European Heart Journal (2015) 36, 950–955 doi:10.1093/eurheartj/ehv047
EURObservational research programme: EUROASPIRE The EUROASPIRE survey of cardiovascular prevention and diabetes in 24 countries in Europe
Introduction
Methods and results EUROASPIRE IV was a cross-sectional survey undertaken in 78 centres from 24 European countries. A total of 16,426 patients ,80 years after acute coronary syndrome or revascularization were identified from hospital medical records and 7998 (24% females) were interviewed and examined at least 6 months later using standardized methods and instruments. At interview, 16% of patients smoked cigarettes, and nearly half of those smoking at the time of the event were still smokers with the highest prevalence in the youngest ,50 years patients. Two-fifths of patients (38%)
Conclusion EUROASPIRE IV continues to show that implementation of evidencebased guidelines on secondary prevention is far from optimal. A large
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
The aim of the Joint European Societies (JES) Guidelines on cardiovascular disease prevention (CVD) prevention is to improve the practice of preventive cardiology through development of national guidelines and their implementation in everyday clinical practice.1 Patients with coronary or other atherosclerotic disease are the highest clinical priority for prevention with defined lifestyle, medical risk factor, and therapeutic targets. Diabetes is a major risk factor in patients with coronary artery disease and patients with both diagnoses have a two-fold higher mortality than coronary patients without diabetes, making them a group at particularly high risk for a subsequent cardiovascular event or premature death.2 Four European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) cross-sectional surveys, starting in 1995–96, have evaluated guideline implementation in everyday clinical practice across Europe.3 – 7 The most recent EUROASPIRE IV survey was carried out in 2012–13 in 24 countries: Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Finland, France, Germany, Greece, Ireland, Latvia, Lithuania, the Netherlands, Poland, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Turkey, Ukraine, and the UK.8 The survey was undertaken under the auspices of the European Society of Cardiology, EURObservational Research Programme and incorporated the Euro Heart Survey on Diabetes to create the first European Survey of CVD Prevention and Diabetes.9 – 11 The main objectives of EUROASPIRE IV were to identify risk factors in coronary patients with and without diabetes, describe their management through lifestyle and use of drug therapies and provide an objective assessment of clinical implementation of current scientific knowledge on prevention across Europe.
were obese (body mass index ≥ 30 kg/m2) and three fifths (58%) were centrally obese (waist circumference ≥102 cm in men or ≥88 cm in women). Forty-three per cent had blood pressure ≥140/90 mmHg (≥140/80 in people with diabetes); 81% had lowdensity lipoprotein (LDL)-cholesterol ≥1.8 and 27% reported a diagnosis of diabetes. Glycaemic control of patients with a history of diabetes was poor with just over half of them (53%) with HbA1c ,7.0 mmol/L. A large majority of patients reported taking cardioprotective medications: anti-platelets 94%; b-blockers 83%; angiotensin converting enzyme inhibitors/angiotensin receptor blockers 75%; and statins 86%. Only half of the patients (51%) were advised to participate in a cardiac prevention and rehabilitation programme and 81% of those advised attended at least half of the sessions. Time trends across the last three surveys have shown adverse lifestyle trends, a substantial increase in obesity, central obesity and diabetes, and a high prevalence of persistent smoking in younger patients. Despite a substantial increase in blood pressure and lipid-lowering therapies, most patients were still above blood pressure and lipids targets. The rising prevalence of obesity and central obesity is of concern because it is contributing to the increasing prevalence of diabetes, an absolute increase of 9% over 14 years, increasing the risk of recurrent macrovascular disease, the development of microvascular disease and a further reduction in life expectancy. The risk of dying for patients with coronary artery disease and diabetes is substantially higher than for those free from diabetes.2 In a mortality follow-up of the EUROASPIRE I cohort of coronary patients, the independent modifiable risk factors associated with an increased risk of dying were smoking, cholesterol, and glucose.12 Yet the potential to reduce that risk in diabetes is considerable with a combination of lifestyle, risk factor control, and use of evidence-based medications. Management of hyperglycaemia using the new ESC/EASD target HbA1c of ,7.0 mmol/L in diabetes reduces the risk of microvascular complications and, to a lesser extent, that of macrovascular complications.2 The Euro Heart Survey on Diabetes and the Heart demonstrated that abnormal glucose regulation affected a majority of patients with coronary artery disease. Patients with diabetes compared with those without diabetes had a muchpoorerprognosis,whichcould be improved considerably with multifactorial evidence-based management.11
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majority of coronary patients do not achieve the lifestyle targets with high prevalence of persistent smoking, overweight, obesity, and diabetes. Although most patients are receiving cardioprotective drugs, blood pressure, lipid, and glycaemic control are still inadequate. All coronary patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control, and adherence with cardioprotective medications. Coronary intervention should always be followed by prevention.
Kornelia Kotseva 1, Lars Ryde´n 2, Guy De Backer 3, Dirk De Bacquer 3 and David Wood 1 1 International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK 2 Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden 3 Department of Public Health, University of Ghent, Ghent, Belgium
References References are available as supplementary material at European Heart Journal online.
The structure of health care in Sweden reported by Dr Anna Kiessling, National CVD Prevention Coordinator and Members* of the National Working Group for Cardiovascular Prevention and Lifestyle, appointed by the Swedish Society of Cardiology frequent sources of disability. Mortality rates have declined substantially. More than half of the decrease between 1986 and 2002 was attributable to reductions of major risk factors; mainly a decrease in serum cholesterol (Table 1).
