Secondary prevention of heart attacks in high-risk patients is important throughout the world – not only does it save lives but it reduces costs for healthcare systems that are adapting to the needs of ageing populations.1
Despite the challenges, progress has been made in preventing secondary events in people who have already experienced a cardiac event. There are a range of therapies, which if combined with exercise and other lifestyle modifications, can help reduce the risk of cardiovascular events recurring.2
In this question and answer session, Professor Christopher Granger, Professor of Medicine and Member in the Duke Clinical Research Institute, Durham, USA, and Gunnar Brandrup-Wognsen, Global Medical Affairs Leader, AstraZeneca, discuss the progress that has been made in this area, and what more can be achieved.
What is the current situation with managing secondary prevention?
Gunnar Brandrup-Wognsen (GB-W): Much has already been done in managing cardiovascular disease, but 17 million people are still dying every year,1 and this is predicted to continue to increase up to 2025,3 so there is a lot more to do. One of the main things that we can address is secondary prevention.1
Professor Christopher Granger (CG): We know that coronary heart disease just in terms of premature mortality, is the number one cause of mortality in the world and is anticipated to be so for at least the next 20 years.1 In its acute manifestation, acute coronary syndrome, we know that the chance of recurrent events, of mortality, of rehospitalisation, is enormous.4
What do you perceive to be the key challenges in preventing secondary events?
CG: In the first 30 days following an acute coronary syndrome, readmission rates in selected US hospitals are approaching 20%.5 In the United States, this amounts to tens of billions of dollars, just for the care of patients after acute coronary syndrome, so there’s no larger public health burden than coronary heart disease.6
Greater focus on reducing hospital readmission is helping us determine whether we are doing a good job ensuring patients are getting the appropriate instructions, the appropriate teaching, and that we’re following up. This gives us a link between the plan at the time of discharge and what actually happens in the clinic.4
GB-W: There is a lot of money put into primary prevention – on information communication and marketing – and it doesn’t really help in the long-term. With secondary prevention, the research shows us that if you follow the guidelines, you can save a lot of money for society. For example, by encouraging changes in lifestyle (such as cessation of tobacco use, reduction of dietary salt, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol), appropriate use of hypertension medicines, antithrombotic therapies and lipid lowering therapies.1,7
Where are the greatest opportunities to improve secondary prevention?
GB-W: The best improvements in secondary prevention so far have been in tackling the main risk factors. In developed countries, the main risk factors are having an elderly population, hyperlipidaemia, diabetes and renal dysfunction, but these can be addressed by medication or changes in lifestyle. Those are the main issues and addressing them is the way to gain further improvement.1,8
CG: In high income countries, hospital care is good. I think the biggest opportunity now is to make sure that there is more effective transition from the in-patient to the out-patient setting. Then we can focus on adherence to the treatments that we know will effectively reduce the risk of recurrent cardiovascular events, especially during the first-year post-event, but then indefinitely.
What are the differences in managing secondary prevention between STEMI and non-STEMI events?
GB-W: In ST-elevation myocardial infarction (STEMI) the medical technology improvement with coronary bypass surgery and percutaneous coronary intervention (PCI) has really made an impact and the mortality benefit in those patients has been fairly dramatic over the past 20 years.9 However, non-STEMI patients are perceived as lower risk patients as it’s less acute, but actually a lot of registries have shown that those patients are worse off in the longer term.10,11 Therefore, we could really make a difference here by addressing secondary prevention and making sure patients have dual anti-platelet therapy, anti-hypertensive drugs and lipid-lowering drugs.1,7,12
CG: We’ve had a lot of focus on STEMI; these patients get the primary PCI, almost all of them get effective P2Y12 antagonist therapy early on and they tend to have at least a short period of time in cardiac intensive care units where there is a lot of focus on ensuring they are getting the best care.10
The non-STEMI group is much more challenging because these patients tend to be older, have more comorbidities, and are often not treated as intensively in the early hours and days of their presentation. They’re also the ones, paradoxically, where the risk over the next year is substantially higher. For the STEMI group, the risk in the early hours is highest.10 Also, STEMI is declining in incidence whereas non-STEMI is increasingly more common.8,10 One of the ways we can reduce the burden of non-STEMI is to more effectively prevent the recurrent events after the initial presentation.
What is the role for governments and health systems in managing secondary prevention?
GB-W: Governments and health systems make decisions based on the information that they have, therefore it’s important to ensure they have valid data on what’s best for the patients. However, you also have to realise there are budget considerations and the broader health economy is very important.
