Inadequate control of atherosclerotic cardiovascular disease risk factors in Europe: EUROASPIRE repeats itself

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death worldwide and Europe is no exception.1 Over the last six decades there has been a huge increment in the knowledge about causal risk factors for ASCVD. Indeed, healthier lifestyles and pharmacological interventions have significantly contributed to a reduction of about one-third in coronary heart disease and atherothrombotic stroke mortality, mainly in developed areas of the world.2,3 In addition to the challenge to adhere beneficial lifestyle habits, such as smoking cessation,4 weight loss and regular physical activity,5 pharmacological treatments that modify the course of ASCVD were established in robust randomized controlled trials enrolling hundreds of thousands of individuals.6–8 Based on this knowledge, preventive cardiology practice guidelines were created and updated in Europe9–14 and elsewhere15 according to the information accrued over the last 30 years. The basic secondary ASCVD prevention medication kit includes antiplatelet and lipid lowering medications, mostly statins, beta blockers and medications counteracting the renin–angiotensin system mainly for individuals with left ventricular dysfunction or type 2 diabetes, and other blood pressure lowering medications for hypertensives.14,16 As new evidence was published more aggressive blood pressure and, especially, lower low-density lipoprotein (LDL) cholesterol goals were adopted,11,14 the latter meaning the recommendation for the use of high doses of potent statins with the aim of reducing LDL-cholesterol by at least by 50%. Finally, dual antiplatelet therapy became standard of care for at least a year after an acute coronary event.14,16 Guidelines are hard to develop but harder to implement. Both lack of patient and physician literacy about ASCVD,17,18 as well as the so-called clinical inertia,19 certainly reduce the effectiveness of preventive therapies. Establishment and adherence to preventive measures are extremely important to reduce the burden of ASCVD. This is where registries like the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) enter the scene to verify how physicians and patients are dealing with guideline recommendations in the real world.20–24 The information contained in these registries helps development of policies and programs from government, medical societies and patient organizations in order to reduce ASCVD morbidity and mortality. In this issue of the European Journal of Preventive Cardiology Kornelia Kotseva et al. publish the results of the newest of these surveys: EUROASPIRE V.24 The authors must be congratulated not only for this last study but also for the four previous ones clearly showing that there was an improvement in how secondary prevention patients have been treated over the last 30 years in Europe (Figures 1 and 2). However, unfortunately, the authors show that risk factors still persist uncontrolled in a substantial number of studied individuals. Use of atherosclerotic cardiovascular disease modifying medications at interview: EUROASPIRE I–V. EA: EUROASPIRE; ACE-I: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker. Uncontrolled atherosclerotic cardiovascular disease risk factors at interview: EUROASPIRE I–V. Physical activity not measured in EA I and EA II; blood pressure goals: EA I and EA II < 140/90 mmHg; EA III <140/90 mmHg and 130/80 mmHg in diabetics; EA IV <140/90 mmHg and 140/80 in diabetics; EA V < 140/90 mmHg and 140/85 mmHg in diabetics. Cholesterol goals: EA I and II total cholesterol < 5.5 mmol/L; EA III total cholesterol <4.5 mmol/L; EA IV and EA V low-density lipoprotein cholesterol < 1.8 mmol/L. EA: EUROASPIRE. For instance, numbers of recalcitrant smokers and sedentary individuals persisted, at very similar levels to the previous EUROASPIRE surveys, respectively at 19% and 66%. Interestingly, EUROASPIRE V shows that even after a median 1.1-year subsequent to an ASCVD event, 50% of smokers still did not quit and only 5% of interviewed subjects attended a smoking cessation clinic. This occurred in spite of these services being offered to 85% of those who persisted in smoking. Moreover, if we compare the evolution of the surveys in the last 30 years, as shown in Figure 2, the obesity epidemics became the new elephant on the room of preventive medicine, with 38% of individuals being obese in EUROASPIRE IV25 and V24 in comparison with 25% in EUROASPIRE I.20 Of interest, only 50% of obese patients tried to lose weight. Figure 1 shows that there was a clear increment in the use of antiplatelet drugs, beta blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins as decades passed. In EUROASPIRE V these medications were being used respectively by 93%, 75%, 81% and 84% of interviewed patients. However, despite this, cholesterol and blood pressure goals were attained by only 58% and 29% respectively (Figure 2). When one compares this trend, cholesterol is apparently less controlled in EUROASPIRE IV and V than in the previous surveys. However, it is important to consider that in the last 30 years more aggressive, and harder to reach, goals were proposed for these causal risk factors of ASCVD.9,14 At any rate, EUROASPIRE V shows that cholesterol and blood pressure are still undertreated despite more aggressive recommendations and greater use of blood pressure and cholesterol lowering medications than in the past. Despite the fact that 95% of EUROASPIRE V patients were using the former, 78% due to hypertension diagnosis, still 42% were above recommended values. Seventy-six percent referred total adherence to prescriptions. However, were medications prescribed in adequate doses to lower blood pressure adequately? Certainly the high frequencies of obesity26 and sedentarism27 contributed to the still frustrating results. In EUROASPIRE V, despite 84% of patients being prescribed lipid lowering medications, one may even ask, considering more recent recommendations, why not 100%?28 Only 50% were using high intensity statin or drug combinations to achieve greater LDL-cholesterol reduction. These results from Europe are not much different from the ones encountered in other parts of the world. Danchin et al. have shown that when Western European cholesterol metrics are used to test the success of lipid lowering therapy in 18 non-Western European countries, only 32% of very-high risk patients attained LDL-cholesterol <1.8 mmol/L.29 Therefore, the problem is not only European. Kotseva et al.24 show many other findings that might explain some disappointing results for those who worked so hard in preparing prevention guidelines. Among these: 38% of obese individuals did not obtain dietary guidelines; 46% did not recall receiving advice on physical activity; 15% of hypertensives were not told they had high blood pressure; and 16% of diabetics had not had their glucose blood levels measured at discharge. EUROASPIRE shows evolution but repeats itself in demonstrating persistent inadequate control of ASCVD risk factors in high and very high-risk secondary prevention patients. Certainly, the results of the new survey will help in developing ways to improve ASCVD prevention. However, it will not be an easy task, as shown by Kotseva et al. Finally, the disturbing question is: how much would be the real need for novel therapies30–32 that have proven to add benefit on top of standard pharmacological preventive therapies if one could control these so called classical risk factors in an adequate manner? The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RDS has received honoraria related to consulting, speaker activities and/or research from: Akcea, Amgen, Astra Zeneca, Biolab, Esperion, Kowa, Merck, Novo-Nordisk, and Sanofi/Regeneron. The author(s) received no financial support for the research, authorship, and/or publication of this article.