Anna Kiessling MD, PhD, FESC Cardiologist, Assistant Professor, Senior Lecturer, Department of Clinical Sciences, Unit of Cardiovascular Medicine, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
Healthcare Everyone has equal access to healthcare services under a taxpayerfunded system. The government establishes principles and the county councils provide healthcare. The municipalities provide care for elderly people with disabilities and for school healthcare. Special demands are put on healthcare due to Sweden having proportionally one of Europe’s largest elderly populations. Healthcare costs represent 10% of Sweden’s gross domestic product (GDP). County council and municipal taxes pay for the bulk of these costs. An increasing part of healthcare is financed by county councils but carried out by private care providers. Quality registers are widely used to follow and increase the adherence to guidelines.
Risk factors People in Sweden are living increasingly longer, with an average life span of 83.5 years for women and 79.5 years for men. Cardiovascular disease is the most common cause of death and among the most
Prevention methods and main actors The main authorities acting in the prevention area are † † † † † †
The National Board of Health and Welfare The Swedish Association of Local Authorities and Regions (SALAR) The Swedish Council on Health Technology Assessment The Public Health Agency of Sweden The Swedish Society of Cardiology The Heart and Lung Foundation
Prevention activities The Swedish National Board of Health and Welfare’s National Guidelines for Methods of Preventing Disease state recommendation on methods of preventing disease by a structured support to patients in their efforts to change unhealthy lifestyle habits. The lifestyle habits included are tobacco use, hazardous use of alcohol, insufficient physical activity, and unhealthy eating habits. A national project called the Lifestyle project is running to implement them nationally. Healthy eating habits are discussed widely in Sweden and both evidence based and more populist guidance about different diets is available. Physical activity on prescription (PAP) is increasingly used to minimize a sedentary lifestyle. It is an individually adjusted written
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
EACPR country of the month initiative: Sweden
952
Table 1 factors
CardioPulse
The prevalence of major cardiovascular risk
Risk factor
Prevalence among adults
Trend over time
Smoking
22%
Decreasing
Physical inactivity Adiposity
47% 18%
Decreasing Increasing
Blood lipids (total cholesterol)
5 mmol/L (mean)
Decreasing
................................................................................
Hypertension
46%
Decreasing
Diabetes mellitus Alcohol
9% 7– 10 L/adult .15 years per year
Increasing Increasing
prescription of physical activity including the intensity, duration, and type of activity that the patient should perform to prevent further disease. All undergraduate programmes leading to a healthcare profession at university level have intended learning outcomes at graduation level including competence in prevention. At residency level there are also compulsory goals on preventive and health promoting competences at both individual patient and group level for all specialties including in cardiology. The Swedish Society of Cardiology, The Swedish Medical Society, and other authorities at regional and local levels arrange shorter and longer courses on a regular basis with focus on cardiovascular prevention and on support of healthier lifestyle among patients.
Sweden has no fixed age limits for participation in cardiac rehabilitation, and a well-established countrywide system of cardiac rehabilitation is provided. Most programmes have duration of 2–3 months and include physical activity training, education about healthy food, cardiac risk factors, smoking, and the importance of physical activity and stress reduction. The link from organized cardiac rehabilitation to long-term structures to support maintenance of a healthy life style is increasingly strengthened. A quality audit is presented yearly on a national basis. SWEDEHEART is a national registry of all patients hospitalized for acute coronary syndrome (ACS). The SEPHIA registry (SEcondary Prevention after Heart Intensive care Admission), forming a part of the SWEDEHEART registry, provides information on follow-up of unselected consecutive patients below the age of 75 up to 1 year after an acute myocardial infarction. Results from 2012 shows † At the second follow-up 55% of smokers had quit. Fourteen per cent of smokers had taken part in smoking cessation programmes. † The proportion of patients with systolic blood pressure ,140 mmHg was 65% at the first and second follow-ups, but with differences between hospitals. † Target level for LDL was achieved by 38% 2 months after the myocardial infarction, but with divergence in results between hospitals.
Aims for the future Future plans include focusing on smoking cessation and physical activity. Further, focus on socioeconomically deprived, mentally ill, and minors especially susceptible to marketing of the tobacco and fast food industry. We will see more use of national quality registers in the preventive strategies and new individualized models of cardiac rehabilitation. *Including: Kristina Hambraeus MD, Claes Held MD, Anna Norhammar MD, and Joep Perk MD.
Strengthening evidence for benefits of cardiac rehabilitation highlighted in Cochrane reviews Although cardiac rehabilitation is unlikely to prolong life, it will probably improve its quality and keep people out of hospital, Professor Rod Taylor tells Barry Shurlock PhD
Rod Taylor Someone who has built a part of his academic career on examining the benefits or otherwise of cardiac rehabilitation is Professor Rod
Taylor, Head, Department of Health Services Research, University of Exeter Medical School, Exeter, UK. He, and more recently Dr Lindsey Anderson also based in Exeter, coordinate a portfolio of Cochrane Systematic Reviews that address some of the key questions around cardiac rehabilitation (see Table 1). It started 14 years ago in 2001 with his first Cochrane review and since then he, and a variety of co-authors, have worked on a succession of reviews and their updates. He said: ‘This portfolio not only covers the impact of cardiac rehabilitation in people post-MI, postrevascularization, and those with heart failure, but we are also now looking at higher-risk groups, such as those with atrial fibrillation, post-valve surgery and fitted with ICDs.
