Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries

Transcription

1 Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries EUROASPIRE I and II Group* Summary Background Patients with coronary heart disease (CHD) are the top priority for preventive cardiology. The first EUROASPIRE survey among patients with established CHD in nine countries in showed substantial potential for risk reduction. A second survey (EUROASPIRE II) was done in in the same countries to see whether preventive cardiology had improved since the first. We compared the proportion of patients in both studies who achieved the lifestyle, risk-factor, and therapeutic goals recommended by the Joint European Societies report on coronary prevention. Methods The surveys were undertaken in the same selected geographical areas and hospitals in the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia, and Spain. Consecutive patients (men and women 70 years of age) were identified after coronary-artery bypass graft or percutaneous transluminal coronary angioplasty, or a hospital admission with acute myocardial infarction or ischaemia, and were interviewed at least 6 months later. Findings 3569 and 3379 patients were interviewed in the first and second surveys, respectively. The prevalence of smoking remained almost unchanged at 19 4% vs 20 8%. The prevalence of obesity (body-mass index 30 kg/m 2 ) increased substantially from 25 3% to 32 8%. The proportion with high blood pressure ( 140/90 mm Hg) was virtually the same (55 4% vs 53 9%), whereas the prevalence of high total cholesterol concentrations ( 5 0 mmol/l) decreased substantially from 86 2% to 58 8%. Aspirin or other antiplatelet therapy was as widely used in the second survey as the first (83 9% overall), and reported use of -blockers, angiotensin-converting-enzyme inhibitors, and especially lipidlowering drugs increased. Interpretation The adverse lifestyle trends among European CHD patients are a cause for concern, as is the lack of any improvement in blood-pressure management, and the fact that most CHD patients are still not achieving the cholesterol goal of less than 5 mmol/l. There is a collective failure of medical practice in Europe to achieve the substantial potential among patients with CHD to reduce the risk of recurrent disease and death. Lancet 2001; 357: See Commentary page 972 *Members listed at end of paper. Correspondence to: Prof David A Wood, Cardiovascular Medicine, National Heart and Lung Institute, Imperial College School of Medicine at Charing Cross Campus, Fulham Palace Road, London W6 8RF, UK ( d.wood@ic.ac.uk) Introduction The objective for patients with coronary heart disease (CHD) is to reduce their risk of further coronary and other atherosclerotic events, to improve quality of life, and to increase the chances of survival. Such patients are defined as the highest priority for prevention in the recommendations drawn up by the European Society of Cardiology, the European Atherosclerosis Society, and the European Society of Hypertension (collectively known as the Joint European Societies). 1,2 The aim of these recommendations is to raise the standard of preventive cardiology by stimulating the development and revision of national guidelines by multidisciplinary alliances of professional societies, and their dissemination, implementation, and audit by cardiologists and other physicians in hospitals and the community. The European recommendations define goals with regard to lifestyle, risk factors, and therapy. These goals are to stop smoking, make healthy food choices, and become physically active; to achieve a body-mass index (BMI) of less than 25 kg/m 2, a blood pressure of lower than 140/90 mm Hg, a total cholesterol concentration of less than 5 0 mmol/l, and an LDL-cholesterol concentration of less than 3 0 mmol/l; and to use appropriate prophylactic drugs such as aspirin or other platelet-modifying drugs, -blockers, angiotensin-converting-enzyme (ACE) inhibitors, and anticoagulants. After the publication of the Joint European Societies recommendations on coronary prevention in 1994, the European Society of Cardiology did a survey called EUROASPIRE I (European Action on Secondary Prevention by Intervention to Reduce Events) in nine countries: the Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherlands, Slovenia, and Spain during This study focused on patients with CHD, and was based on a survey in the UK called ASPIRE. 4 Both surveys showed a high prevalence of modifiable risk factors, and therefore substantial potential to reduce the risk of recurrent non-fatal coronary disease and death. After the publication of the 1998 Joint European Societies recommendations on coronary prevention, another survey (EUROASPIRE II) was done in 15 European countries under the auspices of the European Society of Cardiology, Euro Heart Survey Programme, including the same countries, and almost identical centres, that participated in the first survey. The main results of EUROASPIRE II have now been published. 5 One of the objectives of this second survey was to see whether the practice of preventive cardiology in patients with CHD has improved in the centres that took part in EUROASPIRE I. Here we fulfil this objective by comparing the results of EUROASPIRE I and EUROASPIRE II. Study population and methods Sample size and data collection Each survey was undertaken in 21 centres, 20 of which were common to both studies. One of the Italian centres from EUROASPIRE I did not participate in EUROASPIRE II, and one new hospital was added in France in the second survey. THE LANCET Vol 357 March 31,

