Cardiovascular disease (CVD) is the number one cause of death globally; more people die annually from CVD than from any other cause.1 Recent European Heart Network statistics indicate that CVD accounts for 47% of all deaths in Europe, and each year seven million people suffer from an acute coronary syndrome despite advances in medical technology, knowledge and drug treatments.2
With a heritage in CVD going back more than 100 years, AstraZeneca remains committed to driving the scientific debate forward and helping to address the immense unmet need in cardiovascular, renal and metabolic diseases (CVMD).
Exemplifying this ongoing commitment, on Thursday 10th August 2017, AstraZeneca hosted a roundtable debate in Cambridge, UK, on the topic of secondary prevention of recurrent atherothrombotic events. The debate was moderated by Dr Paul Tunnah, CEO of pharmaphorum, and the multi-perspective panel charged with building authority and thought leadership on this topic included:
- Professor Evangelos Giannitsis, Head of the Chest Pain Unit and Private Ambulance at University Hospital Heidelberg, Germany
- Nick Hartshorne-Evans, Chief Executive (Founder), Pumping Marvellous Foundation
- Gunnar Brandrup-Wognsen, Global Medical Affairs Leader, AstraZeneca
The panel also included via videoconference:
- Professor Christopher Granger, Professor of Medicine and Member of the Duke Clinical Research Institute, Durham, USA
There remains significant opportunity to further improve outcomes through effective secondary prevention in high-risk patients who have already had a cardiovascular event.3 These patients are likely to be at high-risk due to one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established CVD, e.g. having had a previous CV event; while also likely exhibiting important behavioural risk factors, including obesity, physical inactivity, tobacco use and harmful use of alcohol.1
Effective intervention and advice is particularly key for high-risk patients, and can play an important role in reducing mortality rates.2
A key part of ensuring effective secondary prevention is appropriate guidelines. A number of professional organisations, for example the European Society of Cardiology (ESC) and the American Heart Association (AHA), are committed to all aspects of secondary prevention after acute myocardial infarction. They share expertise and play an essential role in supporting colleagues to develop better services. Their continuing collaboration to establish professional guidelines, promote cutting-edge scientific research and implement initiatives that encourage good clinical practice is essential to driving best practice secondary prevention.3
However, literature reports suggest that the management of CVD is complicated by the large number of clinical practice guidelines available for conditions that contribute to this disease, lack of awareness of the guidelines by healthcare professionals involved throughout the patient journey, and gaps in implementation of the recommendations within the guidelines; all of which ultimately results in low adherence to the guidelines.3,4 These factors need to be addressed in order to improve secondary prevention and reduce its global impact.
Epidemiology and background of recurrent atherothrombotic events in high-risk patients
The discussion opened with a focus on the epidemiology and background of these events in high-risk patients, including definitions of both recurrent atherothrombotic events and high-risk patients, before moving on to discuss current epidemiology and how it can vary by sex, geography and other key demographics.
The impact of CVD is enormous, with a particularly high prevalence in low- and middle-income countries, where over three quarters of CVD deaths take place.1 Out of the 17 million premature deaths (under the age of 70) due to noncommunicable diseases in 2015, 82% are in low- and middle-income countries, and 37% are caused by CVDs.1
However, most instances of CVD can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol.1 The effects of these behavioural risk factors may manifest as raised blood pressure, raised blood glucose, raised blood lipids, and being overweight or obese. These risk factors can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications.1
The consequences of a heart attack (also known as an acute myocardial infarction (AMI)) are dramatic. Of those who survive an initial heart attack, registry data suggests that up to 20% will go on to experience a second cardiovascular event within the following 12 months, with approximately 50% of major coronary events occurring in those who previously suffered a heart attack.3
Effective secondary prevention is therefore crucial for achieving a reduction in mortality and morbidity, and an individual’s prognosis is significantly improved with the use of evidence-based interventions, such as optimal medical treatment, appropriate lifestyle changes and cardiovascular risk factor control. Importantly, the impact of lifestyle change after a heart attack is rapid: patients who adhere to exercise and diet recommendations have a 54% lower risk of a secondary event, and those who quit smoking a 43% lower risk of recurrent events six months after a heart attack.3
Despite this compelling evidence, preventive care post-heart attack remains sub-optimal. Those with established heart disease and people at high cardiovascular risk are the most likely to be living unhealthy lifestyles, have modifiable risk factors and inadequate use of drug therapies to achieve blood pressure and lipid goals.3
Key points explored by the participants in this section included:
- Burden of recurrent atherothrombotic events
- Challenges around diagnosis of high-risk patients
- Challenges in relation to prevention for high-risk patients
- Rationale/argument for long-term prevention
Cardiovascular disease and adherence to guidelines Professor Evangelos Giannitsis shared his expert opinion on CVD, how you define high-risk patients and the importance of adherence to guidelines.
During the discussion Professor Chris Granger shared his expert opinion on why we need to define high-risk patients and what that means. See what he said in this short video clip.
You can also view the Part 1 discussion – Epidemiology and background of recurrent atherothrombotic events in high-risk patients here.