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Physical inactivity: ,30 min 5 times a week, moderate intensity, or 20 min 3 times a week, vigorous intensity. Hypertension: systolic BP . 140 or diastolic BP . 90 or on medication. Diabetes mellitus: fasting blood glucose .7.0 mmol/L or on medication. Source: WHO statistics (2008), http://apps.who.int/gho/data.
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Table 1
Cochrane reviews on cardiac rehabilitationa
Subject
Date of last published review
Expected date for next update
Exercise-based cardiac rehabilitation for heart failure
April 2014
2016
Home-based cardiac rehabilitation Exercise-based cardiac rehabilitation for coronary heart disease
January 2010 July 2011
Q1 2015 Q2 2015
Patient education in the management of coronary heart disease
December 2011
2015
Psychological interventions for coronary heart disease Exercise-based rehabilitation for atrial fibrillation
October 2011
Q2 2015 Q1 2015
...............................................................................................................................................................................
Exercise-based rehabilitation post-valve surgery Exercise-based rehabilitation for intra-cardiac defibrillators Promoting patient of uptake and adherence to cardiac rehabilitation
Q1 2015 June 2014
Q2 2015 2016
a
Available online at www.onlinelibrary.wiley.
main message was that the evidence for the benefits of cardiac rehabilitation for heart failure has become clearer. The two previous versions of the review had been less certain about the impact, in terms of reduction of hospitalization and increased QOL. Indeed these previous reviews [identified needs for] more high-quality trial evidence, which is what we got this time—for the last update we had 19 trials and this time we had 14 more. Compared to control[s], not only were the QOL benefits of exercise-based rehabilitation statistically significant, based on the Minnesota [living with heart failure] Questionnaire, but these benefits were of a magnitude that are clinically important and meaningful to patients. In a nutshell, this update review shows that the addition of cardiac rehabilitation in heart-failure patients, already receiving optimal standard care, does not necessarily prolong their life, but it appears to improve the quality of those remaining years and reduce the risk of costly and distressing readmissions to hospital’. The possibility that exercise-based cardiac rehabilitation can be carried out effectively at home in a largely unsupervised manner has caught the attention of many healthcare authorities keen to reduce budgets. Two years ago, in January 2013 Professor Taylor and fellow Research GP Dr Hayes Dala, based in Truro, UK, secured a £2 million (E2.5 million) UK National Institute of Health Research Programme Grant (REACH-HF) shared with research colleagues across the country. The aim is to develop and evaluate in a multicentre RCT the costs and benefits of a home-based selfmanagement rehabilitation manual for heart failure patients and their care givers. Over the last 12-months, with patient involvement, the REACH-HF team has developed a ‘Heart Manual’ for heart-failure patients and their carers to promote rehabilitation at home. Commenting in general on Cochrane systematic reviews, Professor Taylor said: ‘I must admit I’m very passionate about them! But they are rarely formally funded and therefore often have to be driven by goodwill, fresh air and lots of enthusiasm!’ Currently in Denmark on sabbatical leave with the CopenHeart research group, he says he has ‘become a convert to their approach’, whereby every PhD student undertakes a Cochrane review, as primary research. But his advice to anyone contemplating the job is: ‘Don’t underestimate the size and duration of the task!’
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Our reviews have been contributed to by a team of UK and international investigators that includes researchers and clinicians and we are—in addition to assessing the question of the impact of rehabilitation in specific groups of cardiac patients—also asking how best to provide cardiac rehabilitation. Should we continue with supervised centre-based, often in a hospital setting, provision or expand into community, or unsupervised at-home based models of care. We are also trying to ‘dismantle’ the rehab model by examining what might be the benefits that come from three cornerstones of rehabilitation, namely exercise and physical promotion, education and psychological interventions. My interest in cardiac rehabilitation started when I did my PhD in the 1990s on the effects of exercise training in people at high risk of a cardiac event, and that also introduced me to the power of the randomized clinical trial [RCT]. As regards Cochrane reviews, I learnt on the job with my first review, alongside a bit of training that I had picked up!’ ‘A very nice exemplar’ of a Cochrane, in his view, is the one on exercise-based rehabilitation for heart failure that he and eight others published in its third version online in April last year, 2014 (www.onlinelibrary.wiley.com/doi/10.1002/14651858. CD003331). It was led by final-year medical student Viral Sagar (now medically qualified), who wanted to get a systematic review under his belt whilst undertaking his studies at Exeter. Co-authors include the pioneer heart-failure researcher and cardiologist Dr Andrew Coats (now Academic Vice-President in the global UK–Australia partnership based on Monash University and the University of Warwick). With the help of information specialist Simon Briscoe, also based at Exeter University Medical School, databases were searched to locate potential studies, yielding 8746 references. Professor Taylor and Dr Sagar, working independently, winnowed these down to 41 papers and then extracted and cross-checked the key data, if need be contacting the authors of the original papers. As part of the rigorous Cochrane review process, they assessed the general characteristics of the RCTs and undertook a detailed assessment of their potential bias. They then pooled data for mortality, hospitalization, and health-related quality of life (QOL) across trials, using meta-analysis. Commenting on the work, Professor Taylor said: ‘The good thing about this review was that it illustrates the importance of keeping Cochrane reviews up-to-date with an evolving evidence base. The