2 Within each hospital, we identified consecutive patients (men and women 70 years of age at the time of index event or procedure) with the following diagnoses: first elective or emergency coronary-artery bypass graft (CABG); first elective or emergency percutaneous transluminal coronary angioplasty (PTCA) without previous CABG; first or recurrent acute myocardial infarction without previous CABG or PTCA; and first or recurrent acute myocardial ischaemia without previous CABG, PTCA, or myocardial infarction. In each country, the objective was to obtain information on a minimum of 400 living patients ie, 100 with each of the diagnoses described above. Thus, to allow for deaths and nonresponse to interview, a sample of at least 525 consecutive patients was identified: 150 for acute myocardial infarction (because of the larger number of in-hospital deaths than in the other categories) and 125 in each of the other three groups. Data were collected by trained research assistants, who reviewed all individual medical records, and interviewed and examined the patients by use of standardised methods and instruments at least 6 months after their acute hospital admission or procedure. Methods Information on personal and demographic details; personal and family history of CHD; reported medication; and lifestyle advice in relation to smoking, diet, exercise, weight, blood pressure, lipids, and diabetes was obtained at interview. Height and weight were measured in light indoor clothes without shoes (the same make of scales was used for each survey, and the scales were calibrated at the start of the surveys). Blood pressure was measured on the right upper arm in a sitting position by use of automatic digital sphygmomanometers (Takeda UA 731 [Takeda Medical, Japan] in EUROASPIRE I and Omron 711 [Matsusaka Co, Japan] in EUROASPIRE II). In EUROASPIRE I, blood pressure was measured once only, but in EUROASPIRE II it was measured twice. The blood-pressure comparisons in this paper are based on the first measurement from EUROASPIRE II. Concentration of carbon monoxide in breath was recorded in ppm (Smokerlyser, Bedfont Scientific, UK, Model EC 50). Venous blood was drawn for measurement of cholesterol concentrations in plasma (EUROASPIRE I) or serum (EUROASPIRE II). Since two different blood-pressure recording devices were used, the performance of both was compared by taking 100 randomly ordered (50/50) blood-pressure measurements from cardiology outpatients in the coordinating centre. For systolic blood pressure, no systematic bias was seen, whereas for diastolic blood pressure, a systematic difference of 2 64 mm Hg (95% CI ; p=0 0003) was found. The Omron instrument gave higher readings than the Takeda. Diastolic bloodpressure readings from the first survey were adjusted for this bias. In EUROASPIRE I, plasma was separated from venous blood samples drawn into tubes containing potassium edetate as anticoagulant and used for lipid measurements. Plasma samples were stored at 20 C or below and transported frozen to the central clinical research laboratory (Zaventem, Belgium), where total cholesterol measurements were done on a Hitachi 747 analyser with Raichem (Hemagen Diagnostics, San Diego, CA, USA) cholesterol reagent. During the course of the study, the coefficient of variation for total cholesterol measurement was less than 1 8%. In EUROASPIRE II, serum separated from venous blood samples was used for lipid Number of patients (participation rate*) EUROASPIRE I EUROASPIRE II Czech Republic 331 (65 2%) 410 (83 2%) Finland 415 (82 0%) 348 (89 2%) France 396 (83 5%) 365 (79 4%) Germany 392 (77 2%) 402 (66 6%) Hungary 421 (80 6%) 389 (80 4%) Italy 425 (72 9%) 258 (66 3%) Netherlands 387 (74 3%) 357 (72 7%) Slovenia 413 (83 1%) 446 (77 4%) Spain 389 (84 2%) 404 (88 2%) Coronary-artery bypass graft 909 (80 5%) 827 (79 6%) Percutaneous transluminal coronary angioplasty 904 (80 4%) 935 (78 6%) Acute myocardial infarction 930 (75 9%) 890 (75 7%) Acute myocardial ischaemia 826 (75 0%) 727 (77 3%) Sex Men 2717 (78 6%) 2544 (77 9%) Women 852 (75 7%) 835 (77 2%) Age at index event 60 years 1915 (77 2%) 1852 (77 8%) >60 years 1654 (78 8%) 1527 (77 7%) Total 3569 (77 9%) 3379 (77 8%) *Participation rate of patients who were contacted and found alive. Table 1: Size of interviewed study population and participation rate measurements. Serum samples were stored at a minimum of 20 C and transported frozen to the central laboratory at the Department of Medicine, University of Manchester, UK, where total cholesterol measurements were done on a Cobas Mira S auto-analyser (Roche Diagnostics) with Unimate 7 (Roche) cholesterol reagent. During the course of the study, the coefficient of variation for total cholesterol measurement was 1 2%. Since the methods used for cholesterol measurement in EUROASPIRE I and EUROASPIRE II differed, the performance of the methods was compared by remeasuring 236 samples from EUROASPIRE I at the EUROASPIRE II central laboratory. A difference between the two methods of mmol/l (0 622 to 0 747) was found ie, measurements were 13% higher by the method used in EUROASPIRE