Multiple cardiovascular risk factor control: still a challenge?

The burden of coronary artery disease (CAD) is strongly related to the number and lack of control of cardiovascular risk factors. This is an international issue, present in countries from different continents.1 Smoking, sedentarism and unhealthy diets are not only prevalent but are also deeply entrenched in many societies. Diabetes, dyslipidemia, central obesity and hypertension are frequently co-existent within individuals and interact in deleterious ways towards cardiovascular disease (CVD).2 The World Health Organization (WHO) advocates that all countries, either developed or developing, should make sustainable policies for fighting non-communicable diseases, as these are currently the most important threats to health.3 The control of risk factors usually requires individuals to undertake lifestyle changes, which are always difficult to achieve and maintain, including increasing physical activity, changing nutritional habits and cessation of smoking. As has long been known, to modify lifestyle habits is a complex and challenging task. Also, for optimal risk factor management, medication is needed in correct dosages, and this clearly implies good adherence to prescribed regimens.4 For different risk factors, specific goals have been established and stated in European and American guidelines:4,–6 these are always subject to change, in accordance with breaking science results. However, guidelines implementation is far from good, with the latest results of the Euroaspire Study7 reporting a high percentage of non-adherence in Europe. Barriers to implementation are many, and if the control of one isolated risk factor may be difficult to achieve the successful management of multiple risk factors can be really challenging! Often, there is the need to change one at a time, negotiating with the patient and starting by working on the one that may be easiest to modify. Attention to failure is fundamental, and it is important to include coping strategies within plans for behaviour change, as failure to achieve targets for one risk factor is likely to decrease motivation for changing others. Different regions of the world share common challenges, but also have different and specific challenges. The International ChoLesterol management Practice Study (ICLPS)8 shows some interesting findings regarding the challenge of multiple cardiovascular risk factor control outside western Europe. The ICLPS8 investigated the achievement of targets defined in guidelines from 2012 (in place at the time of the study: August 2015–August 2016) for low-density lipoprotein (LDL) cholesterol in patients receiving lipid therapy in 18 countries and 452 centres outside western Europe: Africa, Asia, Eastern Europe, Latin America and the Middle East. A total of 9886 patients was assessed, 837 were ineligible, and 9046 patients were enrolled (91.5%). The aim of the study discussed in this editorial9 was to evaluate the level of, and association between, multiple risk factor control in patients with dyslipidemia, diabetes and hypertension, in whom LDL-cholesterol, blood pressure and haemoglobin A1c (HbA1c) could be assessed. Its hypothesis was that patients with low control of one risk factor are less likely to achieve the control of others, in different countries and continents. Previous studies10,11 have demonstrated significant reductions in mortality associated with the control of the classic risk factors which were identified as being responsible for 90% of acute coronary syndromes in the INTERHEART Study.1 Effectively, the present study adds to the extensive literature that indicates that risk factor control is suboptimal, even in high and very high risk subjects, and that poor control of one risk factor is associated with poor control of others. Some points to stress: Almost half of the sample were women (48.7%), which is higher than in most studies. All patients were at high and mostly at very high cardiovascular risk, so that they were those who most needed, risk factor control, but that does not mean their risk factors were controlled. Of the patients 96.9% had type 2 diabetes, 67.8% metabolic syndrome, 40.4% obesity, 33.5% documented CAD and 39.6% atherosclerotic disease, so many patients had known CVD, which directs these results to secondary prevention. Targets achieved were: LDL-cholesterol 43.9%; blood pressure 55.5%; diabetes 39.3%. All three risk factors were controlled in 12.2% of patients; none were controlled in 17.7% patients; 38% had one risk factor and 32.1% had two risk factors controlled. The authors state that the control of risk factors did not differ markedly among countries and was identical to European countries with documented CAD.9 However, the recently published paper of Euroaspire V latest results7 referred only to patients with documented CAD and the ICLPS9 included a heterogeneous population, without CAD and with CAD. Nevertheless, it confirms the need for better risk factor control, which will necessarily include strategies to support adherence to lifestyle modification and medication. Many reasons for non-adherence have been identified,12 relating to the individual patient, the disease, the treatment and/or the health system.12 These may differ in prevalence among the countries, but factors such as low educational level, low financial status, depression and old age are generally considered important. Improving adherence requires a multifaceted approach, engaging precision medicine and population health.13 Multidisciplinary cardiovascular prevention and rehabilitation programmes are excellent for promoting lifestyle modification and pharmacological adherence. For example, smoking cessation advice is ideally inserted in a cardiac rehabilitation programme (CRP).14 Regarding anxiety, depression and stress management, it has been demonstrated that CRPs can improve psychological aspects of patients after acute coronary syndromes.15 In the GOSPEL study,16 1620 patients randomly assigned to residential CRPs for one month were compared to 1621 receiving usual care for classic risk factor control and healthy lifestyle habits with no cardiac rehabilitation. The CRP group had better risk factor control, including lipids, blood pressure and smoking cessation and at 3 years’ follow-up patients who underwent CRP had a healthier lifestyle, regarding physical activity, nutrition and stress. Also, the creation of wellness and health centres is important and cost-effective for primary prevention.17 Globally, strategies linked to government health structures are fundamental.12 The creation of a well-structured web of dedicated accessible prevention centres linked to hospitals, to primary care providers and to patient associations would be of vital importance. Promoting the education of healthcare providers, patients, family members and the general population regarding health and cardiovascular risk factor control is a priority. Even more difficult, at a high level, governments need actively to promote change in societal habits and change in the environment, to really promote health. So, challenge still goes on! 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.