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The veteran athlete’s heart Are there cardiac concerns in later life, with the increasing number of people taking part in athletic endurance events? and LGE.4 Unlike the previous study, the veteran athletes were truly lifelong athletes with 35–52 years of continuous training and competition. Interestingly, six lifelong veteran endurance athletes (50% of cohort) demonstrated LGE and this was significantly associated with the number of years spent training (P , 0.001), and number of competitive marathons (P , 0.001) completed. The obvious limitation of the study was its small sample size of only 12 veteran athletes. The authors concluded that generalizations would be difficult and future studies employing large cohorts of lifelong veteran male and female athletes are warranted. Finally, there has been recent interest on atherosclerosis and endurance running. Mohlenkamp et al. evaluated calcium artery calcification (CAC) scores in the same cohort of veteran runners studied by Breuckmann et al. They documented 36% of marathon runners aged .50 having a CAC score .100 compared with 21% in controls matched to age and Framingham risk factors.5 A major limiting factor of the study was that more than half of the runners in the study were previous smokers and 5% of runners were active smokers. This could have explained the higher calcium scores observed and supports the notion for a larger well-designed study which excludes confounding factors such as smoking. Some authors have already concluded that overzealous exercise may be harmful. A prospective cohort study of 416 175 Taiwanese men and women between 1996 and 2008 was published in Lancet in 2011.6 The authors reported that beyond 90 min of daily moderate physical activity and 45 min of daily vigorous activity the mortality benefit of exercise plateaus, whereby any more exercise has no additional reward. Based on the aforementioned, there is a particular interest in the veteran athlete’s heart, yet there is no defined normal spectrum for the electrical, structural, and functional description of lifelong ultra-endurance athletes. It is possible that the descriptions in the
Figure 1 Determinants of the veteran athlete’s heart.
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Participation in chronic intensive physical training is associated with a plethora of unique electrical, structural, and functional changes. The constellation of these modifications is termed the ‘Athletes Heart’. The current knowledge of the ‘athlete’s heart’ is largely amassed from studies on young cohorts (,35 years) whereas data relating to the older athlete are sparse. However, there is a large population of veteran endurance athletes who have been exercising since youth, for example, 35% of marathon runners are aged .40 years old. As with the general population, veteran athletes are subject to the normal ageing process and acquire risk factors for cardiac disease as life progresses. Small-scale studies suggest that this emerging population of athlete’s develop adverse cardiac remodelling and myocardial scarring that may culminate in arrhythmias. However, it is presently unclear whether these observed changes are age related, due to lifelong risk factors for cardiovascular disease, represent physiological chronic adaptation to exercise or an acquired cardiomyopathy (Figure 1). The absence of data pertaining to cardiovascular adaptation in veterans does not enable a concrete differentiation between changes related to chronic athletic training compared with those representing cardiac pathology. There are numerous reports that chronic intensive exercise may be associated with deleterious effects in the 5 –7th decade. Probably the best example is the 5-fold increase of lone atrial fibrillation in veteran athletes.1 Similarly, there are reports of a higher rate of atrial flutter and sinus node disease (SND). The prevalence of ventricular cardiac arrhythmias has not been fully characterized in this cohort of athletes and knowledge is solely based on young sportsmen. However, Heidbuchel et al. observed a high incidence of major arrhythmic events (39%) including sudden cardiac death (20%) amongst 46 young athletes who presented with frequent ventricular ectopy or non-sustained ventricular tachycardia who were followed for 5 years.2 The suspected mechanisms underlying the reported arrhythmias in veteran athletes remain uncertain with theories ranging from high vagal tone, myocardial fibrosis, and adverse cardiac remodelling. Breuckmann et al. undertook cardiac MRI (CMR) imaging of 102 men aged at least 50 years who had completed at least five full-distance marathons during the past 3 years and had no history of heart disease or diabetes.3 Twenty per cent of the veteran marathon runners had late-gadolinium enhancement (LGE) which was 3-fold more than the sedentary controls (P ¼ 0.077). The authors went on to separate the pattern of LGE and found that the majority (58%) of the runners had an atypical patchy to streaky subepicardial to midmyocardial hyper enhancement termed non-coronary artery disease (CAD) pattern compared with 42% who had a CAD pattern. There were a few limitations to the above study. Importantly, the study was confined to male Caucasians. Furthermore, the definition of a veteran athlete used in the study was very lenient (3 years of ultraendurance running). A considerably smaller but more recent study evaluated 12 lifelong veteran male endurance athletes with CMR
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literature regarding the negative effects of long-term exercise represent the tip of the pyramid of athletes who have sought clinical advice and may not be representative of the wider veteran athlete population. Large-scale studies are required on the veteran athlete with the aim of offering a scientifically sound account of the chronic effects of exercise. This will be important in providing evidence-based advice to veteran athletes and those wanting to commit their life to competitive sport (Figures 2 and 3).
Figure 3 Magnetic resonance imaging of 72-year-old asymptomatic ultra-endurance veteran athlete with an extensive anterior subendocardial scar.
Conflict of interest: none declared.
References References are available as supplementary material at European Heart Journal online.
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
Figure 2 Computed tomography image of 72-year-old asymptomatic ultra-endurance veteran athlete with a significant stenosis of the proximal left anterior descending artery.
