Searching for the holy grail of cardiovascular prevention

If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health. Hippocrates (c. 460–377 BC) The Global Burden of Disease Study reported that the largest number of deaths in 2016 (17.6 million) were due to cardiovascular disease (CVD), with ischaemic heart disease and cerebrovascular disease together claiming the lion’s share (>85% of all deaths from CVD).1 Globally, deaths from CVD increased by 14.5% between 2006 and 2016, although the age-standardized death rates for CVD decreased by 14.5% over the same time period. Thus as the magnitude of CVD continues to accelerate globally, the pressing need for a greater awareness of cardiovascular prevention and a more focused effort in response, at both international and national levels, become ever more urgent. It is said that prevention is better than cure and this proverb is particularly true with regard to cardiovascular medicine. Lifestyle, dietary and pharmacological interventions to modify risk factors are all effective preventive measures. Risk factor modification can reduce clinical events and premature death, not only in people with established CVD, but also in those at high cardiovascular risk due to the presence of one or more risk factors. If prevention were practised as instructed, it would markedly reduce the prevalence of CVD.2,3 Unfortunately, both primary and secondary prevention of CVD are huge challenges that are far from optimally met at present. For instance, in 2016 almost one-quarter of European citizens smoked and more than half of European adults were overweight (16.7% were obese), while the large majority reported that they engaged in little or no physical activity.4 These general population statistics are reflected in the EUROASPIRE IV report, which found that a large majority of coronary patients do not achieve the guideline standards for secondary prevention, with a high prevalence of persistent smoking, unhealthy diet and physical inactivity – resulting in most patients being overweight or obese with a high prevalence of diabetes.5 Importantly, the control of risk factors is inadequate despite the high reported use of medication. It is therefore not only the prevailing risk factors that are of concern, but also the poor implementation of the preventive measures to control them. To guide actions in clinical practice for the prevention of CVD, the 6th Joint Task Force of the European Society of Cardiology and 10 other professional societies involved in the field recently published the 2016 European Guidelines on Cardiovascular Disease Prevention in Clinical Practice.6 This document was designed as a support for healthcare professionals on how to best communicate with patients about their cardiovascular risk and about the benefits of a healthy lifestyle. In addition, the guidelines provide healthcare professionals with tools to promote population-based strategies, which can be integrated into national or regional prevention frameworks or translated into locally delivered healthcare services. These new guidelines emphasize for the first time the population approach, without neglecting the single-individual approach based mainly on non-pharmacological measures. The paper by Vinther et al.,7 published in this issue of the European Journal of Preventive Cardiology, tackles a thorny issue: how suitable is the screening of the general population recommended by the current European Guidelines on CVD prevention? Based on a cross-sectional population-based study of 978 men and women aged 40–65 years examined in 2010–2011, the authors estimated the proportion of the general Danish population fulfilling the criteria for medical treatment and lifestyle intervention to prevent CVD, as laid down by the current 2016 European Guidelines. A total of 12.5% of the population fulfilled the criteria for immediate medical treatment to prevent CVD. A further 30.4% would have been recommended medical treatment if the initial lifestyle intervention failed, making a total of 42.9% of the population eligible for medical treatment, i.e. nearly half the Danish population aged 40–65 years. The authors raise doubts about the sustainability of these guidelines in relation to screening the general population. Because Denmark, like many other European countries, is classified as low risk in the SCORE charts used in the guidelines to assess the CVD risk in asymptomatic people, the results of this analysis would theoretically be generalizable to a large proportion of European citizens. In an era of limited resources, any low-cost strategy in health promotion and primary prevention is, of course, highly desirable. In fact, the European Guidelines on CVD prevention recommend lifestyle advice as a first approach and the use of medication is recommended only if lifestyle changes prove insufficient. This is the crucial point: only if the initial lifestyle intervention fails should medical treatment be recommended. This then leads to the inevitable question: are we really aggressive enough in striving for an effective modification of incorrect lifestyles before resorting to use of medication? This question applies both at the individual level – that is, the doctor–patient interaction – and to the healthcare system as a whole. In the study of Vinther et al.,7 as many as 21.4% of the sample were smokers, the median body mass index was 28.8 kg/m2 and no information was given on physical activity. So there is clearly room for improvement! In reference to just physical activity, a 2012 report showed that 31.1% of adults worldwide are physically inactive, the proportion ranging from 17% in southeast Asia to about 43% in the Americas and the eastern Mediterranean.8 In line with these data, in Italy 39.9% of adults were inactive in 2015.9 Even more worryingly, globally 81% of school-going adolescents aged 11–17 years were insufficiently physically active in 2010 – that is, they did less than the 60 minutes of moderate to vigorous intensity physical activity daily, as recommended by the World Health Organization.10 Not surprisingly, it has very recently been reaffirmed that higher recreational and non-recreational physical activity is associated with a lower risk of mortality and CVD events in individuals people from low-income, middle-income and high-income countries. Increasing physical activity is a simple, widely applicable, low-cost strategy that could reduce deaths and CVD in middle age throughout the worldwide.11 Unfortunately, for many people taking drugs is preferred as a ‘softer’ option than making the effort required to modify an unhealthy lifestyle. And for physicians it is also easier and quicker to prescribe drugs than to take the time and energy (and patience) to create an alliance with the patient so as to really have an impact on their wrong behaviours. True, it is the patient who must bear the ultimate responsibility for the success or failure of their lifestyle change, but the health system can also play an influential role part through a more vigorous campaign at the population level, while at the grass roots level healthcare professionals undoubtedly have a key role part to play in helping individuals people change their wrong attitude. It has long been said that the ABCs of cardiovascular prevention, both primary and secondary, are easier to say than to do.12 The holy grail in cardiovascular prevention does not exist. But if all of us – as citizens, parents and doctors – begin to believe actively in the importance of a healthy lifestyle and see ourselves as models for those around us, we will probably be able to reduce the impact of cardiovascular disease – without the need to resort to medication – and live on a healthier planet. The author(s) declares 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.