The best approach is to show governments that increasing the focus on secondary prevention of a myocardial infarction will ultimately save the tax-payers money, because secondary prevention is where this can happen. Registries and the quality index are one way to improve the system. They highlight some of the points that are believed or in fact the evidence shows are improving the quality of care.12 If you follow those points and measure them, then you can establish whether you can improve quality.
CG: The government plays a really important role in promoting the better application of secondary prevention measures after acute coronary syndrome because it is something that’s incredibly important. Governments have been extremely important in coupling reimbursement to quality of care.
We need to be as specific as possible in the quality measures of the evidence-based care after acute coronary syndromes and linking that in some way to reimbursement. We have to be able to measure it, put resources into measuring how we’re doing, and then the government can get involved with assuring that we’re performing at a high level.
Finally, how are different countries addressing secondary prevention?
CG: I think systems that tie reimbursement to outcomes are being implemented in many countries around the world. Examples include the United Kingdom where primary care is incentivised so that patients’ blood pressure, lipids levels and diabetes are being managed; simple critically important risk factors have been much better managed following the National Health Service focus on tying reimbursement to these activities. Also, in some of the Scandinavian countries, such as Denmark and Sweden, the governments have put an enormous focus on having high quality registries, with the idea of improving quality of care. As a result, the care patients receive following an acute coronary syndrome is some of the best in the world.
The success of these different approaches show that we can learn from what other countries have found to be successful in improving secondary prevention.
GB-W: A key question is, ‘how does the patient run through the healthcare system?’. And with the diversity of the healthcare systems around the world, the process looks different when you look at each country; how they come into the systems, how they run through the system, and the follow up.
If we look at the Swedish system, with an elderly population, in the case of myocardial infarction less than half of patients are treated in a cardiology department. The rest are admitted to a general ward because they’ve got so many concomitant diseases. The cardiologists are often not focused on dealing with diabetes, hypertension, rheumatoid arthritis or perhaps dementia, which is increasingly common. Therefore, a lot of patients are treated in a pathway outside of the cardiology department, admitted to a general ward and being treated by a general physician or an internal medicine doctor. But do they know the guidelines from ESC? Not usually. They can’t be an expert in all fields and so there is diversity in how patients are treated.
1. WHO Cardiovascular Diseases Fact Sheet. Updated May 2017. Available from http://www.who.int/mediacentre/factsheets/fs317/en/. Accessed on 20 November 2017.
2. World Health Organization. Prevention of Recurrences of Myocardial Infarction and Stroke Study. Available from http://www.who.int/cardiovascular_diseases/priorities/secondary_prevention/country/en/index1.html. Accessed on 20 November 2017.
3. American Heart Association. Latest statistics show heart failure on the rise; cardiovascular diseases remain leading killer. January 26, 2017. Available from http://newsroom.heart.org/news/latest-statistics-show-heart-failure-on-the-rise;-cardiovascular-diseases-remain-leading-killer. Accessed on 20 November 2017.
4. 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.
5. Partners Healthcare. 30-Day Unplanned Readmission Rates for Heart Attack, Pneumonia, Heart Failure. Available from http://qualityandsafety.partners.org/Cost-Effective-Care/Readmission-Rates-For-Heart-Conditions-And-Pneumonia.aspx. Accessed on 20 November 2017.
6. American Heart Association. Heart Disease and Stroke Statistics 2017: At-a-Glance. Available from http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_491265.pdf. Accessed on 20 November 2017.
7. Roffi M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016;37:267–315.
8. Sanchis-Gomar F, Perez-Quilis C, Leischik R, and Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med 2016;4(13):256–268.
9. National Institute for Health and Care Excellence Briefing Paper. Acute coronary syndromes (including myocardial infarction). February 2014. Available from https://www.nice.org.uk/guidance/qs68/documents/acute-coronary-syndromes-including-myocardial-infarction-briefing-paper2. Accessed on 20 November 2017.
10. MINAP. Myocardial Ischaemia National Audit Project: How the NHS cares for patients with heart attacks. April 2013 –March 2014.
11. Cohen M. Long-term outcomes in high-risk patients with non-ST-segment elevation myocardial infarction. J Thromb Thrombolysis 2016;41:464–474.
12. Frederix I, Dendale P and Schmid J-P. Who needs secondary prevention? Eur J Prev Cardiol 2017;24(3_suppl):8–13.