EURObservational research programme: EUROASPIRE The EUROASPIRE survey of cardiovascular prevention and diabetes in 24 countries in Europe
Introduction
Methods and results EUROASPIRE IV was a cross-sectional survey undertaken in 78 centres from 24 European countries. A total of 16,426 patients ,80 years after acute coronary syndrome or revascularization were identified from hospital medical records and 7998 (24% females) were interviewed and examined at least 6 months later using standardized methods and instruments. At interview, 16% of patients smoked cigarettes, and nearly half of those smoking at the time of the event were still smokers with the highest prevalence in the youngest ,50 years patients. Two-fifths of patients (38%)
Conclusion EUROASPIRE IV continues to show that implementation of evidencebased guidelines on secondary prevention is far from optimal. A large
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
The aim of the Joint European Societies (JES) Guidelines on cardiovascular disease prevention (CVD) prevention is to improve the practice of preventive cardiology through development of national guidelines and their implementation in everyday clinical practice.1 Patients with coronary or other atherosclerotic disease are the highest clinical priority for prevention with defined lifestyle, medical risk factor, and therapeutic targets. Diabetes is a major risk factor in patients with coronary artery disease and patients with both diagnoses have a two-fold higher mortality than coronary patients without diabetes, making them a group at particularly high risk for a subsequent cardiovascular event or premature death.2 Four European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) cross-sectional surveys, starting in 1995–96, have evaluated guideline implementation in everyday clinical practice across Europe.3 – 7 The most recent EUROASPIRE IV survey was carried out in 2012–13 in 24 countries: Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Finland, France, Germany, Greece, Ireland, Latvia, Lithuania, the Netherlands, Poland, Romania, Russia, Serbia, Slovenia, Spain, Sweden, Turkey, Ukraine, and the UK.8 The survey was undertaken under the auspices of the European Society of Cardiology, EURObservational Research Programme and incorporated the Euro Heart Survey on Diabetes to create the first European Survey of CVD Prevention and Diabetes.9 – 11 The main objectives of EUROASPIRE IV were to identify risk factors in coronary patients with and without diabetes, describe their management through lifestyle and use of drug therapies and provide an objective assessment of clinical implementation of current scientific knowledge on prevention across Europe.
were obese (body mass index ≥ 30 kg/m2) and three fifths (58%) were centrally obese (waist circumference ≥102 cm in men or ≥88 cm in women). Forty-three per cent had blood pressure ≥140/90 mmHg (≥140/80 in people with diabetes); 81% had lowdensity lipoprotein (LDL)-cholesterol ≥1.8 and 27% reported a diagnosis of diabetes. Glycaemic control of patients with a history of diabetes was poor with just over half of them (53%) with HbA1c ,7.0 mmol/L. A large majority of patients reported taking cardioprotective medications: anti-platelets 94%; b-blockers 83%; angiotensin converting enzyme inhibitors/angiotensin receptor blockers 75%; and statins 86%. Only half of the patients (51%) were advised to participate in a cardiac prevention and rehabilitation programme and 81% of those advised attended at least half of the sessions. Time trends across the last three surveys have shown adverse lifestyle trends, a substantial increase in obesity, central obesity and diabetes, and a high prevalence of persistent smoking in younger patients. Despite a substantial increase in blood pressure and lipid-lowering therapies, most patients were still above blood pressure and lipids targets. The rising prevalence of obesity and central obesity is of concern because it is contributing to the increasing prevalence of diabetes, an absolute increase of 9% over 14 years, increasing the risk of recurrent macrovascular disease, the development of microvascular disease and a further reduction in life expectancy. The risk of dying for patients with coronary artery disease and diabetes is substantially higher than for those free from diabetes.2 In a mortality follow-up of the EUROASPIRE I cohort of coronary patients, the independent modifiable risk factors associated with an increased risk of dying were smoking, cholesterol, and glucose.12 Yet the potential to reduce that risk in diabetes is considerable with a combination of lifestyle, risk factor control, and use of evidence-based medications. Management of hyperglycaemia using the new ESC/EASD target HbA1c of ,7.0 mmol/L in diabetes reduces the risk of microvascular complications and, to a lesser extent, that of macrovascular complications.2 The Euro Heart Survey on Diabetes and the Heart demonstrated that abnormal glucose regulation affected a majority of patients with coronary artery disease. Patients with diabetes compared with those without diabetes had a muchpoorerprognosis,whichcould be improved considerably with multifactorial evidence-based management.11
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majority of coronary patients do not achieve the lifestyle targets with high prevalence of persistent smoking, overweight, obesity, and diabetes. Although most patients are receiving cardioprotective drugs, blood pressure, lipid, and glycaemic control are still inadequate. All coronary patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control, and adherence with cardioprotective medications. Coronary intervention should always be followed by prevention.
Kornelia Kotseva 1, Lars Ryde´n 2, Guy De Backer 3, Dirk De Bacquer 3 and David Wood 1 1 International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK 2 Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden 3 Department of Public Health, University of Ghent, Ghent, Belgium
References References are available as supplementary material at European Heart Journal online.
The structure of health care in Sweden reported by Dr Anna Kiessling, National CVD Prevention Coordinator and Members* of the National Working Group for Cardiovascular Prevention and Lifestyle, appointed by the Swedish Society of Cardiology frequent sources of disability. Mortality rates have declined substantially. More than half of the decrease between 1986 and 2002 was attributable to reductions of major risk factors; mainly a decrease in serum cholesterol (Table 1).
