
• On hypoglycaemics or insuline because of type 2 diabetes for at least six months, but not more than three years prior to this study

Volunteers were seen by trained technicians for an interview and examination using standardised methods and central laboratory measurement of lipids and glucose.

A total of 4366 individuals participated (78% of all eligible patients): 58% females, mean age approximately 60 years. 2853 were on drug treatment for arterial hypertension, 1529 on lipid lowering drugs and 1031 were treated for type 2 diabetes.

Smoking of tobacco was still prevalent in 16.5% of all subjects, even in 30% of men < 50 years of age. 37% and 43% of men and women respectively didn't exercise on a regular basis and didn't intend to do so. Four out of five patients (83.4%) were overweight or obese (Body Mass Index of > = 25 Kg/m2) and most were centrally obese as well.

Blood pressure was not within guideline recommended limits (BP < 140/90 mmHg or < 130/80 mmHg in patients with diabetes), in 71% of volunteers, despite the use of blood pressure lowering drugs by 79% of the subjects.

Among all individuals treated with lipid lowering drugs and/or with a total cholesterol of >= 4.5 mmol/l, only 31% was on target according to the guidelines. Among all subjects treated for type 2 diabetes, fasting glycaemia was < 7 mmol/l in 27% and HbA1c < 6.5% in 53%.

These lifestyle and risk factor results clearly demonstrate a challenging gap between what is recommended in the guidelines based on scientific evidence and what is achieved in daily practice in high risk individuals in primary prevention of CVD. Primary prevention needs a comprehensive, multidisciplinary approach involving the high-risk population, their GP's and other health professionals, a health insurance system dedicated to prevention and all this complemented by a population strategy involving the community at large.