II. Samples from the EUROASPIRE I and II surveys (n=183) were also measured again at the EUROASPIRE II central laboratory and at the Laboratory of Analytical Biochemistry, National Public Health Institute, Helsinki, Finland; no significant difference was found between results obtained in these laboratories (mean difference mmol/l [ to 0 029]). On the basis of a regression analysis of individual results, the cholesterol values from EUROASPIRE I were corrected by a multiplication factor of 1 13 for comparitive purposes. All data were stored electronically onto notebook computers, where information was held on each patient, by means of a unique identification number for country, centre, and individual. Computer disks were sent by each country to the coordinating centre (Cardiac Medicine, National Heart and Lung Institute, University of London, UK), where they were checked for completeness, internal consistency, and accuracy. All data were stored under the provisions of the UK Data Protection Act. Statistical analyses All statistical analyses were done with SAS statistical software (version 6.12) in the Department of Public Health, Ghent University, Belgium. Descriptive statistics were used to estimate the prevalence of risk factors and medication by survey, country, and diagnostic category. To assess prevalence of risk factors, a sample of THE LANCET Vol 357 March 31, 2001

3 Prevalence (%) Prevalence (%) Men n=496 n=411 Women n=96 n=105 n=903 n=882 n=199 n=220 EUROASPIRE I EUROASPIRE II n=1317 n=1249 n=555 n=508 < Age (years) Prevalence of smoking by age and sex interviewed patients was calculated as sufficient to estimate prevalences with precision of at least 5%. Calculation of 95% CIs for differences was done according to the Newcombe-Wilson hybrid score method. 6 Results 4863 hospital medical records were reviewed in EUROASPIRE I, and 4914 in EUROASPIRE II; 3569 and 3379 patients were interviewed, respectively. In this paper, comparisons are based only on the data obtained at interview. Table 1 shows the number of patients interviewed and participation rate by country, diagnostic category, sex, and age. The total participation rate of those who were contacted and found alive was 77 9% for EUROASPIRE I and 77 8% for EUROASPIRE II. In the first survey, the proportions of interviewed patients in the four diagnostic categories were as follows: CABG 25 5%, PTCA 25 3%, acute myocardial infarction 26 1%, and acute myocardial ischaemia 23 1%. In the second survey, the corresponding proportions were 24 5%, 27 7%, 26 3%, and 21 5%. The proportion of female patients was 23 9% in the first and 24 7% in the second survey. The proportions of patients older than 60 years of age were 46 3% and 45 2%, respectively. The prevalence of coronary risk factors by survey, country, and diagnostic category is presented in table 2. Overall, the prevalence of smoking increased from 19 4% to 20 8%, with substantial variation between centres and diagnostic categories in the size and direction of change. Generally more men smoked than women. The largest increase in smoking occurred in patients younger than 50 years, and especially in women (figure). The proportion of patients who were overweight (BMI 25 kg/m 2 ) or obese (BMI 30 kg/m 2 ) was consistently higher in the second survey than in the first, in all countries and diagnostic categories (table 2). More than half the patients in both surveys had high blood pressure (systolic blood pressure 140 mm Hg and/or diastolic blood pressure 90 mm Hg; table 2). The proportion of patients with very high blood pressure ( 160/95 mm Hg) was 27 6% in EUROASPIRE I and 28 0% in EUROASPIRE II. The overall proportion of patients with a blood pressure of 140/90 mm Hg or higher was virtually unchanged in the second survey, although there were some differences between countries and diagnostic categories. Of those on blood-pressurelowering medication, which was not necessarily taken as an antihypertensive treatment, the proportion achieving the blood-pressure goal of less than 140/90 mm Hg had only increased from 43 8% to 45 4% (table 3). High cholesterol concentrations in blood ( 5 mmol/l) were found in 86 2% of patients in the first and 58 8% in the second survey (table 2). The proportions of patients with a cholesterol concentration of 6 0 mmol/l or higher were 53 2% in EUROASPIRE I and 26 7% in Smoking* Obesity High blood pressure High serum cholesterol Reported diabetes mellitus EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROSPIRE II Czech Republic 73 (22 1%) 79 (19 3%) 104 (31 4%) 164 (40 1%) 207 (62 5%) 190 (46 4%) 261 (89 4%) 292 (72 5%) 72 (21 8%) 88 (21 5%) Finland 53 (12 8%) 75 (21 6%) 123 (29 6%) 117 (33 6%) 231 (55 7%) 183 (52 6%) 345 (83 3%) 147 (42 6%) 64 (15 4%) 65 (18 7%) France 99 (25 0%) 88 (24 2%) 131 (33 4%) 135 (37 5%) 200 (50 6%) 200 (55 0%) 328 (84 8%) 218 (60 2%) 66 (16 7%) 100 (27 5%) Germany 66 (16 8%) 67 (16 8%) 89 (22 7%) 122 (30 6%) 227 (57 9%) 263 (65 8%) 322 (84 1%) 256 (66 3%) 53 (13 5%) 54 (13 5%) Hungary 98 (23 3%) 117 (30 1%) 98 (23 3%) 143 (36 8%) 216 (51 3%) 161 (41 4%) 170 (89 0%) 215 (60 2%) 112 (26 6%) 82 (21 1%) Italy 79 (18 6%) 39 (15 1%) 95 (22 4%) 61 (23 6%) 245 (57 7%) 146 (56 6%) 149 (92 6%) 95 (56 9%) 73 (17 2%) 56 (21 8%) Netherlands 123 (31 8%) 101 (28 3%) 73 (18 9%) 98 (27 7%) 216 (55 8%) 191 (53 8%) 155 (91 2%) 154 (44 3%) 