Anna Kiessling MD, PhD, FESC Cardiologist, Assistant Professor, Senior Lecturer, Department of Clinical Sciences, Unit of Cardiovascular Medicine, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
Healthcare Everyone has equal access to healthcare services under a taxpayerfunded system. The government establishes principles and the county councils provide healthcare. The municipalities provide care for elderly people with disabilities and for school healthcare. Special demands are put on healthcare due to Sweden having proportionally one of Europe’s largest elderly populations. Healthcare costs represent 10% of Sweden’s gross domestic product (GDP). County council and municipal taxes pay for the bulk of these costs. An increasing part of healthcare is financed by county councils but carried out by private care providers. Quality registers are widely used to follow and increase the adherence to guidelines.
Risk factors People in Sweden are living increasingly longer, with an average life span of 83.5 years for women and 79.5 years for men. Cardiovascular disease is the most common cause of death and among the most
Prevention methods and main actors The main authorities acting in the prevention area are † † † † † †
The National Board of Health and Welfare The Swedish Association of Local Authorities and Regions (SALAR) The Swedish Council on Health Technology Assessment The Public Health Agency of Sweden The Swedish Society of Cardiology The Heart and Lung Foundation
Prevention activities The Swedish National Board of Health and Welfare’s National Guidelines for Methods of Preventing Disease state recommendation on methods of preventing disease by a structured support to patients in their efforts to change unhealthy lifestyle habits. The lifestyle habits included are tobacco use, hazardous use of alcohol, insufficient physical activity, and unhealthy eating habits. A national project called the Lifestyle project is running to implement them nationally. Healthy eating habits are discussed widely in Sweden and both evidence based and more populist guidance about different diets is available. Physical activity on prescription (PAP) is increasingly used to minimize a sedentary lifestyle. It is an individually adjusted written
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
EACPR country of the month initiative: Sweden
952
Table 1 factors
CardioPulse
The prevalence of major cardiovascular risk
Risk factor
Prevalence among adults
Trend over time
Smoking
22%
Decreasing
Physical inactivity Adiposity
47% 18%
Decreasing Increasing
Blood lipids (total cholesterol)
5 mmol/L (mean)
Decreasing
................................................................................
Hypertension
46%
Decreasing
Diabetes mellitus Alcohol
9% 7– 10 L/adult .15 years per year
Increasing Increasing
prescription of physical activity including the intensity, duration, and type of activity that the patient should perform to prevent further disease. All undergraduate programmes leading to a healthcare profession at university level have intended learning outcomes at graduation level including competence in prevention. At residency level there are also compulsory goals on preventive and health promoting competences at both individual patient and group level for all specialties including in cardiology. The Swedish Society of Cardiology, The Swedish Medical Society, and other authorities at regional and local levels arrange shorter and longer courses on a regular basis with focus on cardiovascular prevention and on support of healthier lifestyle among patients.
Sweden has no fixed age limits for participation in cardiac rehabilitation, and a well-established countrywide system of cardiac rehabilitation is provided. Most programmes have duration of 2–3 months and include physical activity training, education about healthy food, cardiac risk factors, smoking, and the importance of physical activity and stress reduction. The link from organized cardiac rehabilitation to long-term structures to support maintenance of a healthy life style is increasingly strengthened. A quality audit is presented yearly on a national basis. SWEDEHEART is a national registry of all patients hospitalized for acute coronary syndrome (ACS). The SEPHIA registry (SEcondary Prevention after Heart Intensive care Admission), forming a part of the SWEDEHEART registry, provides information on follow-up of unselected consecutive patients below the age of 75 up to 1 year after an acute myocardial infarction. Results from 2012 shows † At the second follow-up 55% of smokers had quit. Fourteen per cent of smokers had taken part in smoking cessation programmes. † The proportion of patients with systolic blood pressure ,140 mmHg was 65% at the first and second follow-ups, but with differences between hospitals. † Target level for LDL was achieved by 38% 2 months after the myocardial infarction, but with divergence in results between hospitals.
Aims for the future Future plans include focusing on smoking cessation and physical activity. Further, focus on socioeconomically deprived, mentally ill, and minors especially susceptible to marketing of the tobacco and fast food industry. We will see more use of national quality registers in the preventive strategies and new individualized models of cardiac rehabilitation. *Including: Kristina Hambraeus MD, Claes Held MD, Anna Norhammar MD, and Joep Perk MD.
Strengthening evidence for benefits of cardiac rehabilitation highlighted in Cochrane reviews Although cardiac rehabilitation is unlikely to prolong life, it will probably improve its quality and keep people out of hospital, Professor Rod Taylor tells Barry Shurlock PhD
Rod Taylor Someone who has built a part of his academic career on examining the benefits or otherwise of cardiac rehabilitation is Professor Rod
Taylor, Head, Department of Health Services Research, University of Exeter Medical School, Exeter, UK. He, and more recently Dr Lindsey Anderson also based in Exeter, coordinate a portfolio of Cochrane Systematic Reviews that address some of the key questions around cardiac rehabilitation (see Table 1). It started 14 years ago in 2001 with his first Cochrane review and since then he, and a variety of co-authors, have worked on a succession of reviews and their updates. He said: ‘This portfolio not only covers the impact of cardiac rehabilitation in people post-MI, postrevascularization, and those with heart failure, but we are also now looking at higher-risk groups, such as those with atrial fibrillation, post-valve surgery and fitted with ICDs.
