The Atlas of cardiovascular disease in Europe and a focus on frailty and cardiovascular risk

With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article. For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts. This Focus Issue on epidemiology and prevention contains the ‘European Society of Cardiology: cardiovascular disease statistics 2021’ by Adam Timmis and colleagues of the Atlas Writing Group.1 The authors point out that their report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.2 Data sources include the World Health Organization (WHO), the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC-sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards WHO 2025 targets for non-communicable diseases. Salient observations in this report include the following. (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high-income (81.6 years) compared with middle-income (74.2 years) countries (Figure 1). (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese, with similar prevalence in high- and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries, where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures. The authors conclude that risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO non-communicable disease targets for 2025 are unlikely to be met across ESC member countries. Median life expectancy in European Society of Cardiology member countries, stratified by sex and national income status.1 Median life expectancy in European Society of Cardiology member countries, stratified by sex and national income status.1 This Issue contains two Special Articles of the series the Year in Cardiovascular Medicine. In ‘The year in cardiovascular medicine 2021: acute cardiovascular care and ischaemic heart disease’,2 Susanna Price from the Royal Brompton Hospital in London, UK, and colleagues point out that in a year when COVID-19 continued to dominate healthcare, its impact on cardiovascular disease in the acute and emergency settings remained evident.3–8 The cardiovascular literature documented persistent disruption in healthcare delivery, with continued reduction in patients presenting with ST-segment elevation myocardial infarction (STEMI) and increased late presentations of STEMI, infarct size, and complications, delay in revascularization, reduction in admissions for acute heart failure, and an associated increased in-hospital acute heart failure mortality. Despite this immense disruption to healthcare, significant advances were nonetheless made in the fields of acute coronary syndromes, ischaemic heart disease, and acute cardiovascular care, with several important papers published in the European Heart Journal and elsewhere that significantly furthered our knowledge in these fields. In a second article from this series, ‘The year in cardiovascular medicine 2021: dyslipidaemia’,9 Lale Tokgozoglu from the Hacettepe University in Ankara, Turkey, and colleagues indicate that the past year was an exciting time for clinical lipidology when we learnt more about existing therapies as well as therapies targeting novel pathways discovered through genetic studies.10–12 LDL cholesterol (LDL-C) remained the main target, and a variety of drugs to lower LDL-C through different mechanisms were explored. Emerging evidence on the atherogenity of triglyceride-rich lipoproteins led to renewed interest in lowering them with new treatments. Lp(a) was back in focus, with evidence on causality and new targeted therapeutics which dramatically lower Lp(a) levels. We will be able to personalize lipid-lowering therapy further with this enriched armamentarium once we have the results of the cardiovascular outcome studies with some of these new agents. Survival rate of the 2002 cohort over the subsequent 15 years, through 2017, broken down by frailty category.15 Survival rate of the 2002 cohort over the subsequent 15 years, through 2017, broken down by frailty category.15 Frailty is associated with an increased risk of all-cause mortality and cardiovascular events.13,14 Limited data exist from the modern era of CVD prevention on the relationship between frailty and cardiovascular mortality. In a Clinical Research article entitled ‘Frailty and cardiovascular mortality in more than 3 million US Veterans’, William Shrauner from Harvard Medical School in Boston, MA, USA, and colleagues hypothesized that frailty is associated with an increased risk of cardiovascular mortality.15 All US Veterans aged ≥65 years who were regular users of Veteran Affairs care from 2002 to 2017 were included. Frailty was defined using a 31-item previously validated frailty index, ranging from 0 to 1. The primary outcome was cardiovascular mortality, with secondary analyses examining the relationship between frailty and cardiovascular events (myocardial infarction, stroke, and revascularization). Survival analysis models were adjusted for age, sex, ethnicity, geographic region, smoking, hyperlipidaemia, statin use, and blood pressure medication use. There were 3 068 439 US Veterans included in the analysis. Mean age was 74 years in 2002, 76 years in 2014, 98% were male, and 87.5% were White. In 2002, the median (interquartile range) frailty score was 0.16 (0.10–0.23). This increased and stabilized to 0.19 (0.10–0.32) for 2006–2014. The presence of frailty was associated with an increased risk of cardiovascular mortality at every stage of frailty. Frailty was associated with an increased risk of myocardial infarction and stroke, but not revascularization (Figure 2). The authors conclude that in this population, both the presence and severity of frailty are tightly correlated with cardiovascular death, independent of underlying CVD. This study is the largest and most contemporary evaluation of the relationship between frailty and cardiovascular mortality to date. Further work is needed to understand how this risk can be diminished. We were very sorry to hear that the First Author of this contribution, Professor William Shrauner, unfortunately passed away. His considerable contribution to science will be remembered and will live on in contributions such as the one published here. This manuscript is accompanied by an Editorial by S. Goya Wannamethee from UCL in London, UK.16 The author notes that the quest to find new risk markers to assess CVD risk continues, and frailty may be a promising additional marker where current prediction scores tend to predict less well in older adults. Screening for frailty is already recommended in specific settings and geriatric clinics. With an ageing population, much effort is needed to reduce adverse CVD events associated with frailty through developing preventive strategies and primary prevention approaches (early identification and management of frailty) in the wider older population, as well as tailored targeted interventions for frail adults with CVD. The last contribution is a Viewpoint article entitled ‘Combination lipid-lowering therapy as first-line strategy in very high-risk patients’ authored by Kausik Ray from the Imperial College London in the UK, and colleagues.17 The authors note that advances in the armamentarium of LDL-C-lowering therapies enable physicians to achieve LDL-C goals in very high-risk patients without restriction to a specific drug class. Indeed, LDL-C lowering per se, and not the drug target resulting in LDL-C lowering, is the main driver of cardiovascular risk reduction. Therefore, physicians should move away from ‘high-intensity statin treatment’ and ‘the wait and watch paradigm’ and instead start treating all very high- and extremely high-risk patients with combination therapy as the basic standard of care. This may afford significant improvements in population health across Europe. The issue is also complemented by two Discussion Forum contributions. In a commentary entitled ‘Long-term beta-blocker treatment in stable patients after myocardial infarction: a potential impact due to changes in the diagnosis of myocardial infarction?’, Jan Gerrit van der Stouwe from the University Hospital Basel in Switzerland and colleagues comment on the recent publication ‘Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study’ by Anders Holt from the Herlev and Gentofte University Hospital in Copenhagen, Denmark.18,19 Holt et al. respond in a separate comment.20 The editors hope that readers of this issue of the European Heart Journal will find it of interest.