Latest Euroaspire III Data Highlight Ongoing Failures in Primary and Secondary Prevention

Shelley Wood

May 07, 2010

May 7, 2010 (Prague, Czech Republic) - The latest results from European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroASPIRE III) survey should hammer home the message that despite all of the drugs available to ward off primary and secondary cardiovascular events, an exploding population of people both with and without a history of coronary events is failing to reach risk-factor targets.

Dr Kornelia Kotseva

That's the conclusion of Dr Kornelia Kotseva (Imperial College London, UK), who presented new EuroASPIRE numbers in two separate presentations here at the EuroPREVENT 2010 meeting.

The European Society of Cardiology (ESC) conducted the first EuroASPIREsurvey in 1995–1996 in nine countries, followed by a second survey in 1999-2000 in 15 countries. Both of these showed high rates of modifiable cardiovascular risk factors in patients with coronary heart disease (CHD). The third EUROASPIRE survey, performed in 2006–2007 in 22 countries, has so far failed to show much in the way of improvement. As previously reported by heartwire , an analysis of eight countries participating in EuroASPIRE I, II, and III, published in the Lancet last year, showed that management of lipid levels and hypertension in patients with coronary heart disease remains woefully suboptimal despite more choices for drug therapy.

At EuroPREVENT, Kotseva presented new data indicating that when all 22 countries are included in the analysis, risk-factor control among patients with existing coronary disease is "getting even worse." In a poster presentation focused on patients with known CHD at baseline, Kotseva and colleagues showed that among almost 9000 patients, 56% had blood-pressure levels higher than the target 140/90 mm Hg (130/80 mm Hg for diabetics); moreover, just 44% of patients taking antihypertensive medications had their BP adequately controlled.

The pattern was similar for cholesterol, with 51% of patients having serum cholesterol levels above the target of 4.5 mmol/L and just 55% of those taking lipid-lowering drugs having successfully lowered their cholesterol to targets.

More than one-third of CHD patients had diabetes, and of those taking glucose-lowering drugs, just 10% had fasting glucose levels of 6.1 mmol/L or less.

As reported in the Lancet last year, while physicians seem to be making strides in cholesterol control, blood-pressure control has remained static over successive surveys at the same time that levels of overweight and obesity have climbed and smoking has remained relatively unchanged.

"One of the reasons for poor control of the blood pressure and lipids is the increase in obesity, so the lifestyle is the major cause of concern for us now," Kotseva said. Both Kotseva and Dr David Wood (Imperial College London), the senior author on EuroASPIRE, also pointed to physician-related factors.

"One is that all too many physicians are not uptitrating therapies to the optimal doses, adding second- or potentially even third-line drugs to achieve the targets defined in the guidelines," Wood said. "Second, I think there is a real problem with adherence to medications over the long term. If patients don't understand the reasons they're being prescribed these drugs and the importance of adhering to the therapy over their lifetimes, it's not surprising that they stop their medications. The physician should do more than just issue a prescription; it requires education of the patient."

Primary-Prevention Numbers Also "Cause for Concern"

The same explanations likely apply in the primary-prevention setting, where the situation appears equally provoking, Kotseva noted. She presented primary-prevention results from EuroASPIRE in an oral session at EuroPREVENT showing that here, too, physicians seem unable to provide the advice or drugs to help people control their risk of cardiovascular events.

People with no personal history of coronary heart disease were included for the first time in the third EuroASPIRE study, Kotseva noted, with all 22 countries enrolling primary patients in the study.

The primary-prevention analysis for EuroASPIRE included men and women under age 80 with no history of coronary or atherosclerotic disease, who had been started on one or more drugs to lower blood pressure, lipids, or glucose at least six months previously (but no more than three years prior). In all, 5678 high-risk patients on drug therapy were identified, of whom 4366 agreed to participate. The main outcome measure was the proportion of high-risk individuals achieving the European lifestyle risk-factor and therapeutic targets for cardiovascular disease prevention, as defined in the 2003 ESC guidelines (these have subsequently been updated, Kotseva noted, but not before these data were collected).

Overall, she said, the proportion of people reaching targets was "very poor" and a "major cause for concern," with less than one-third of patients on blood-pressure–lowering drugs achieving the goals set by the guidelines. Likewise, less than one-third of primary-prevention patients on lipid-lowering drugs achieved goals for total and LDL cholesterol, less than 10% achieved goals for glucose, and only two out of five reached guideline-recommended targets for HbA1c.

As with the CHD analysis, a key reason for the low control of lipids and glucose in the primary-prevention group can be explained by the prevalence of poor lifestyle factors--more than 80% of subjects had a body-mass index (BMI) above 25, with 50% defined as obese. Inadequate drug dosages or poor patient compliance likely also play a role here, she speculated.

"Frankly Shocking"

Mid-afternoon, Kotseva and another coauthor, Dr Dirk De Bacquer (University of Ghent, Belgium), could be found gazing dolefully at their secondary-prevention poster, pondering why it is that after 10 years of carefully audited EuroASPIRE data, physicians don't seem to be getting the message.

One might expect a bit more of an impact, particularly for such a monumental collaborative effort that has cost, according to Wood, more than €1.5 million.

Kotseva pointed out that systematic, multidisciplinary efforts such as EuroACTION have proven that risk-factor targets can be reached, but the fact that physicians have not acted on an individual level to get their patients to goal is "frankly shocking."

De Bacquer, for his part, points to personal accountability on the part of patients who, at least in the case of the CHD analysis, have had a life-threatening coronary event yet have seemingly not been motivated to lose weight or quit smoking. "It's depressing," he said glumly.

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