40 (10 3%) 47 (13 2%) Slovenia 55 (13 3%) 65 (14 6%) 79 (19 2%) 125 (28 0%) 220 (53 4%) 283 (63 4%) 357 (89 0%) 272 (68 3%) 72 (17 4%) 106 (23 8%) Spain 47 (12 1%) 72 (17 8%) 108 (27 8%) 136 (34 1%) 214 (55 2%) 197 (49 4%) 284 (80 4%) 210 (53 0%) 89 (22 9%) 142 (35 2%) CABG 129 (14 2%) 130 (15 7%) 221 (24 3%) 262 (31 8%) 532 (58 5%) 457 (55 3%) 617 (86 0%) 446 (56 5%) 191 (21 0%) 202 (24 5%) PTCA 184 (20 4%) 209 (22 4%) 187 (20 8%) 288 (30 9%) 450 (49 8%) 483 (51 9%) 583 (84 2%) 489 (56 3%) 137 (15 2%) 191 (20 4%) Acute myocardial 194 (20 9%) 227 (25 5%) 269 (29 0%) 273 (30 9%) 504 (54 2%) 441 (49 6%) 639 (86 0%) 457 (55 1%) 174 (18 7%) 188 (21 2%) infarction Acute myocardial 186 (22 5%) 137 (18 9%) 223 (27 0%) 278 (38 6%) 490 (59 5%) 433 (60 0%) 532 (88 7%) 467 (69 4%) 139 (16 8%) 159 (21 9%) ischaemia Total 693 (19 4%) 703 (20 8%) 900 (25 3%) 1101 (32 8%) 1976 (55 4%) 1814 (53 9%) 2371 (86 2%) 1859 (58 8%) 641 (18 0%) 740 (21 9%) Difference (95% CI) 1 4% ( 0 5 to 3 3) 7 5% (5 4 to 9 6) 1 6% ( 3 9 to 0 8) 27 4% ( 29 5 to 25 2) 4 0% (2 1 to 5 8) CABG=coronary-artery bypass graft. PTCA=percutaneous transluminal coronary angioplasty. *Self-reported, or >10 ppm carbon monoxide in breath. Body-mass index 30 kg/m 2. Systolic blood pressure 140 mm Hg and/or diastolic blood pressure 90 mm Hg. Total cholesterol concentration 5 0 mmol/l. Table 2: Prevalence of risk factors THE LANCET Vol 357 March 31,

4 No BP-lowering medication BP-lowering medication All patients EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II Czezh Republic 20/49 (40 8%) 24/40 (60 0%) 104/282 (36 9%) 195/369 (52 8%) 124/331 (37 5%) 219/409 (53 6%) Finland 30/54 (55 6%) 13/23 (56 5%) 154/361 (42 7%) 152/325 (46 8%) 184/415 (44 3%) 165/348 (47 4%) France 27/44 (61 4%) 23/34 (67 6%) 168/351 (47 9%) 141/330 (42 7%) 195/395 (49 4%) 164/364 (45 0%) Germany 32/77 (41 6%) 20/46 (43 5%) 133/315 (42 2%) 117/354 (33 0%) 165/392 (42 1%) 137/400 (34 2%) Hungary 18/39 (46 2%) 4/11 (36 4%) 187/382 (49 0%) 224/378 (59 0%) 205/421 (48 7%) 228/389 (58 6%) Italy 23/42 (54 8%) 6/15 (40 0%) 157/383 (41 0%) 106/243 (43 6%) 180/425 (42 3%) 112/258 (43 4%) Netherlands 49/112 (43 8%) 35/79 (44 3%) 122/275 (44 4%) 129/276 (46 7%) 171/387 (44 2%) 164/355 (46 2%) Slovenia 45/75 (60 0%) 15/31 (48 4%) 147/337 (43 6%) 148/415 (35 7%) 192/412 (46 6%) 163/446 (36 6%) Spain 33/76 (43 4%) 39/61 (63 9%) 141/312 (45 2%) 163/338 (48 2%) 174/388 (44 8%) 202/399 (50 6%) CABG 68/142 (47 9%) 43/91 (47 2%) 309/767 (40 3%) 326/735 (44 4%) 377/909 (41 5%) 369/826 (44 7%) PTCA 54/116 (46 6%) 43/85 (50 6%) 399/787 (50 7%) 405/846 (47 9%) 453/903 (50 2%) 448/931 (48 1%) Acute myocardial infarction 67/123 (54 5%) 40/59 (67 8%) 359/807 (44 5%) 408/830 (49 2%) 426/930 (45 8%) 448/889 (50 4%) Acute myocardial ischaemia 88/187 (47 1%) 53/105 (50 5%) 246/637 (38 6%) 236/617 (38 2%) 334/824 (40 5%) 289/722 (40 0%) Total 277/568 (48 8%) 179/340 (52 6%) 1313/2998 (43 8%) 1375/3028 (45 4%) 1590/3566 (44 6%) 1554/3368 (46 1%) Difference (95% CI) 3 9% ( 2 8 to 10 5) 1 6% ( 0 9 to 4 1) 1 6% ( 0 8 to 3 9) BP=blood pressure. CABG=coronary-artery bypass graft. PTCA=percutaneous transluminal coronary angioplasty. Table 3: Therapeutic control of blood pressure EUROASPIRE II; the proportions with 7 0 mmol/l or more were 20 8% and 9 5%, respectively; and the proportions with 8 mmol/l or more were 5 7% and 3 5%. Overall there was an increase from 20 9% to 49 2% in the proportion of patients on lipid-lowering drugs who achieved the goal of a cholesterol concentration lower than 5 0 mmol/l, but most patients on treatment had still not reached this goal (table 4). There were variations in the size and direction of these changes between countries and diagnostic categories. The prevalence of reported diabetes mellitus increased between the surveys (table 2). Table 5 shows reported medication at interview by survey, country, and diagnostic category. More than four fifths of the patients in both studies took aspirin or other antiplatelet drugs; the proportion was slightly higher in the second survey than in the first. For other prophylactic drugs, increased use was seen in every country and each diagnostic category, but there were large variations between countries. Use of -blockers increased from 53 7% in EUROASPIRE I to 66 4% in EUROASPIRE II. The increase in use of ACE inhibitors was from 29 5% to 42 7%. The prevalence of other antihypertensive drugs (not shown) was 2 1% in the first and 3 3% in the second survey. The prevalence of lipid-lowering drugs increased from 32 0% in the first to 62 9% in the second survey. Statin medication increased from 18 5% in the first to 57 7% in the second survey, and statins accounted for 91 7% of all lipid-lowering drugs in EUROASPIRE II compared with 57 8% in the first survey. Anticoagulants were used by nearly 7% of patients in the two surveys. Use of calcium antagonists fell from 36 3% to 25 9%. The prevalence of antidiabetic drugs increased from 10 4% in EUROASPIRE I to 15 0% in EUROASPIRE II. Discussion The results of this comparison of the findings from two European surveys during and will be concerning for all involved in the care of patients with CHD. Adverse lifestyle trends, especially the substantial increase in obesity in every country, and of smoking among younger patients, are probably a consequence of wider social changes. However, physicians must also accept some responsibility for them, because most patients with CHD did not participate in any form of professional cardiac rehabilitation programme that addresses lifestyle. 