COMMENTARY

Do Cardiologists Care About CV Prevention?

Melissa Walton-Shirley, MD

Disclosures

August 29, 2018

It was during the ESC 2018 session "Implementation of Cardiovascular Disease Prevention in Daily Practice—Insights From EUROASPIRE V" that the reality of what physicians should be to our patients was never more clearly revealed. We should be guardians, teachers, enforcers of the truth. But unarguable data reveal that most of us do not offer our patients what will ultimately save them from myocardial infarction, stroke, heart failure, and death: prevention strategies. The presentations prove that we are running our patients "in and out of clinics" but not engaging them.

The session's first talk, by Guy De Backer, Sint Martens Latem, Belgium, was titled "Are Patients Treated As They Should [Be] According to Management Guidelines?" He began with an overview of EUROASPIRE V, a survey on cardiovascular disease (CVD) prevention and diabetes that looked at consecutive men and women who were hospitalized for acute coronary syndrome or elective coronary artery bypass grafting or percutaneous coronary intervention no earlier than 6 months and no more than 2 years before being surveyed. More than 8000 patients from 27 countries participated The mean age was 64 years (patients age ≥ 80 years were excluded).

Although the 2016 ESC guidelines[1] recommend that smokers be identified and given smoking cessation advice and tools, only 12% of smokers surveyed became abstinent , 57% had reduced smoking, 4% were attending cessation clinics, 8% were using nicotine replacement, and 4% were using smoking cessation drugs. Whatever smokers are being advised, it isn't working.

Only 46% of patients were advised to participate in a cardiac rehab program. In terms of dietary advice, 70% were advised to reduce salt intake, 69% to increase fruits and vegetables, and 61% to reduce sugar. A disappointing 25% of patients with a body mass index greater than 30 kg/m2 said they were never advised to lose weight.

At the end of the first presentation, a German doctor, Stephan Jacob, stepped to the microphone. "I came late and I thought I would not find a place to sit, but look. This is a shame," he said, indicating a number of empty seats.

Sparsely attended session on CV prevention.

Later, he told me, "We are not really focusing on what's important . Yes, we need emergent care, but the follow-up is horrible." As long as patients were in the rehab center he formerly chaired, things went smoothly, but when they left there was no expert coordination, he explained. He was emphatic that labeling patients as inpatient or outpatient is BS. "Everyone makes the excuse that the other one should do it," he said. His specialty? Endocrinology. "Makes sense," I said aloud.

A line to get into the Hotline presentations.

Lars Rydén from Stockholm, Sweden, spoke next in his talk, "Screening for Diabetes in Patients with CAD—How Should It Be Done?" The theme of his talk is best summed by this statement: "To just let the patient with coronary artery disease walk around [with undetected diabetes] is extremely ignorant in my eyes." He reviewed data from as early as 1993[2] showing that having diabetes in addition to one, two, or three risk factors (dyslipidemia, systolic blood pressure > 120 mm Hg, and smoking) increases your risk for death significantly. For instance, adding diabetes to all three risk factors increased the death rate from 6 to 47 deaths per 10,000 person-years. We have been ignoring these data for a long time.

Rydén's urgency and frustration are well founded. The International Diabetes Federation projects a 50% increase in the incidence of diabetes by 2045, from 425 million people with diabetes to 629 million worldwide. [3]

Kornelia Kotseva from London, United Kingdom, gave a talk titled "Reaching Lipid Targets in Coronary Patients." The news was a bit better when EUROASPIRE IV was compared to EUROASPIRE V. There was an 11% positive trend in control of low-density lipoprotein cholesterol (LDL-C), "but 31% control over all is still poor control," she said. In EUROASPIRE V, 32% of patients receiving high-intensity statins met LDL-C goals compared with 25% in the older survey. This is "probably not good enough," she concluded. In patients with diabetes, rates of uncontrolled LDL-C declined from 73% for EUROASPIRE IV to 63% for EUROASPIRE V. "This means still two thirds of patients with diabetes don't reach their target," Kotseva warned.

David Allan Wood, from London, began his talk, "How to Improve Implementation of Guidelines in Daily Practice," by saying, "Cardiac rehab has lost its crown." He spoke of a schism between the rehabilitationists and the preventionists. With regard to the typical US cardiac rehab program,[4] he described it as merely, "Exercise, exercise, exercise with no reference to obesity, weight management, lipids, or adherence." He also noted that there is often no mention of smoking cessation. "But there is some hope," he said.

When six of nine risk factors were addressed in a rehab and prevention setting (including smoking, diet, physical activity, blood pressure, cholesterol, glucose, cardiovascular drug use, and stress management), all-cause mortality decreased 37% compared with traditional programs.[5] Programs that measured, monitored, and managed risk factors by prescribing, uptitrating, and monitoring adherence to medications also reduced all-cause mortality.

Wood then made a firm recommendation for the construction of a preventive cardiology program to integrate nurses, dietitians, physiotherapists, occupational therapists, pharmacists, and psychologists to work alongside cardiologists. They should address lifestyle and measure, monitor, and manage blood pressure, lipids, and glucose. Equally important, they should monitor adherence.

He then concluded that, "All over Europe, our patients receive the highest level of acute coronary care, but dilating a segment of a coronary artery and implanting a stent is not addressing the disease as a whole…and it is naive to believe that interventional cardiology on its own can significantly impact the overall chances for survival without addressing lifestyle and risk factors that brought the patient into the hospital in the first place…. We need to match high-quality intervention with high-quality preventative cardiology."

That is the crux of the matter, and there has been no truer statement in the entirety of the ESC 2018 meeting. It's a pity there weren't more attendees in the room to hear it.

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