European Journal of Preventive Cardiology | 2019
Inadequate control of atherosclerotic cardiovascular disease risk factors in Europe: EUROASPIRE repeats itself
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide and Europe is no exception. Over the last six decades there has been a huge increment in the knowledge about causal risk factors for ASCVD. Indeed, healthier lifestyles and pharmacological interventions have significantly contributed to a reduction of about one-third in coronary heart disease and atherothrombotic stroke mortality, mainly in developed areas of the world. In addition to the challenge to adhere beneficial lifestyle habits, such as smoking cessation, weight loss and regular physical activity, pharmacological treatments that modify the course of ASCVD were established in robust randomized controlled trials enrolling hundreds of thousands of individuals. Based on this knowledge, preventive cardiology practice guidelines were created and updated in Europe and elsewhere according to the information accrued over the last 30 years. The basic secondary ASCVD prevention medication kit includes antiplatelet and lipid lowering medications, mostly statins, beta blockers and medications counteracting the renin–angiotensin system mainly for individuals with left ventricular dysfunction or type 2 diabetes, and other blood pressure lowering medications for hypertensives. As new evidence was published more aggressive blood pressure and, especially, lower low-density lipoprotein (LDL) cholesterol goals were adopted, the latter meaning the recommendation for the use of high doses of potent statins with the aim of reducing LDL-cholesterol by at least by 50%. Finally, dual antiplatelet therapy became standard of care for at least a year after an acute coronary event. Guidelines are hard to develop but harder to implement. Both lack of patient and physician literacy about ASCVD, as well as the so-called clinical inertia, certainly reduce the effectiveness of preventive therapies. Establishment and adherence to preventive measures are extremely important to reduce the burden of ASCVD. This is where registries like the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) enter the scene to verify how physicians and patients are dealing with guideline recommendations in the real world. The information contained in these registries helps development of policies and programs from government, medical societies and patient organizations in order to reduce ASCVD morbidity and mortality. In this issue of the European Journal of Preventive Cardiology Kornelia Kotseva et al. publish the results of the newest of these surveys: EUROASPIRE V. The authors must be congratulated not only for this last study but also for the four previous ones clearly showing that there was an improvement in how secondary prevention patients have been treated over the last 30 years in Europe (Figures 1 and 2). However, unfortunately, the authors show that risk factors still persist uncontrolled in a substantial number of studied individuals. For instance, numbers of recalcitrant smokers and sedentary individuals persisted, at very similar levels to the previous EUROASPIRE surveys, respectively at 19% and 66%. Interestingly, EUROASPIRE V shows that even after a median 1.1-year subsequent to an ASCVD event, 50% of smokers still did not quit and only 5% of interviewed subjects attended a smoking cessation clinic. This occurred in spite of these services being offered to 85% of those who persisted in smoking. Moreover, if we compare the evolution of the surveys in the last 30 years, as shown in Figure 2, the obesity epidemics became the new elephant on the room of preventive medicine, with 38% of individuals being obese in EUROASPIRE IV and V in comparison with 25% in EUROASPIRE I. Of interest, only 50% of obese patients tried to lose weight.