In recent years, advances in medical technology, knowledge, and new drugs have helped to improve outcomes in cardiovascular disease (CVD) – but nevertheless it remains a leading cause of death and serious illness.1,2 CVD is the number one cause of death globally; more people die annually from CVD than from any other cause.1 The most recent European Heart Network statistics indicate that CVD accounts for 47% of all deaths in Europe. Each year seven million people suffer from an acute coronary syndrome.2
Those with CVD or who are at high risk of developing CVD – due to one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established disease – need early detection and management using counselling and medicines. However, this results in inequalities in outcomes between different countries, in part due to differences in the primary healthcare programmes available for early detection and treatment of those at risk.1,3 In addition, many risk factors such as obesity are on the increase.3 Worldwide, obesity has more than doubled since 1980 and in 2014, more than 1.9 billion adults were overweight, with raised BMI a major risk factor for CVD.4 Other important behavioural risk factors are physical inactivity, tobacco use and harmful use of alcohol; however, a combination of risk factors often causes heart attacks and strokes.1
Leading doctors are also concerned about the challenges in implementation of preventive measures such as clinical guidelines, which can provide patients and clinicians with unbiased and evidence-based advice that could save or improve patients’ lives.3
Effective intervention and advice is particularly important for high-risk patients, such as those who have already had a cardiovascular event – where secondary prevention can play an important role in reducing mortality rates.2 As management of CVD and coronary artery disease involves many specialties, it is important to maintain focus to bring together the knowledge needed to manage patients correctly and ensure the guidelines are followed.
In this interview, Professor Evangelos Giannitsis, Head of the Chest Pain Unit and Private Ambulance at University Hospital Heidelberg (Germany), shared his thoughts on the importance of adherence to cardiovascular guidelines, particularly those related to secondary prevention after a myocardial infarction.
Q: How would you define a patient at high risk of secondary cardiovascular events?
A: A high-risk patient is a patient who has high-risk features or a combination of these features. High-risk features include older age, diabetes, chronic renal disease, peripheral artery disease, high cholesterol levels, and uncontrolled high blood pressure.1
Q: How does the patient journey vary in different countries and regions?
A: This is difficult because even in one region or in one continent the patient journey depends on healthcare structure and budgets. It may be very different in India versus Germany, France and Italy, but I am sure there is no perfect system. For example, in Germany, office-based specialists would be involved and responsible for managing the patient; however, in the UK, the patient journey is mainly handled by hospital-based physicians. In my opinion, there are too many physicians involved, too many steps between the professionals and we don’t always have studies to tell us which pathways are correct.
Q: What can be done to improve implementation of guidelines?
A: A number of countries are experimenting with systems that reward adherence, or disincentivise non-adherence, to guidelines.5
For instance, in Sweden, the SWEDEHEART [Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies] Registry is an online registry that reports the outcome of every patient hospitalised for acute coronary syndrome.6 It compares hospitals, not individual doctors, and over time the quality index has risen. So consistent implementation of guidelines has had a positive effect in Sweden.
Q: What is the role for specialists outside cardiology in addressing secondary prevention?
A: Non-cardiology specialists play a huge role for patients following a heart attack because patients will usually seek medical intervention for another disease, such as from a dentist or a gastroenterologist, a few weeks or months after the event. All these disciplines should have insight into the pathology of the patient’s disease or their treatment. They should also maintain very close interaction with the treating cardiologist or the specialist from the earlier coronary intervention.
Q: How can we link up those specialists to create a more cohesive treatment pathway?
A: To bring all disciplines together is a very difficult challenge. A high-risk patient (may) not just have coronary artery disease, but also peripheral artery disease, diabetes, and renal failure. All the physicians in these other areas should have broader insights into the major disease of the patient. For instance, a diabetes specialist should have a comprehensive view, not just look at the blood sugar control therapy.
One possibility is increasing referrals to comprehensive patient management programmes like the cardiac rehabilitation programmes that have been set up in a number of European centres. These bring together a multi-disciplinary team to provide an individual training programme for a patient after an event, as well as patient education. The programmes cover physical activity and all other behavioural risk factors (e.g. nutrition, smoking, stress). These programmes have shown great improvements with reduction of mortality, re-event rate and hospital admissions, but there is still the challenge of compliance when the patient is at home.7
Q: In the context of broader CVD, how big a problem is preventing secondary events?
A: We have a lot of tools in secondary prevention but an event rate that is unacceptably high. Although we have reduced recurrent events a lot over the past few years, we still have to refine our efforts to reduce it further, either through drugs, lifestyle interventions or novel technologies.3 These include assist devices to prevent rehospitalisation for heart failure, or bridging for patients who could be heart transplant candidates. There are a lot of novel technologies and drugs that might further reduce recurrent events.
Q: Is there one particular area where you would like to see greater focus on secondary prevention?
A: There are some areas where there is space for improvement. For example, we can still improve LDL [low density lipoprotein] cholesterol lowering, we can still reduce recurrent heart attacks by promoting appropriate dual anti-platelet therapy, and blood pressure control can be improved by drugs that are effective and have fewer side effects than current therapies.
1. WHO Cardiovascular Diseases Fact Sheet. Updated May 2017. Available from http://www.who.int/mediacentre/factsheets/fs317/en/. Accessed on 18 August 2017.
2. Frederix I, Dendale P and Schmid J-P. Who needs secondary prevention? Eur J Prev Cardiol 2017;24(3_suppl):8–13.
3. Grobbee DE and Pellicia A. Secondary prevention of cardiovascular disease: Unmet medical need, implementation and innovation. Eur J Prev Cardiol 2017;24(3_suppl):5–7.
4. WHO Obesity and Overweight Fact Sheet. Updated June 2016. Available from http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed on 18 August 2017.
5. Jeffery RA, et al. Interventions to improve adherence to cardiovascular disease guidelines: a systematic review. BMC Family Practice 2015;16:147–162.
6. CardioPulse. SWEDEHEART: Sweden’s new online cardiac registry, the first of its kind. Eur Heart J 2009;30:2165–2173.
7. Piepoli MF, et al. Challenges in secondary prevention after acute myocardial infarction: A call for action. Eur J Prev Cardiol 2016;23(18):1994–2006.