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on November 17, 2015
Physical inactivity: ,30 min 5 times a week, moderate intensity, or 20 min 3 times a week, vigorous intensity. Hypertension: systolic BP . 140 or diastolic BP . 90 or on medication. Diabetes mellitus: fasting blood glucose .7.0 mmol/L or on medication. Source: WHO statistics (2008), http://apps.who.int/gho/data.
Cardiac rehabilitation
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Table 1
Cochrane reviews on cardiac rehabilitationa
Subject
Date of last published review
Expected date for next update
Exercise-based cardiac rehabilitation for heart failure
April 2014
2016
Home-based cardiac rehabilitation Exercise-based cardiac rehabilitation for coronary heart disease
January 2010 July 2011
Q1 2015 Q2 2015
Patient education in the management of coronary heart disease
December 2011
2015
Psychological interventions for coronary heart disease Exercise-based rehabilitation for atrial fibrillation
October 2011
Q2 2015 Q1 2015
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Exercise-based rehabilitation post-valve surgery Exercise-based rehabilitation for intra-cardiac defibrillators Promoting patient of uptake and adherence to cardiac rehabilitation
Q1 2015 June 2014
Q2 2015 2016
a
Available online at www.onlinelibrary.wiley.
main message was that the evidence for the benefits of cardiac rehabilitation for heart failure has become clearer. The two previous versions of the review had been less certain about the impact, in terms of reduction of hospitalization and increased QOL. Indeed these previous reviews [identified needs for] more high-quality trial evidence, which is what we got this time—for the last update we had 19 trials and this time we had 14 more. Compared to control[s], not only were the QOL benefits of exercise-based rehabilitation statistically significant, based on the Minnesota [living with heart failure] Questionnaire, but these benefits were of a magnitude that are clinically important and meaningful to patients. In a nutshell, this update review shows that the addition of cardiac rehabilitation in heart-failure patients, already receiving optimal standard care, does not necessarily prolong their life, but it appears to improve the quality of those remaining years and reduce the risk of costly and distressing readmissions to hospital’. The possibility that exercise-based cardiac rehabilitation can be carried out effectively at home in a largely unsupervised manner has caught the attention of many healthcare authorities keen to reduce budgets. Two years ago, in January 2013 Professor Taylor and fellow Research GP Dr Hayes Dala, based in Truro, UK, secured a £2 million (E2.5 million) UK National Institute of Health Research Programme Grant (REACH-HF) shared with research colleagues across the country. The aim is to develop and evaluate in a multicentre RCT the costs and benefits of a home-based selfmanagement rehabilitation manual for heart failure patients and their care givers. Over the last 12-months, with patient involvement, the REACH-HF team has developed a ‘Heart Manual’ for heart-failure patients and their carers to promote rehabilitation at home. Commenting in general on Cochrane systematic reviews, Professor Taylor said: ‘I must admit I’m very passionate about them! But they are rarely formally funded and therefore often have to be driven by goodwill, fresh air and lots of enthusiasm!’ Currently in Denmark on sabbatical leave with the CopenHeart research group, he says he has ‘become a convert to their approach’, whereby every PhD student undertakes a Cochrane review, as primary research. But his advice to anyone contemplating the job is: ‘Don’t underestimate the size and duration of the task!’
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Our reviews have been contributed to by a team of UK and international investigators that includes researchers and clinicians and we are—in addition to assessing the question of the impact of rehabilitation in specific groups of cardiac patients—also asking how best to provide cardiac rehabilitation. Should we continue with supervised centre-based, often in a hospital setting, provision or expand into community, or unsupervised at-home based models of care. We are also trying to ‘dismantle’ the rehab model by examining what might be the benefits that come from three cornerstones of rehabilitation, namely exercise and physical promotion, education and psychological interventions. My interest in cardiac rehabilitation started when I did my PhD in the 1990s on the effects of exercise training in people at high risk of a cardiac event, and that also introduced me to the power of the randomized clinical trial [RCT]. As regards Cochrane reviews, I learnt on the job with my first review, alongside a bit of training that I had picked up!’ ‘A very nice exemplar’ of a Cochrane, in his view, is the one on exercise-based rehabilitation for heart failure that he and eight others published in its third version online in April last year, 2014 (www.onlinelibrary.wiley.com/doi/10.1002/14651858. CD003331). It was led by final-year medical student Viral Sagar (now medically qualified), who wanted to get a systematic review under his belt whilst undertaking his studies at Exeter. Co-authors include the pioneer heart-failure researcher and cardiologist Dr Andrew Coats (now Academic Vice-President in the global UK–Australia partnership based on Monash University and the University of Warwick). With the help of information specialist Simon Briscoe, also based at Exeter University Medical School, databases were searched to locate potential studies, yielding 8746 references. Professor Taylor and Dr Sagar, working independently, winnowed these down to 41 papers and then extracted and cross-checked the key data, if need be contacting the authors of the original papers. As part of the rigorous Cochrane review process, they assessed the general characteristics of the RCTs and undertook a detailed assessment of their potential bias. They then pooled data for mortality, hospitalization, and health-related quality of life (QOL) across trials, using meta-analysis. Commenting on the work, Professor Taylor said: ‘The good thing about this review was that it illustrates the importance of keeping Cochrane reviews up-to-date with an evolving evidence base. The
