Improving lifestyles could halve the number of deaths caused by cardiovascular disease, says Joep Perk.
Eradicating cardiovascular disease in everyone under 75 years of age might seem an overwhelming task. Nonetheless, convincing scientific evidence informs a clear rationale for taking action. Health workers and policymakers are urged to join hands and work together to achieve this goal at both the individual and population level.
For now, cardiovascular diseases (CVDs) remain a major cause of mortality, causing more than 4 million deaths in Europe each year, nearly half of all deaths. Rates of CVD mortality are dropping in most European countries yet remaining high or even increasing in Eastern Europe. In a shift away from the Western world, 80% of all CVD mortality now occurs in countries undergoing rapid economic transition, such as China and India.
It is tempting to be complacent with the great leaps made in cardiological care. But that would be a mistake. It is true that modern cardiology greatly improves the prognosis for someone who has suffered a heart attack, but only once they make it to the hospital. One in four people with myocardial infarction (MI) dies before reaching a hospital. Consequently, the case for disease prevention remains strong. According to INTERHEART (a study that accessed the risk factors for MI in 52 countries), behavioural factors — such as smoking, alcohol consumption, physical inactivity, poor diet, stress, hypertension and abnormal blood lipids — play a role in almost 90% of MI cases1. Likewise, over three-quarters of these deaths could be prevented with adequate changes in lifestyle, according to the World Health Organization2.
Action to eradicate, eliminate or minimize the impact of heart disease requires action on two fronts: at the population level and on the individual level.
Action to eradicate, eliminate or minimize the impact of heart disease requires action on two fronts: at the population level and on the individual level. Given that the underlying atherosclerotic disease starts early in life and progresses over decades before clinical symptoms manifest, prevention must be seen as a life-long effort. Prevention should not only target the cardiac patient but also focus on behaviour at the population level, which can be the most effective and cheapest approach3. We know that prevention works, because changes in risk factors account for 50% of reductions in mortality, whereas improved treatments account for only 40% (ref. 4).
In the past two decades, scientists have mapped the mechanisms underlying the relationship between human behaviour and the formation of atherosclerotic plaques in the vascular wall. New imaging techniques have made it possible to visualize how the plaques first form. Moreover, CVD risk assessment models, such as the Framingham prediction algorithm used in the United States and SCORE in Europe, help identify individuals at increased risk. Clinicians should therefore be able to deliver evidence-based preventive care. Unfortunately, surveys such as the EURIKA study5 indicate that this is not happening. In Europe, for example, a large proportion of patients with established atherosclerosis have CVD risk factors that are uncontrolled, including high blood pressure, elevated blood lipids, continued smoking, poor diet and exercise habits. Even after a heart attack, the preventive care of the patient could be improved through lifestyle intervention, but this is not happening, as demonstrated in the OASIS-5 study6. Many lives that could be saved are being lost.
Levels of risk
The European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) provide a timely update7. Produced by the Fifth Joint Task Force (JTF) with members of the European Society of Cardiology and eight other medical societies, they recommend the what, why, for whom, how and where of prevention programmes.
What is the new message from the Fifth JTF? For one thing, men over 40 years of age and women over 50 years of age (or post-menopause) should be screened for four levels of CVD risk factors. For example, in the SCORE model: age, sex, smoking habits, blood pressure and cholesterol levels are entered in the algorithm (see www.heartscore.org).
In general clinical practice, the family doctor is the key person to initiate, coordinate and provide long-term follow-up for CVD prevention. But nurse-led programmes are also important. After discharge from the hospital, CVD patients must be offered guideline-oriented treatment, and patients who suffered a heart attack should be given the chance to participate in a prevention and rehabilitation programme to support lifestyle modification and adherence to drug regimens.
In clinical practice, prevention programmes focus on high-risk groups and patients with diagnosed CVD. But this is not enough. Only population-wide strategies can control the global prevalence of CVD. Public information campaigns are needed to persuade people to assume a healthy lifestyle. Political initiatives have had a major impact on public health: creating smoke-free environments; lowering salt content in processed food and eliminating trans-fatty acids in food products; lowering the price of fruit and vegetables; and promoting childhood sports at schools, the workplace and during leisure time.
Healthcare professionals, the scientific community at large and policymakers should combine their efforts and take up the challenge of preventing premature deaths in cardiovascular disease.
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Jørgensen, T. et al. Eur. J. Prev. Cardiol. doi:10.1177/2047487312441726 (2012).
Di Chiara, A. & Vanuzzo D. Eur. Heart J. 30, 1027–1029 (2009).
Banegas, J. R. et al. Eur. Heart J. 32, 2143–2152 (2011).
Chow, C. K. et al. Circulation 121, 750–758 (2010).
Perk, J. et al. Eur. Heart J. 33, 1635–1701 (2012).
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Perk, J. Perspective: The power of disease prevention. Nature 493, S6 (2013). https://doi.org/10.1038/493S6a