Cardiovascular disease claims the most lives every year but is largely preventable according to the President of the European Association of Preventive Cardiology, a branch of the European Society of Cardiology
Ischaemic heart disease and stroke are the world’s biggest killers. 1 The good news is that 80% of cardiovascular diseases can be prevented with healthy lifestyle habits. 2
In the INTERHEART study, approximately 90% of myocardial infarctions could be explained by suboptimal lifestyle factors including high blood cholesterol, high blood pressure, smoking, diabetes, obesity, insufficient exercise, drinking alcohol, not eating enough fruits and vegetables, and psychosocial factors. 3
While we do not have studies on the impact of eliminating all of these risk factors, we do have epidemiological research showing that when there is a population reduction in blood pressure or blood cholesterol that results in a decreased incidence of myocardial infarction. Similarly, countries that have introduced a ban on smoking in public places have seen an almost immediate decrease in the incidence of acute coronary events.
The reverse is also true: in parts of the world where smoking bans have been revoked, rates of myocardial infarction have gone up. We will see what happens to the incidence of acute coronary syndromes in Austria, which cancelled its smoking ban last year.
Should cardiovascular prevention focus on individuals or populations?
Cardiovascular prevention should be delivered at individual and population levels. 2 For most cardiologists, the focus is on high-risk patients. Here we address lifestyle issues and prescribe medications to control blood pressure and cholesterol to reduce the likelihood of another cardiovascular event.
Governments have a role to play in prevention at the individual level by reimbursing medications and providing funding for cardiac rehabilitation programmes. However, the role of public authorities is even more crucial when it comes to providing healthy environments so that people do not get sick in the first place. Targeting individual high-risk patients has a very high impact on a relatively small part of the population: population-based approaches are the most far-reaching.
Most heart attacks occur in people not being seen by a cardiologist. So, if we really want to decrease the global number of cardiovascular events we should also focus on the low-risk population. Small shifts in the risk of disease, or of risk factors, across a whole population consistently leads to greater reductions in disease burden than a large shift in high-risk individuals only. 2 Population approaches also benefit children and reduce health inequalities within and between countries.
All governments should introduce and enforce smoking bans, increase opportunities for physical activity by promoting cycling, tax unhealthy foods and sugary drinks, and much more. In the area of nutrition, Denmark led the way in 2003 by banning industrially produced trans fats, and the European Union (EU) has followed today setting a limit for trans fatty acids to 2% of food’s total fat content.
What can GPs do?
Cardiovascular prevention is a lifelong endeavour. It starts before birth and even before conception.
Women and men who smoke before conceiving a child cause epigenetic alterations that are detrimental to the cardiovascular health of their offspring.
As the health professional who sees people throughout their life course, GPs have a central role to play in the prevention of cardiovascular disease in all of their patients. That means checking risk factors at every consultation and repeating messages about smoking, weight, activity, diet, and so on.
Who is at the greatest risk of cardiovascular disease?
It is often forgotten that the people at the highest risk of a heart attack are those who have already had one. Opening blocked arteries is an effective treatment and patients are back on their feet very quickly. But they are not cured. Unfortunately, the EUROASPIRE surveys show that coronary patients still have high levels of smoking, unhealthy diets and physical inactivity, resulting in obesity and diabetes. 4 To improve this situation, doctors must prescribe medications at sufficient dosages and refer patients to cardiac rehabilitation. Patients can do their part by complying with lifestyle advice and taking their pills.
Other high-risk groups are those with diabetes, chronic inflammatory diseases such as rheumatoid arthritis, and patients who have undergone chemotherapy or radiotherapy. Then, of course, there are those who have high levels of multiple lifestyle risk factors.
How does the future look?
Motivation is a key element of cardiovascular prevention and digital health has the potential to help avoid first and subsequent cardiovascular events. We already have research showing that daily monitoring with a health app after a cardiac rehabilitation programme increases prolonged participation in exercise. I’m convinced that digital solutions will help us in our continuing battle to reduce the burden of cardiovascular disease.
From a public policy perspective, there is a lot of positive movement today across the EU, including efforts to reduce alcohol consumption and limiting advertising of unhealthy food to children. But this is just a start. Together, the European Association of Preventive Cardiology (EAPC) and the European Society of Cardiology are fully committed to working with policymakers and health stakeholders for a heart-healthy Europe, free from avoidable disease.
1 World Health Organization: The top 10 causes of death.
2 Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016;37:2315–2381. doi:10.1093/eurheartj/ehw106.
3 Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937–952.
4 Kotseva K, Wood D, De Bacquer D, et al. EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries. Eur J Prev Cardiol. 2016;23:636–648.
Prof Dr Paul Dendale
Head of the Department of Cardiology,
Jessa Hospital, Hasselt, Belgium
Professor of Cardiovascular Pathophysiology,
President European Association of Preventive Cardiology (ESC)
Tel: +32 11 33 70 25
Fax: +32 11 33 70 28