Comparison of the rates of stroke and acute coronary events in northern France

In this issue of the European Journal of Preventive Cardiology Dominique Cottel and co-workers1 present a well-conducted register study from the north of France in which they investigated the prevalence of acute coronary events (ACEs) and of stroke among the 78,000 inhabitants aged 35 to 74 years in the city of Lille. They found that in the period 2008–2014 one in 50 of the inhabitants was diagnosed as suffering from ACE or stroke. The rationale of this study was the relative lack of data comparing the prevalence of both types of vascular disease, the access to complete data registries and the fact that both groups of patients may have had a comparable or at least similar risk factor burden. Could comparing the risk burden and clinical outcome between the two groups provide new knowledge in the field of preventive cardiology? The study showed several interesting findings: in the younger age groups the prevalence of ACEs was more prominent in the male population as was the higher attack rate (incident and recurrent rates) both compared with patients with stroke and compared with women. The increase in the prevalence of ACE and stroke with increasing age confirmed earlier findings but in the elderly men stroke surpassed ACE as the more common disorder. Crude mortality and attack rates remained higher among men than women in all age groups. The authors suggest that an explanation of the changing rate of ACE versus stroke among males may be the increasingly common use of lipid-lowering agents among the elderly and possibly even the lack of satisfactory blood pressure control. Does this report provide new insight in cardiovascular epidemiology? It is well known that there are considerable global variations in the prevalence of coronary heart disease and cerebrovascular disease.2 In several Far-East countries stroke places a heavier burden on population health, mainly due to nutritional habits and poor hypertension control. The strength of this report is the quality of the registries, the complete data as to morbidity and mortality and a well-defined adult population, although an extension of the population to a higher age group could have given additional valuable information. Even the effort to compensate for the changing diagnostic criteria for ACE over the years must be mentioned. Yet, as in all observational and registry-based studies, the presented data raise questions, they provide no causality, no explanations. There is no information on behavioral cardiovascular risk factors such as smoking, nutritional and physical habits in the Lille population, no data on previously undetected or untreated hypertension or on atrial fibrillation. Furthermore, given the high recurrence rate where more than every second patient after ACE suffered from recurrent disease within the relatively short time span of the study it would have been worthwhile to investigate the quality of secondary preventive care of these patients. There is no lack of guidance for the clinician, there are up-to-date dedicated guidelines for the prevention of cardiovascular disease and for stroke,3–5 but as shown in the EUROASPIRE surveys significant shortcomings remain in the implementation of preventive care:6 many patients do not reach target values for blood pressure and blood lipids and many remain physically inactive, overweight or do not stop smoking. In Sweden where the outcome of secondary prevention has been carefully monitored in the SEPHIA register we see that in spite of a gradual improvement over the past 15 years still less than one-third of the ACE patients reaches all of the four targets for prevention (smoking, physical activity, systolic blood pressure and low-density lipoprotein cholesterol).7 There are remarkably few studies auditing the quality of preventive care among stroke patients. At the 2015 EuroPrevent congress in Lisbon, Elin Good, winner of the young investigators award, reported the outcome of a study of 393 patients with high-grade (>70%) carotid artery stenosis. Under a period of four years each third patient had suffered from a recurrent ACE or stroke. It appeared that the management of cardiovascular risk among these very high risk patients was deficient in all aspects, there was no documentation of counselling on diet, exercise, smoking cessation or adherence to medication.8 But for the cerebrovascular patient the challenge is larger: in contrast to effective methods for the cardiac patient there are still doubts about the effectiveness of interventions for improving modifiable risk factor control in the secondary prevention of stroke.9 Here there is definitely a need for new studies and new intervention methods. In conclusion, when observing the impressive fall in cardiovascular mortality and morbidity over the past two decades, especially in the high-income countries, one may be tempted to be satisfied with the positive development. Therefore, the main merit of the study by Cottel and her team is that it clearly shows that the challenge for secondary prevention still remains. In particular, the remarkably high rates of recurrent events sends a distinct message to clinicians (and not only in France!) to strengthen the quality of preventive cardiology in daily clinical practice. The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author received no financial support for the research, authorship, and/or publication of this article.