Treatment of European coronary patients fails to meet standards of international guidelines

Large proportions of European coronary patients are failing to achieve lifestyle, risk factor and therapeutic targets for the prevention of further disease, according to results of the third EUROASPIRE survey.

(1) The survey, conducted on behalf of the European Society of Cardiology (ESC), analysed medical records and interviewed almost 9000 patients with coronary heart disease in 22 countries of Europe.

"It is a matter of the greatest professional concern that so many coronary patients are not being managed to the standards set in European prevention guidelines and as a result are at increased risk of atherosclerotic disease and a shorter life expectancy," said Professor David Wood from the National Heart & Lung Institute in London, the principal investigator of EUROASPIRE III.

EUROASPIRE III is the third survey of the series and was carried out in 2006-2007 in patients from 76 coronary care centres in Europe. Consecutive patients with a diagnosis of coronary heart disease were identified and interviewed and examined at least six months after their coronary event.

Results from the interviews showed that

• 17% smoked cigarettes
• 35% were obese
• 53% were centrally obese
• 56% had blood pressure levels above target (140/90 mmHg, 130/80 mmHg for patients with diabetes)
• 51% had serum cholesterol levels above target (4.5 mmol/l)
• 25% had a history of diabetes, of whom only 10% were adequately controlled (fasting glucose levels under 6.1 mmol/l)

The report, published today by the European Journal of Cardiovascular Prevention and Rehabilitation , also found that the use of cardioprotective medication was below recommendations.

Lifestyle, risk factor and therapeutic targets for the prevention of cardiovascular disease are clearly set out in the Joint European Societies guidelines, and give the highest priority to those with coronary disease.(2) Among the goals of the guidelines are to stop smoking, follow a healthy diet, be physically active, maintain a maximum body mass index of 25 kg/m2, blood pressure no higher than 140/90 mmHg (130/80 in diabetics) and total cholesterol no higher than 4.5 mmol/l.

Detailed results showed that almost one-third of all EUROASPIRE subjects were smokers in the month prior to their event, and this proportion had fallen by around half by the time of interview. Only one in seven patients was advised to attend a smoking cessation service, and only one-third of those actually did so.

Forty per cent of patients reported no increase in physical activity after their event, and only one-third reported doing regular exercise to increase their physical fitness. One in five obese patients said they had never been told they were overweight, one half had not followed dietary advice to lose weight, and almost two-thirds had not increased their physical activity.

Investigator Dr Kornelia Kotseva from the National Heart & Lung Institute in London described the prevalence of smoking and obesity in European coronary patients as "alarming", noting that nearly one in five patients continued smoking after a coronary event and fewer than one in five were within target BMI. "Compared to our two previous surveys," she said, "the prevalence of obesity has substantially increased. All coronary patients should be professionally encouraged to lose weight."

She also noted that, despite an increase in the use of preventative drug treatments, the majority of patients are still not achieving blood pressure and cholesterol targets.

"Adverse lifestyle trends in our coronary patients – more smoking in younger females, increasing obesity and central obesity, more diabetes – now represent the biggest challenge for those leading prevention and rehabilitation programmes," said Dr Kotseva. "We need to invest in prevention across Europe. All coronary patients need to be involved in professional, multidisciplinary prevention programmes."

Professor Wood added: "These results show that, despite the existence of clear, evidence-based guidelines, their integration into routine clinical care is still disappointing, and there is still much room throughout Europe to raise the standards of preventive cardiology."