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The veteran athlete’s heart Are there cardiac concerns in later life, with the increasing number of people taking part in athletic endurance events? and LGE.4 Unlike the previous study, the veteran athletes were truly lifelong athletes with 35–52 years of continuous training and competition. Interestingly, six lifelong veteran endurance athletes (50% of cohort) demonstrated LGE and this was significantly associated with the number of years spent training (P , 0.001), and number of competitive marathons (P , 0.001) completed. The obvious limitation of the study was its small sample size of only 12 veteran athletes. The authors concluded that generalizations would be difficult and future studies employing large cohorts of lifelong veteran male and female athletes are warranted. Finally, there has been recent interest on atherosclerosis and endurance running. Mohlenkamp et al. evaluated calcium artery calcification (CAC) scores in the same cohort of veteran runners studied by Breuckmann et al. They documented 36% of marathon runners aged .50 having a CAC score .100 compared with 21% in controls matched to age and Framingham risk factors.5 A major limiting factor of the study was that more than half of the runners in the study were previous smokers and 5% of runners were active smokers. This could have explained the higher calcium scores observed and supports the notion for a larger well-designed study which excludes confounding factors such as smoking. Some authors have already concluded that overzealous exercise may be harmful. A prospective cohort study of 416 175 Taiwanese men and women between 1996 and 2008 was published in Lancet in 2011.6 The authors reported that beyond 90 min of daily moderate physical activity and 45 min of daily vigorous activity the mortality benefit of exercise plateaus, whereby any more exercise has no additional reward. Based on the aforementioned, there is a particular interest in the veteran athlete’s heart, yet there is no defined normal spectrum for the electrical, structural, and functional description of lifelong ultra-endurance athletes. It is possible that the descriptions in the
Figure 1 Determinants of the veteran athlete’s heart.
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Participation in chronic intensive physical training is associated with a plethora of unique electrical, structural, and functional changes. The constellation of these modifications is termed the ‘Athletes Heart’. The current knowledge of the ‘athlete’s heart’ is largely amassed from studies on young cohorts (,35 years) whereas data relating to the older athlete are sparse. However, there is a large population of veteran endurance athletes who have been exercising since youth, for example, 35% of marathon runners are aged .40 years old. As with the general population, veteran athletes are subject to the normal ageing process and acquire risk factors for cardiac disease as life progresses. Small-scale studies suggest that this emerging population of athlete’s develop adverse cardiac remodelling and myocardial scarring that may culminate in arrhythmias. However, it is presently unclear whether these observed changes are age related, due to lifelong risk factors for cardiovascular disease, represent physiological chronic adaptation to exercise or an acquired cardiomyopathy (Figure 1). The absence of data pertaining to cardiovascular adaptation in veterans does not enable a concrete differentiation between changes related to chronic athletic training compared with those representing cardiac pathology. There are numerous reports that chronic intensive exercise may be associated with deleterious effects in the 5 –7th decade. Probably the best example is the 5-fold increase of lone atrial fibrillation in veteran athletes.1 Similarly, there are reports of a higher rate of atrial flutter and sinus node disease (SND). The prevalence of ventricular cardiac arrhythmias has not been fully characterized in this cohort of athletes and knowledge is solely based on young sportsmen. However, Heidbuchel et al. observed a high incidence of major arrhythmic events (39%) including sudden cardiac death (20%) amongst 46 young athletes who presented with frequent ventricular ectopy or non-sustained ventricular tachycardia who were followed for 5 years.2 The suspected mechanisms underlying the reported arrhythmias in veteran athletes remain uncertain with theories ranging from high vagal tone, myocardial fibrosis, and adverse cardiac remodelling. Breuckmann et al. undertook cardiac MRI (CMR) imaging of 102 men aged at least 50 years who had completed at least five full-distance marathons during the past 3 years and had no history of heart disease or diabetes.3 Twenty per cent of the veteran marathon runners had late-gadolinium enhancement (LGE) which was 3-fold more than the sedentary controls (P ¼ 0.077). The authors went on to separate the pattern of LGE and found that the majority (58%) of the runners had an atypical patchy to streaky subepicardial to midmyocardial hyper enhancement termed non-coronary artery disease (CAD) pattern compared with 42% who had a CAD pattern. There were a few limitations to the above study. Importantly, the study was confined to male Caucasians. Furthermore, the definition of a veteran athlete used in the study was very lenient (3 years of ultraendurance running). A considerably smaller but more recent study evaluated 12 lifelong veteran male endurance athletes with CMR
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literature regarding the negative effects of long-term exercise represent the tip of the pyramid of athletes who have sought clinical advice and may not be representative of the wider veteran athlete population. Large-scale studies are required on the veteran athlete with the aim of offering a scientifically sound account of the chronic effects of exercise. This will be important in providing evidence-based advice to veteran athletes and those wanting to commit their life to competitive sport (Figures 2 and 3).
Figure 3 Magnetic resonance imaging of 72-year-old asymptomatic ultra-endurance veteran athlete with an extensive anterior subendocardial scar.
Conflict of interest: none declared.
References References are available as supplementary material at European Heart Journal online.
CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]
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Figure 2 Computed tomography image of 72-year-old asymptomatic ultra-endurance veteran athlete with a significant stenosis of the proximal left anterior descending artery.
