Elsevier

The Lancet

Volume 373, Issue 9667, 14–20 March 2009, Pages 929-940
The Lancet

Articles
Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries

https://doi.org/10.1016/S0140-6736(09)60330-5Get rights and content

Summary

Background

The first and second EUROASPIRE surveys showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease. The third EUROASPIRE survey was done in 2006–07 in 22 countries to see whether preventive cardiology had improved and if the Joint European Societies' recommendations on cardiovascular disease prevention are being followed in clinical practice.

Methods

EUROASPIRE I, II, and III were designed as cross-sectional studies and included the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Consecutive patients (men and women ≤70 years) were identified after coronary artery bypass graft or percutaneous coronary intervention, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later.

Findings

3180 patients were interviewed in the first survey, 2975 in the second, and 2392 in the third. Overall, the proportion of patients who smoke has remained nearly the same (20·3% in EUROASPIRE I, 21·2% in II, and 18·2% in III; comparison of all surveys p=0·64), but the proportion of women smokers aged less than 50 years has increased. The frequency of obesity (body-mass index ≥30 kg/m2) increased from 25·0% in EUROASPIRE I, to 32·6% in II, and 38·0% in III (p=0·0006). The proportion of patients with raised blood pressure (≥140/90 mm Hg in patients without diabetes or ≥130/80 mm Hg in patients with diabetes) was similar (58·1% in EUROASPIRE I, 58·3% in II, and 60·9% in III; p=0·49), whereas the proportion with raised total cholesterol (≥4·5 mmol/L) decreased, from 94·5% in EUROASPIRE I to 76·7% in II, and 46·2% in III (p<0·0001). The frequency of self-reported diabetes mellitus increased, from 17·4%, to 20·1%, and 28·0% (p=0·004).

Interpretation

These time trends show a compelling need for more effective lifestyle management of patients with coronary heart disease. Despite a substantial increase in antihypertensive and lipid-lowering drugs, blood pressure management remained unchanged, and almost half of all patients remain above the recommended lipid targets. To salvage the acutely ischaemic myocardium without addressing the underlying causes of the disease is futile; we need to invest in prevention.

Funding

European Society of Cardiology through grants from Merck Sharp & Dohme (EUROASPIRE I); AstraZeneca, Bristol-Myers Squibb, Merck Sharp & Dohme, and Pfizer (EUROASPIRE II); and AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Pfizer, Sanofi-Aventis, Servier, Merck/Schering-Plough, and Novartis (EUROASPIRE III).

Introduction

Cardiovascular disease is a major cause of disability, contributes substantially to the escalating costs of health care, and is the most common cause of death in most European countries.1, 2, 3 Management of patients with coronary heart disease should aim to reduce the risk of further atherosclerotic events, improve quality of life, and lengthen survival. Patients with coronary or other atherosclerotic cardiovascular diseases are given high priority in the Joint European Societies' guidelines on prevention of cardiovascular disease in clinical practice from 1994 to 2007.4, 5, 6, 7 Over this series of guidelines, the recommendations for lifestyle management remain the foundation of preventive cardiology: to stop smoking, make healthy food choices, and become physically active. The evidence for the effectiveness of cardiovascular disease prevention and rehabilitation programmes that address lifestyle is compelling8, 9, 10 and yet less than a third of patients are able to access such programmes in Europe.11

The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) surveys by the European Society of Cardiology have shown that the integration of cardiovascular disease prevention into daily clinical practice is wholly inadequate. The first EUROASPIRE survey was done in 1995–96 in nine European countries, the second in 1999–2000 in 15 European countries, and the third in 2006–07 in 22 countries, including eight countries that participated in EUROASPIRE I and II.12, 13, 14, 15

This third survey provides an opportunity to view time trends over more than a decade in the practice of preventive cardiology in patients with coronary heart disease in Europe. This Article compares the results of EUROASPIRE I, II, and III surveys in eight European regions.

Section snippets

Sample size and data collection

EUROASPIRE I, II, and III surveys were done in selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, and Slovenia. Within each country the national coordinator selected one geographical area with a large population (greater than 500 000 people). The area had to include at least one hospital that offered interventional cardiology and cardiac surgery, and one or more acute hospitals that admitted patients with acute myocardial

Results

4353 hospital medical records were reviewed in EUROASPIRE I, 4378 in EUROASPIRE II, and 3840 in EUROASPIRE III; 3180, 2975, and 2392 patients were interviewed, respectively. In this Article, the comparisons between the three surveys are based only on the data obtained at interview. The median time from index event to interview was 1·48 years (IQR 1·14–1·98) in the first survey, 1·45 years (1·14–1·90) in the second, and 1·22 years (0·98–1·63) in the third.

The overall participation rate was 77·2%

Discussion

The results of the EUROASPIRE surveys should be a cause of concern to all health policy makers, physicians, and other health-care professionals responsible for the care of patients with coronary heart disease in hospitals and the community. The adverse lifestyle trends, especially the increase in smoking in younger female patients, and the substantial increase in obesity in every country in the survey indicate a need for better preventive cardiology programmes. Furthermore, the comparison

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