Editor’s Presentation: ‘It takes a village to reduce cardiovascular risk’

Handschin and colleagues reported real-world prospective cross sectional data about 1003 primary care hypertensive patients, aiming at evaluating the cardiovascular risk profile of hypertensive patients according to the 2013 European Society of Hypertension/European Society of Cardiology Guidelines. It suggests that optimal blood pressure control (therapeutic targets) was achieved in only one-third of patients and that nearly 45% of hypertensive patients had a high or very high overall cardiovascular risk, corresponding to a 10-year risk for cardiovascular morbidity and mortality of greater than 20%. Moreover, a high proportion of patients (78.5%) had more than three cardiovascular risk factors, diabetes mellitus, and subclinical or end-organ damage. The findings of this study are important because they are a wake-up call for the prevention community to involve the family and the local community health worker to help high-risk populations better manage their hypertension and other risk factors. Clearly the lack of success in achieving optimal targets reflected by this study suggests that self-care is not sufficient to manage blood pressure and accompanying cardiovascular risk factors. In this regard a multidisciplinary team-based approach remains essential in order to provide comprehensive successful prevention programmes (holistic care). ‘It takes a village to reduce cardiovascular risk!’.1 Risk prediction scores try to estimate in the best possible way, combining information from various risk factors, the absolute risk that individuals free from symptomatic cardiovascular disease (CVD) will develop a cardiovascular event in the future.2 Cardiovascular prediction models in primary care typically include predictors such as age, sex, smoking, markers of glucose intolerance, blood pressure and lipid levels. Yet, different versions and definitions are used in the 363 available published cardiovascular prediction models. Several limitations of the current prediction scores are evident, for example, the importance of ethnicity in the estimation of absolute cardiovascular risk is not yet set in stone. Here Perini and colleagues compared two cholesterol versions of the SCORE model in a large multi-ethnic cohort from Amsterdam, comprising individuals from various ethnicities. The differences between the two SCORE models in risk classification were small and the pattern of misclassification did not differ between ethnic groups. Only women received a slightly lower predicted risk when using the total/high-density lipoprotein cholesterol model compared with using the total cholesterol model. In conclusion, the final decisions about the initiation of (non)-pharmacological treatment should be based on the patient’s preferences and the doctor’s clinical judgement in a shared decision approach, with clear expectations of benefit, potential side effects and adherence to treatment. Multivariable CVD risk assessment tools are used to estimate an individual’s risk of CVD and are promoted in primary CVD prevention guidelines. The NORRISK 2 score model is newly developed from NORRISK, a Norwegian adaptation of the SCORE model, validated using Norwegian population samples.3 In the study presented here this risk score was implemented in a Norwegian general population to evaluate secular and longitudinal trends in CVD risk. A decline in overall risk score and a reduced proportion of individuals being at high risk during the last decade was observed, explained by favourable changes in modifiable risk factors. Total cholesterol had a larger impact on the total score in men than in women, whereas smoking was the major single risk factor in women. A limitation is the challenge to compare the results with previous studies, as various scoring tools use different cut-off values, thus, comparison of results should be done with caution. Physical activity reduces the risk of CVD. The effects could also be related to a more complex web of protein changes. The study by Stattin and colleagues performed a cross-sectional analysis to investigate associations between leisure-time physical activity and plasma protein biomarkers determined by cardiovascular multiplex panels, which included a combined 184 proteomics biomarkers. Physical activity was determined by validated (against accelerometry) questionnaires to determine occupational physical activity, weekly leisure exercise and daily time spent walking or cycling. In two independent population-based cohorts, they identified associations between physical activity during leisure time and 75 cardiovascular biomarkers and replicated 28 of those associations, using high throughput proteomics. Since leisure-time physical activity is a modifiable risk factor acting on many pathways, including inflammation, oxidative stress, and energy, fat and glucose metabolism,4,5 the observed associations are potentially of clinical significance. The directions of the associations suggest also that a higher physical activity is associated with more beneficial cardiovascular biomarker profiles. Recently the possibility of a physical activity health paradox has arisen because of the observation of an increased early death rate reported among men with a high level of occupational physical activity (OPA).6 Moreover, a debate concerning the cardiovascular protective effect of leisure-time physical activity (LTPA) has begun.7 The aims of the epidemiologic study presented in this issue were to investigate the interplay between OPA and LTPA as well as with job strain on coronary heart disease (CHD) risk in a large population (N = 3310; 25–64 years old) of northern Italian working men from three previous longitudinal (follow-up 13–16 years) pooled cohorts study. Results of this study have confirmed the major beneficial effect of LTPA on CHD risk in physically inactive male workers. Moreover, the combination of physical inactivity with high job strain work presents a multiplier effect on the risk for CHD and the recommended LTPA practice has a marked protective effect. Studies of geographical inequalities in CVD incidence and survival are challenging. Several factors may vary geographically: environmental exposures that affect risk; the neighbourhood context, which influences people’s ability to adopt a healthy lifestyle; access to preventive healthcare and screening services; and expected time to an emergency medical service.8,9 Nevertheless, such studies can help to target areas with a heavy CVD burden and/or an unfavourable mortality rate among incident cases, which, in turn, may enable the rational allocation of prevention resources. A comprehensive analysis was carried out of geographical inequalities in survival after acute myocardial infarction (AMI) in Denmark in the time period 2004–2014. Researchers found that survival after AMI tended to correlate with sociodemographic indicators. In individual-level models, geographical inequality in immediate case fatality was observed with high mortality in northern parts of Jutland after accounting for sociodemographic characteristics. The authors have explored ways to find evidence for the causal links between neighbourhood context and health. Besides the current evidences, and recommendations from scientific societies, the proportion of patients accessing cardiac rehabilitation remains stubbornly below stated targets, with uptake ranging from 10% to 60% globally.10 In particular, sub-optimal uptake is compounded by poorer uptake in more deprived groups, further compounding inequalities in health.11,12 To estimate the cost-effectiveness of cardiac rehabilitation, a scoping review of the current evidence relating to its effectiveness and cost-effectiveness was undertaken using the 2016 Cochrane review.13 It is observed that cardiac rehabilitation, as it is currently delivered, is cost-effective across all different groups of populations (differentiated according to levels of deprivations), due to its low cost and high effectiveness in improving cardiovascular outcomes. Furthermore, there was a business case for spending money on incentives which increase cardiac rehabilitation uptake to a 65% target, stratified by levels of deprivations, with a justifiable expenditure of £68.4 m per year. Left ventricular assist devices are increasingly used in the treatment of patients with severe left heart failure.14 However, functional capacity and, in parallel, quality of life do not always improve.15 In the present issue, Laoutaris mainly focuses on the role of modifying pump speed to favour pulsatility on functional capacity and complications and he analyses well the limits of our actual knowledge about it, providing an extensive review. The available evidence on regulation of pump speed and pulsatility on exercise capacitance are summarized and exercise training is proposed as a possible way to favour pulsatility. A ‘hypothesis of increasing patients’ speed’ is introduced, suggesting that exercise training may further contribute to the patient’s recovery, enhancing peakVO2 and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field. This indicates a potential new field of research, but it also highlights the still large lack of knowledge in this field to improve quality of life of these patients. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.