5 Tobacco smoking results in addiction for most users, and chronic use warrants repeated clinical intervention just as do other addictive disorders. 7 There is good evidence that physicians and other professionals can help patients to stop smoking, and nicotine replacement and other therapies can aid this process. 8,9 A physician s advice to stop smoking is an important first step, and many patients respond to such a warning; but breaking this addiction over the long-term requires more intensive professional support. Obesity is a consequence of a diet high in calories (usually in the form of saturated fat) and physical inactivity. However, it is commonly neglected in a clinical examination. 10 Modification of the unhealthy food choices of a lifetime requires professional dietary intervention and increased physical activity. Reduction of obesity in this way will have favourable effects on blood pressure, the lipoprotein profile, propensity to hyperglycaemia and thrombosis, and will also reduce the need for drug therapies. A Mediterranean-style diet is recommended for all patients with CHD, and professional dietetic support is required to realise what will be, for many patients, a radical change to their traditional eating habits. Exercise rehabilitation also reduces the risk of coronary disease and improves survival. 11 Addressing these adverse lifestyle characteristics requires a specialised programme; cardiologists, general practitioners, and other health-care professionals have a responsibility to provide such a service. There was virtually no change between surveys in the proportion of patients who reached the blood-pressure goal of less than 140/90 mm Hg, and to find that one in two patients with established atherosclerotic disease is still not reaching this goal is disappointing. Since blood pressure was measured only once, the proportion of patients who actually required antihypertensive therapy will be overestimated. However, in more than a quarter of these patients in both surveys, blood pressure was at a level ( 160/95 mm Hg) that would justify prophylactic antihypertensive medication even in healthy people. For so many patients with established vascular disease to have such high blood pressure is not acceptable in modern medical practice. The adverse trends in obesity will contribute to inadequate control of blood pressure, but other explanations also apply. Overall, the proportion of patients treated and controlled with one or more antihypertensive drugs (whether started mainly for bloodpressure control or not) has not changed. Therefore, in , half of all patients had still not achieved the blood-pressure goal despite the fact that more were being treated than in This observation supports the 998 THE LANCET Vol 357 March 31, 2001

5 No lipid-lowering medication Lipid-lowering medication All patients EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II Czech Republic 22/205 (10 7%) 39/172 (22 7%) 9/87 (10 3%) 72/231 (31 2%) 31/292 (10 6%) 111/403 (27 5%) Finland 30/253 (11 9%) 43/124 (34 7%) 39/161 (24 2%) 155/221 (70 1%) 69/414 (16 7%) 198/345 (57 4%) France 24/225 (10 7%) 34/113 (30 1%) 35/162 (21 6%) 109/248 (44 0%) 59/387 (15 2%) 144/362 (39 8%) Germany 26/248 (10 5%) 22/123 (17 9%) 35/135 (25 9%) 108/263 (41 1%) 61/383 (15 9%) 130/386 (33 7%) Hungary 13/149 (8 7%) 51/169 (30 2%) 8/42 (19 0%) 91/188 (48 4%) 21/191 (11 0%) 142/357 (39 8%) Italy 10/124 (8 1%) 22/64 (34 4%) 2/37 (5 4%) 50/103 (48 5%) 12/161 (7 4%) 72/167 (43 1%) Netherlands 3/107 (2 8%) 20/83 (24 1%) 12/63 (19 0%) 174/265 (65 7%) 15/170 (8 8%) 194/348 (55 7%) Slovenia 26/278 (9 4%) 33/171 (19 3%) 18/123 (14 6%) 93/227 (41 0%) 44/401 (11 0%) 126/398 (31 7%) Spain 35/243 (14 4%) 55/142 (38 7%) 34/110 (30 9%) 131/254 (51 6%) 69/353 (19 6%) 186/396 (47 0%) CABG 37/436 (8 5%) 73/252 (29 0%) 63/281 (22 4%) 271/538 (50 4%) 100/717 (14 0%) 344/790 (43 5%) PTCA 41/393 (10 4%) 78/261 (29 9%) 68/299 (22 7%) 302/608 (49 7%) 109/692 (15 8%) 380/869 (43 7%) Acute myocardial infarction 61/509 (12 0%) 86/292 (29 4%) 43/234 (18 4%) 286/537 (53 3%) 104/743 (14 0%) 373/830 (44 9%) Acute myocardial ischaemia 50/494 (10 1%) 82/356 (23 0%) 18/106 (17 0%) 124/317 (39 1%) 68/600 (11 3%) 206/673 (30 6%) Total 189/1832 (10 3%) 319/1161 (27 5%) 192/920 (20 9%) 983/2000 (49 2%) 381/2752 (13 8%) 1303/3162 (41 2%) Difference (95% CI) 17 2% (14 3 to 20 1) 28 3% (24 8 to 31 6) 27 4% (25 2 to 29 5) Table 4: Therapeutic control of cholesterol view that treatment is started with low-dose prescriptions, and is then not titrated up, as well as the issue of poor patient compliance. To comply with lifelong treatments, patients must have a clear understanding of the progressive nature of atherosclerotic disease, their level of risk, and the need to take these drugs for the rest of their lives. With the modern armamentarium of effective and safe antihypertensive drug therapies, a blood-pressure goal of less than 140/90 mm Hg should be achievable in most patients with CHD. By contrast with blood-pressure control, there has been a real improvement, despite the rising prevalence of obesity, in the proportion of patients who reach the total cholesterol goal of less than 5 0 mmol/l. Laboratory analysis comparing concentrations of total cholesterol in EUROASPIRE I and II showed that the proportion of patients reaching the cholesterol target of less than 5 0 mmol/l was overestimated in the first survey. 