Challenges to secondary prevention in current clinical practice
In the second part of the discussion, the panel focused on challenges to secondary prevention in current clinical practice, and began by discussing the current patient journey and what it looks like from first event through to secondary prevention. They then broached the complex topic of clinical guidelines, asking whether they were meeting patient needs.
Secondary prevention programmes – the level of preventive care focusing on early risk stratification, use of referral services and initiation of treatment to stop the progress of an established disease process – are highly and widely recommended for all heart disease patients, to restore quality of life, maintain or improve functional capacity and prevent recurrence of disease. Cardiac rehabilitation – risk assessment and management, advice on physical activity, psychosocial support and the appropriate prescription and adherence to cardioprotective drugs – is the most investigated method of secondary prevention interventions, and the core components of cardiac rehabilitation are well known (see infographic).3
Secondary prevention is traditionally divided into three phases – in-patient, out-patient and long-term intervention – but is actually a continuous lifelong process; a pathway that follows the patient journey, made up of a number of stages that are designed to support patients return to a normal life. Despite there being standard objectives and core components across all cardiac rehabilitation programmes, different countries provide different structure, content, duration, intensity and volume of support based on their local/national requirements and regulations.2 However, this support generally includes residential, ambulatory community, or home-based programmes.
Residential in-patient programmes are specifically structured to provide more intensive and/or complex interventions and are often reserved for high-risk patients. Out-patient programmes have the same objectives as the residential programmes.3
Given the complexity of the management of this disease, use of guidelines, in particular the most appropriate guidelines, is essential when managing CVD and its associated risk factors. Guideline implementation has been shown to improve clinical practice. However, despite evidence to support the use of guidelines, there remains a gap in their implementation.4
Key points explored by the participants in this section included:
- Are the guidelines clear and do any areas need clarification?
- Are physicians following the guidelines?
- Gaps between the guidelines and common clinical practice
- Critical unmet needs for patients/their families, for physicians, and for broader health systems
The patient journey in secondary prevention Nick Hartshorne-Evans shared his expert opinion on opportunities to improve the patient journey.
During the discussion Professor Chris Granger shared his expert opinion on the factors behind why physicians either consciously or unconsciously fail to follow the guidelines. See what he said in this short video clip.
You can also view the Part 2 discussion – Challenges to secondary prevention in current clinical practice here.
The opportunity for improved secondary prevention of recurrent atherothrombotic events among high-risk patients
The third part of the discussion focused on the opportunity for improved secondary prevention of recurrent atherothrombotic events among high-risk patients. The panel began by discussing what they thought the ideal patient journey would look like, from first event through to immediate secondary prevention and then longer-term prevention. This included the patient journey through different health specialists; a key consideration bearing in mind the typical age of patients and the incidence of concomitant diseases. The participants then moved on to consider whether changes to the guidelines should be considered and, if so, in what areas.
Comprehensive secondary prevention, including pharmacological intervention, has been shown to be a relatively cost-effective intervention in heart disease patients, compared with invasive therapies or cardiac surgery. Given the economic challenges in healthcare it is noteworthy that in low and middle-income countries, cardiac prevention has been demonstrated to be both effective and cost-effective.3
However, despite the availability of suitable secondary prevention programmes, only one third to one half of eligible patients are referred or finally take up a preventive programme.3 There are a number of reasons for this and they fall into three groups:
- Patient-related gaps such as education and empowerment, adherence to healthy lifestyle interventions and adherence to preventive pharmacological therapy
- Healthcare provider gaps such as healthcare providers’ knowledge and motivation, risk stratification, post-discharge plan, and awareness and communication among health professionals in acute care and in primary care
- Healthcare systems gaps such as availability of structured secondary prevention programmes, referral to structured secondary prevention interventions and performance indicators
One area that if addressed going forward would result in better outcomes and reduced healthcare costs is adherence to medication, which is low in individuals at high-risk and in patients with cardiovascular disease. At present the low adherence to medication results in worse outcomes and higher healthcare costs.3
Key points explored by the participants in this section included:
- Why should policymakers pay particular attention to secondary prevention of recurrent atherothrombotic events among high-risk patients?
- What should policymakers be doing to improve the patient journey?
- What role should all stakeholders play in improving secondary prevention of recurrent atherothrombotic events among high-risk patients?
What opportunities are there to drive improvements in secondary prevention? View our summary of opportunities in this infographic.
Recent successes and future opportunities in secondary prevention Professor Christopher Granger and Gunnar Brandrup-Wognsen shared their expert opinion on the progress made in secondary prevention so far, and what more they think can be achieved
During the discussion Nick Hartshorne-Evans shared his expert opinion on what the burden of recurrent atherothrombotic events means to him as an expert patient. See what he said in this short video clip.
Who are the relevant stakeholders and what are their roles in improvement of secondary prevention of recurrent atherothrombotic events? View our summary on improving secondary prevention in this infographic.
You can also view the Part 3 discussion – The opportunity for improved secondary prevention of recurrent atherothrombotic events among high-risk patients here.
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. 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.
4. Jeffery RA, et al. Interventions to improve adherence to cardiovascular disease guidelines: a systematic review. BMC Family Practice 2015;16:147–162.