Congress Reports

MedWire - ESC (Munich, Germany), September 3, 2008: This Clinical Trials Update Session on the fifth and final day of the European Society of Cardiology (ESC) Congress 2008 featured new research data from large studies. Findings from the Euro Consumer Heart Index 2008, which examined cardiac care in Europe from the patients’ perspective, and EUROASPIRE III*, which was a snapshot of the management of high-risk individuals in primary care, are summarized below.

The Euro Consumer Heart Index 2008
Dr. Arne Bjornberg, Health Consumer Powerhouse, Stockholm, Sweden

The Euro Consumer Heart Index is a unique study commissioned by the Health Consumer Powerhouse, a Swedish organization that provides consumer information and analysis in healthcare. The main objective of the study was to increase healthcare transparency and consumer empowerment by developing an overall picture of cardiovascular care as seen from the patient’s perspective, explained Dr. Bjornberg, who co-authored the report.

The study concentrated on indicators that reflect the performance of healthcare systems in the European member states. A total of 28 indicators were chosen in five disciplines: information, consumer rights, and choice; access; prevention; procedures; and outcomes.

The data sources were not standardized among countries; instead the researchers used any source that could provide “reasonably solid” data. “We defined these as comprehensive uniform trustworthy sources, or ‘CUTS’,” said Dr. Bjornberg. Examples of CUTS include World Health Organization (WHO) databases, health data from the Organization for Economic and Cooperation and Development, special Eurobarometers, or scientific papers. “European healthcare suffers from an extreme CUTS shortage,” he remarked.

The study authors also undertook extensive work to validate the data, through contact with cardiac societies, ministries of health, national health agencies, and surveys of patients and patient organizations. The resulting Index can be viewed online here.

The study’s key findings were as follows:

• Good cardiac care can be found in specialist clinics in all 29 European countries; however, no country excels across the entire range of indicators;
• Richer nations tend to have better cardiac care: Luxemburg, Norway, and Switzerland are among the top countries in the Euro Consumer Heart Index and also top the European table of healthcare spending per capita;
• Most countries score poorly in the area of prevention, with the notable exception of France;
• Access and waiting times for cardiac care are generally good, unlike in other areas of medicine;
• There is a surprising lack of correlation between the use of highly effective therapies - namely statins and clopidogrel - and the prevalence of heart disease; for example, clopidogrel use per capita is highest in Greece and France despite both countries having below-average prevalence of heart disease;
• Adherence to guidelines on the use of cardiac medications varies widely across Europe and seems to depend more on local professional and administrative culture than on evidence-based recommendations;
• There is significant room for improvement in prehospital care;
• Information for patients on where to seek cardiac care is a “disaster,” with only three countries publishing data on the quality of care in different clinics.

“Good cardiac care is available in essentially all European Union states,” Dr. Bjornberg concluded. “However we need more CUTS and an increased focus on screening and prevention as a cost-effective way to reduce cardiovascular disease.”

Discussion
Dr. Gunter Breithardt, University of Münster Medical School, Germany

The discussant, Dr. Breithardt, described the Euro Consumer Heart Index as an ambitious project that had yielded interesting results, despite some gaps in the data. He said while one might debate the ranking of individual countries on individual items, the overall picture was more important, as it showed that there is room for improvement in many countries.

“This endeavor should be taken more seriously by those who are asked for advice on data and ranking,” he remarked.

EUROASPIRE III: Management of high-risk patients in primary care
Dr. David Wood, Imperial College School of Medicine, London, UK

EUROASPIRE III was a cross-sectional survey of 4366 patients who were at high risk of developing cardiovascular disease (CVD) and were being managed in primary care in 12 European countries. All patients had been prescribed antihypertensive and/or lipid-lowering and/or antidiabetic therapy between 6 months and 3 years prior to enrolment. None had known coronary or atherosclerotic disease.

The aim of the survey was to assess the lifestyle, risk factor, and therapeutic management of high-risk individuals, Dr. Wood explained. Accordingly, the main outcome measures were the proportion of patients achieving targets for CVD prevention as defined in the 2003 European guidelines on CVD prevention. [1]

The main findings were as follows:

• 16% of patients were current smokers;
• Of those who smoked at the time of starting therapy, just 11% subsequently quit; persistent smokers tended to be younger (under 60 years);
• Nearly half of all patients were obese and nearly two-thirds had abdominal obesity;
• Abdominal obesity was more prevalent among women than men ;
• Nearly 80% of patients had a blood pressure >140/90 mm Hg;
• Around 80% of patients had elevated total cholesterol and low-density lipoprotein (LDL) cholesterol;
• Therapeutic control of risk factors was poor: the proportions of patients with well-controlled blood pressure, total cholesterol, and LDL cholesterol were 26%, 31%, and 31%, respectively;
• Three out of ten patients had diabetes; of these, just 27% had a fasting glucose <7.0 mmol/L, and 53% had a glycosylated hemoglobin <6.5%;
• Cardioprotective drugs were underprescribed, with usage ranging from 22% (for antiplatelet agents) to 56% (for renin-angiotensin system blockers);
• A majority of patients thought they should know their risk of CVD, yet most underestimated their risk or did not know it;
• The vast majority (82%) of patients had not been advised to follow a lifestyle and risk factor management program.

“The lifestyle of high-risk patients is a major cause for concern, with high prevalences of persistent smoking and both obesity and central obesity,” Dr. Wood concluded. “Blood-pressure, lipid, and glucose control are completely inadequate, with most patients not achieving the targets defined in the guidelines.”

Discussion
Dr. Lars Rydén, Karolinska Institute, Stockholm, Sweden

Dr. Rydén described the findings from EUROASPIRE III as “disappointing” and said he “agreed completely” with the authors’ conclusions. He also suggested that the situation in real-world practice might be even worse than in the survey, since EUROASPIRE involved enthusiastic and motivated patients and doctors.

He said he hoped the results would give rise to self-criticism, improved guideline adherence, investment in patient education, and better organization of nurse-led clinics.

Reference

1. De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 2003; 24(17): 1601-1610.

Footnote:
*European Action on Secondary Prevention through Intervention to Reduce Events