3,5,12 The improvement in cholesterol management also reflects the large increase in use of lipid-lowering drugs, and the greater use of statins instead of other lipid-lowering drugs. However, although the proportion treated and controlled increased from 21% to 49%, most patients on lipidlowering drugs still did not achieve the cholesterol goal. Antiplatelet therapies -blockers ACE-inhibitors EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II Czech Republic 282 (85 2%) 359 (87 6%) 216 (65 3%) 302 (73 7%) 93 (28 1%) 193 (47 1%) Finland 341 (82 2%) 285 (81 9%) 323 (77 8%) 306 (87 9%) 72 (17 4%) 85 (24 4%) France 325 (82 1%) 312 (85 7%) 223 (56 3%) 220 (60 4%) 133 (33 6$) 140 (38 5%) Germany 325 (82 9%) 346 (86 3%) 171 (43 6%) 273 (68 1%) 123 (31 4%) 179 (44 6%) Hungary 303 (72 0%) 292 (75 1%) 243 (57 7%) 328 (84 3%) 195 (46 3%) 221 (56 8%) Italy 366 (86 1%) 236 (91 5%) 209 (49 2%) 158 (61 2%) 135 (31 8%) 134 (51 9%) Netherlands 300 (77 5%) 289 (81 0%) 181 (46 8%) 172 (48 2%) 105 (27 1%) 136 (38 1%) Slovenia 328 (79 4%) 367 (82 3%) 214 (51 8%) 293 (65 7%) 129 (31 2%) 265 (59 4%) Spain 327 (84 1%) 346 (85 6%) 135 (34 7%) 191 (47 3%) 69 (17 7%) 88 (21 8%) CABG 803 (88 3%) 721 (87 3%) 483 (53 1% 542 (65 6%) 304 (33 4%) 358 (43 3%) PTCA 808 (89 4%) 844 (90 3%) 539 (59 6%) 651 (69 6%) 211 (23 3%) 381 (40 8%) Acute myocardial infarction 793 (85 3%) 756 (85 0%) 541 (58 2%) 643 (72 3%) 359 (38 6%) 450 (50 6%) Acute myocardial ischaemia 493 (59 7%) 511 (70 2%) 352 (42 6%) 407 (56 0%) 180 (21 8%) 252 (34 7%) Total 2897 (81 2%) 2832 (83 9%) 1915 (53 7%) 2243 (66 4%) 1054 (29 5%) 1441 (42 7%) Difference (95% CI) 2 7% ( ) 12 8% ( ) 13 1% ( ) BP-lowering drugs Lipid-lowering drugs Statins Anticoagulants EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II EUROASPIRE I EUROASPIRE II Czech Republic 282 (85 2%) 370 (90 2%) 95 (28 7%) 235 (57 3%) 21 (6 3%) 159 (38 8%) 13 (3 9%) 15 (3 7%) Finland 361 (87 0%) 325 (93 4%) 162 (39 0%) 224 (64 4%) 145 (34 9%) 218 (62 6%) 31 (7 5%) 38 (10 9%) France 352 (88 9%) 330 (90 7%) 165 (41 7%) 248 (68 1%) 80 (20 2%) 222 (61 0%) 22 (5 6%) 12 (3 3%) Germany 315 (80 4%) 355 (88 5%) 138 (35 2%) 271 (67 6%) 122 (31 1%) 263 (65 6%) 24 (6 1%) 20 (5 0%) Hungary 382 (90 7%) 378 (97 2%) 94 (22 3%) 200 (51 4%) 28 (6 7%) 176 (45 2%) 57 (13 5%) 42 (10 8%) Italy 383 (90 1%) 243 (94 2%) 107 (25 2%) 154 (59 7%) 29 (6 8%) 147 (57 0%) 13 (3 1%) 3 (1 2%) Netherlands 275 (71 1%) 278 (77 9%) 139 (35 9%) 272 (76 2%) 54 (14 0%) 268 (75 1%) 35 (9 0%) 57 (16 0%) Slovenia 337 (81 6%) 415 (93 0%) 125 (30 3%) 260 (58 3%) 96 (23 2%) 251 (56 3%) 24 (5 8%) 40 (9 0%) Spain 313 (80 5%) 343 (84 9%) 118 (30 3%) 261 (64 6%) 86 (22 1%) 244 (60 4%) 27 (6 9%) 25 (6 2%) CABG 767 (84 4%) 735 (89 0%) 334 (36 7%) 563 (68 2%) 200 (22 0%) 514 (62 2%) 70 (7 7%) 80 (9 7%) PTCA 788 (87 2%) 850 (90 9%) 371 (41 0%) 651 (69 6%) 221 (24 5%) 609 (65 1%) 47 (5 2%) 47 (5 0%) Acute myocardial infarction 807 (86 8%) 830 (93 4%) 287 (30 9%) 565 (63 6%) 162 (17 4%) 521 (58 6%) 82 (8 8%) 86 (9 7%) Acute myocardial ischaemia 638 (77 2%) 622 (85 6%) 151 (18 3%) 346 (47 6%) 78 (9 4%) 304 (41 8%) 47 (5 7%) 39 (5 4%) Total 3000 (84 1%) 3037 (89 9%) 1143 (32 0%) 2125 (62 9%) 661 (18 5%) 1948 (57 7%) 246 (6 9%) 252 (7 5%) Difference (95% CI) 5 9% (4 3 to 7 5) 30 9% (28 6 to 33 1) 39 2% (37 0 to 41 2) 0 6% ( 0 6 to 1 8) CABG=coronary-artery bypass graft. PTCA=percutaneous transluminal coronary angiography. Table 5: Use of medication THE LANCET Vol 357 March 31,

6 So, as for blood pressure, more patients in EUROASPIRE II were being treated for hyperlipidaemia than in EUROASPIRE I, but these drugs are either not being used as effectively as they should be, or there is poor patient compliance, or both. The advent of statins has provided physicians with an effective, safe, once-daily drug that, when prescribed at the doses used in clinical trials with disease endpoints, can reach the lipid targets in most patients The Joint European Societies recommendations recognise that most patients with CHD can reach the cholesterol and LDL goals with a combination of diet and these drugs. In the trials of secondary prevention, use of statins was associated with a reduction in total and LDL cholesterol of about 20% and 30%, respectively. For patients in whom the total cholesterol and LDL-cholesterol goals have not been reached, the dose of lipid-lowering drugs should be increased, and doses used in clinical trials with disease endpoints should be prescribed. With this strategy, the cholesterol goal of less than 5 0 mmol/l is realistic for most patients with CHD, and there is no need to resort to higher doses not yet adequately tested in clinical trials. The prevalence of reported diabetes mellitus increased in most centres. This adverse trend is likely to reflect the rising prevalence of obesity, although better detection of diabetes among patients with CHD might also be a contributing factor. The following drugs or classes of drugs have been shown in single trials or meta-analyses to reduce total and cardiovascular mortality in patients with CHD: aspirin or other platelet-modifying drugs (and, in selected patients, anticoagulants); -blockers in patients after acute myocardial infarction; and ACE inhibitors in patients with symptoms or signs of heart failure at the time of myocardial infarction, or persistent left ventricular systolic dysfunction (ejection fraction <40%), or at high risk for other reasons. The results of the HOPE trial provide further evidence for the use of ACE inhibitors in the management of patients with CHD and preserved ventricular function. 