These are the results of the primary-prevention EUROASPIRE III study, a survey of 12 participating countries that was designed to assess lifestyle, risk-factor, and therapeutic management of individuals at high risk of developing cardiovascular disease.

Dr David Wood

"The lifestyle of high-risk patients is a major cause for concern, with high prevalences of persistent smoking and both obesity and central obesity," said lead investigator Dr David Wood (Imperial College School of Medicine, London, UK). "Blood-pressure, lipid, and glucose control are completely inadequate, with most patients not achieving the targets defined in the guidelines."

Presenting the results of EUROASPIRE III here at the European Society of Cardiology (ESC) Congress 2008, Wood said that even among patients with diabetes mellitus, many are not achieving blood-pressure control, and the use of other cardioprotective drugs are not prescribed enough. Ironically, many patients want to be informed about their risk of heart disease, he said. Unfortunately, most being treated believe they are low or moderate risk and falsely assume they have an equivalent risk when compared with others of the same age and sex.

The first EUROASPIRE survey, which was done among patients with established coronary heart disease, showed that there was a substantial potential for risk reduction. Subsequent surveys drawn from the same countries multiple years later, however, indicate the potential for risk reduction had been missed, as many heart-disease patients continue to smoke, are still overweight, and have uncontrolled blood-pressure and cholesterol levels.

These new EUROASPIRE findings now suggest that primary-prevention patients are also drastically undertreated, as well as not adhering to lifestyles that promote cardiovascular health. The investigators studied the medical records of 5687 individuals and conducted interviews in more than 75% of these high-risk patients. High-risk patients are defined as men and women 80 years of age and younger without a history of coronary or other atherosclerotic disease who had been started on one or more of the following: antihypertensive therapy, lipid-lowering drugs, and/or diabetes therapies.

In terms of lifestyle, 16% of patients smoked, with nearly 90% of patients continuing to smoke at the time of the EUROASPIRE interview, a disappointing finding showing that only 1 in 10 patients had quit. Almost 50% of patients were overweight, and in terms of the prevalence of elevated risk factors, almost 80% had blood-pressure, triglyceride, and LDL-cholesterol levels exceeding the recommended European targets. Among diabetic patients, only 27% had fasting glucose levels and 53% had HbA_1c levels that met the definition for therapeutic control. The prescription of cardioprotective drugs, including statins, was also underprescribed, report investigators.

Importantly, Wood told the audience that almost 85% of patients wanted to know their risk of heart disease, but very few knew their 10-year risk of developing coronary heart disease, and most assumed they were as healthy as men and women of their own age. More than 80% of those participating in the survey were not provided with a professional lifestyle and risk-factor management program, despite ample evidence that such programs, including the EUROACTION nurse-led multidisciplinary approach, improve lifestyles and patient care and reduce the prevalence of cardiovascular risk factors.

Dr Lars Rydén

Speaking to the audience following the EUROASPIRE III presentation, Dr Lars Rydén (Karolinska Institute, Stockholm, Sweden) said that these patients represent a high-risk group of patients and that the real-world data are likely much worse, as the centers participating in the EUROASPIRE studies include active investigators and dedicated clinicians.

Interestingly, there had been some belief that patients would not want to know if they were going to die prematurely, said Rydén, although this does not appear to be the case. "The vast majority of patients actually wanted to know about their risk, but their [self-] estimated risk was considerably lower, so they are living with the false assumption that they will live forever," he said.

Rydén said it is disappointing that patients are not getting advice about managing risk factors through lifestyle modifications and that clinicians have the ability to do better, especially since the ESC guidelines are available in all European languages. He also emphasized the findings from the EUROACTION investigators and suggested that multidisciplinary efforts can effectively alter patient behavior and modify risk factors. Reimbursement for interventions aimed at primary-prevention patients also needs to be altered for these efforts to be effective, said Rydén.