16 Use of all prophylactic drugs in EUROASPIRE II was substantially higher than in the first survey, and this trend was especially pronounced for lipidlowering drugs. The variation in the use of prophylactic drugs between different centres continues to exist, with the exception of antithrombotic therapy. Use of calcium antagonists was lower in EUROASPIRE II, the largest decrease occurring in the PTCA group. The slow incorporation of secondary prevention strategies into clinical practice was also seen in the Spanish PREVESE I and PREVESE II studies the only other surveys to have been done at two time periods in the same centres PREVESE I was done in 1994, and recruited 1242 patients with acute myocardial infarction from 39 hospitals. At a 6-month follow-up interview, the prevalence of smoking was 9%, and 36% had cholesterol concentrations greater than 5 5 mmol/l. PREVESE II was done in 1998 on 2054 patients with acute myocardial infarction from 74 hospitals (including 36 hospitals of those in the first survey). Prescription of blockers rose from 33% to 45%; ACE inhibitors from 33% to 47%; and statins from 4% to 29%. As in EUROASPIRE II, the use of calcium antagonists fell from 26% to 18%. Comparison of the EUROASPIRE surveys reveals a continuing high prevalence of modifiable risk factors in patients with CHD. These results are a call to action for cardiologists, physicians, and other health-care professionals. Adverse trends in smoking, especially among younger patients, and the substantial rise in obesity across all European countries emphasise the overarching importance of a societal approach to coronary prevention. However, without professional support from dietitians and exercise specialists, it would be harder for patients with CHD to resist lifestyle trends in society. In addition to lifestyle intervention, we need to manage blood pressure, lipoproteins, and glycaemia with effective and safe drug therapies. -blockers are available in every European country and they are effective and cheap. Some ACE inhibitors assessed in clinical trials with disease endpoints are now off patent and also widely available, and statins will ultimately follow suit. Therefore almost all patients with CHD could soon be prescribed an antiplatelet drug, a -blocker, an ACE inhibitor, and a statin. Although the higher use of all prophylactic drug therapies is encouraging, the persistent variations in prescribing practices between centres remains a concern. We urgently require research into the differences between health-care systems and how such differences can affect risk-factor management. Preventive cardiology requires an integrated approach, led by cardiologists and involving other physicians and health-care professionals, to achieve the lifestyle, risk-factor, and therapeutic targets of our patients with CHD. EUROASPIRE I and II group Writing Committee K Kotseva, D Wood, G De Backer, D De Bacquer, K Pyörälä, U Keil, S Sans. Scientific Steering/Expert Committees K Pyörälä (Kuopio, Finland, Chairman EUROASPIRE I), G De Backer (Ghent, Belgium, Chairman EUROASPIRE II), G B Ambrosio (Venice, Italy), P Amouyel (Lille, France), D Cokkinos** (Athens, Greece), J W Deckers (Rotterdam, Netherlands), L Erhardt** (Malmö, Sweden), I Graham (Dublin, Ireland), F Gutzwiller* (Zürich, Switzerland), I Keber** (Ljubljana, Slovenia), U Keil (Münster, Germany), S Lehto** (Kuopio, Finland), E Östör (Budapest, Hungary), A Pajak** (Cracow, Poland), S Sans (Barcelona, Spain), J Simon (Pilsen, Czech Republic), J Turk* (Ljubljana, Slovenia), D Wood (London, UK, EUROASPIRE Co-ordinator). Co-ordinating and Data Management Centre D A Wood, B Schofield, T Bowker*, J Ingham*, N McLennan*, K Kotseva**, M Gollapalli**, R Valay** (Cardiac Medicine, Clinical Epidemiology Group, National Heart and Lung Institute, Imperial College School of Medicine, London, UK). Computing and Statistical Centre G De Backer, and D De Bacquer (Department of Public Health, Ghent University, Belgium). Central Laboratories D James* (Clinical Research Laboratories Europe, Zaventem, Belgium), M Mackness** (University Department of Medicine, Manchester Royal Infirmary, UK). Czech Republic J Simon, K Linhartová, P Hafman*, O Mayer**, H Rosolova**, P Bocek** (Charles University, Medical Faculty, Pilsen); M Hrncárek*, P Lupinek*, T Marek*, M Plaskova**, Z Skodova**, R Cifkova** (Department of Preventive Cardiology, Institute of Clinical Experimental Medicine, Prague). Finland K Pyörälä*, S Lehto**, R Lehto, A Kemppainen*, H Koukkunen*, J Luukkonen**, M Puhakka**, K Kärkkäinen**, K Savolainen** (Kuopio University Hospital). France P Amouyel, M Montaye, B Lemaire, S Danet*, R Domanievicz*, M Lenoir*, S Beauchant**, A Dusart**, F Bonte**, N Fiévet**, L Poissonnier**, P Ledoux**, N Marécaux**, C Stéclebout** (Service d'épidémiologie et de santé publique /INSERM U 508, Institut Pasteur de Lille; Hôpital Cardiologique Universitaire, Lille. Hôpital Victor Provo, Roubaix. Hôpital Saint- Philibert, Lomme. Hôpital Gustave Dron, Tourcoing**). Germany U Keil, A Liese, U Broxtermann*, M Heimbach*, J Heidrich**, M Kalic** (Institut für Epidemiologie und Sozialmedizin, Universität Münster); G Breithardt, A Enbergs, S Kerber** (Medizinische Klinik und Poliklinik für Kardiologie und Angiologie, Universität Münster); H Scheld, N Roeder** (Klinik und Poliklinik für Thorax-, Herz- und Gefäßchirurgie, Universität Münster); P Kleine-Katthöfer (St Franziskus Hospital, Münster); G Assmann** (Institut für Arterioskleroseforschung, Universität Münster). Hungary E Östör, S Borbás, M Podmaniczky, T Ruzsányi** (Hungarian Institute of Cardiology, Budapest); A Jánosi, A Belatiny-Kenéz, A Bradák*, Zs Ádám**, Gy Bárczy**, K Birtalan**, I Gallai** (Szt János Hospital, Budapest). Italy G B Ambrosio, C Leprotti (Department of Internal Medicine, Venice City Hospital); P Zardini, L Rossi, A Gallo*, D Tavella** (Department of Cardiology, Borgo Trento Hospital, Verona); P Stritoni, A Pedrocco, F Perissinotto* (Department of Cardiology, Ca' Foncello Hospital, Treviso); D Vanuzzo*, L Pilotto* (Department of Cardiology, S M Misericordia Hospital, Udine*) THE LANCET Vol 357 March 31, 2001

7 Netherlands J W Deckers, F Post*, C Jansen** (Thorax Centre of the Academic Hospital Rotterdam Dijkzigt ); M Veerhoek, A Boer, E Stockx (Sint Franciscus Gasthuis, Rotterdam); R van de Berg*, W J Remme*, R van Vliet*, J Vos**, M van der Knaap** (Zuiderziekenhuis, Rotterdam). Slovenia J Turk*, I Keber**, K Marn*, V Salapura*, E Škof**, E Špan** (University Medical Centre, Ljubljana). Spain S Sans, G Paluzie, I Pérez*, T Puig*, C Varas*, L Balañá** (Institute of Health Studies, Department of Health and Social Security, Barcelona); F Navarro López, G Sanz**, C Ferrer** (Hospital Clínic i Provincial, Barcelona); A Bayés de Luna*, J M Caralps**, M Domínguez** (Hospital de la Santa Creu i Sant Pau, Barcelona); P Monrás, M Rey** (Corporació Sanitària Parc Taulí, Sabadell). *Participants in EUROASPIRE I only. **Participants in EUROASPIRE II only. Acknowledgments We thank the administrative staff, physicians, nurses, and other personnel at the hospitals in which the study was carried out, and all the patients who participated in the study. We also thank Paul Durrington (Manchester Royal Infirmary, UK) and Jouko Sundvall (National Public Health Institute, Helsinki, Finland) for the laboratory comparison of cholesterol estimations from EUROASPIRE I and II. Unrestricted educational grants to the European Society of Cardiology were obtained from Merck, Sharp & Dohme for EUROASPIRE I, and from Astra Zeneca, Bristol-Myers Squibb, Merck, Sharp & Dohme, and Pfizer for EUROASPIRE II. References 1 Pyörälä K, De Backer G, Graham I, Poole-Wilson PA, Wood D. Prevention of coronary heart disease in clinical practice: recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J 1994; 15: Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyörälä K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on coronary prevention. Eur Heart J 1998; 19: EUROASPIRE Study Group. EUROASPIRE: a European Society of Cardiology survey of secondary prevention of coronary heart disease, principal results. Eur Heart J 1997; 18: ASPIRE Steering Group. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996; 75: EUROASPIRE II Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries: principal results from EUROASPIRE II. Eur Heart J 2001; 22: Newcombe RG. Interval estimation for the difference between independent proportions: comparison of eleven methods. Stat Med 1998; 17: Balfour D, Benowitz N, Fagerström K, Kunze M, Keil U. and treatment of nicotine dependence with emphasis on nicotine replacement therapy. Eur Heart J 2000; 21: Van Berkel TFM, Boersma H, Roos-Hesselink JW, Erdman RAM, Simoons ML. Impact of smoking cessation and smoking interventions in patients with coronary heart disease. Eur Heart J 1999; 20: US Public Health Service. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service Report. JAMA 2000; 283: Montaye M, De Bacquer D, De Backer G, Amouyel P. Overweight and obesity: a major challenge for coronary heart disease secondary prevention in clinical practice in Europe. Eur Heart J 2000; 21: Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease. In: Cochrane Library, issue 4. Oxford: Update Software, Vanuzzo D, Pilotto L, Ambrosio GB, et al on behalf of the EUROASPIRE Study Group. Potential for cholesterol lowering in secondary prevention of coronary heart disease in Europe: findings from EUROASPIRE study. Eur Heart J 2000; 153: Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335: The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998; 339: Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients: the Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342: De Velasco JA, Cosin J, Lopez-Sendon JL, et al. La prevención secundaria del infarto de miocardio en España: estudio PREVESE. Rev Esp Cardiol 1997; 50: de Oya M, Lopez-Sendon JL, de Teresa E, Velasco-Rami J, Villa E, Cosin J. The impact of landmark clinical trials on secondary prevention of acute myocardial infarction (AMI) in Spain: PREVESE 98 study. Atherosclerosis 2000; 151: 107 (abstr). 19 Velasco JA. After 4S, CARE and LIPID: is evidence-based medicine being practised? Atherosclerosis 1999; 147(Suppl 1): S THE LANCET Vol 357 March 31,