Reducing Cardiovascular Mortality and Morbidity - What Else Can Be Done?

    Authors

    Abstract

    Since cardiovascular diseases (CVD) are still the leading cause of mortality and morbidity, we have been attempting to increase our efforts to reduce their incidence. In everyday practice we implement cardiovascular (CV) prevention guidelines and educate patients on changing bad lifestyle habits and controling CV risk factors. However, all of that is insufficient without the support of the whole society and public policies. So the question must be asked: what else can we do and how should we act? The example of the Netherlands is used to point out activities, initiatives, associations, and also reforms that have been successful in reducing CV mortality and morbidity.

    Keywords

    cardiovascular diseases, cardiovascular prevention, guidelines

    DOI

    https://doi.org/10.15836/ccar.2015.190

    Full Text

    ## Introduction Unfortunately, texts on cardiovascular (CV) prevention still start with the fact that cardiovascular diseases (CVD) are the leading cause of mortality and morbidity both globally and in Croatia. It is estimated that by 2030 there will be 23.6 million deaths from CVD per year. There is a weak downward trend in mortality and incidence of CVD in North, West, and South Europe, whereas the mortality and incidence are stable in Central and Eastern Europe. ( 1 ) A significant part of the mortality and morbidity due to CVD can be prevented by applying economical and readily-available interventions. The World Health Organization (WHO) estimates that three quarters of all deaths caused by CVD could be prevented by changing bad lifestyle habits (smoking, poor diet, obesity, lack of physical activity, psychosocial stress) which are closely associated with CVD.2 WHO encourages the implementation of an integrated approach to CVD prevention through preventive programs. CV risk factors (improper diet, lack of physical activity, smoking, arterial hypertension, diabetes, dyslipidemia) contribute to the early development of atherosclerosis, its progression, and the development of CVD (ischemic heart disease, cerebrovascular disease, peripheral artery disease). More than 10 years ago, WHO created cartograms for individual risk estimation as well as guidelines for primary and secondary CV prevention. ( 2 ) The European Society of Cardiology (ESC) published their first guidelines on primary and secondary CV prevention in 1994. They have been revised several times since then, most recently in 2012. In 2007 CV prevention guidelines were incorporated into the European Heart Health Charter. Since 2002, ESC has actively participated in health policies with the stated goal that no child born in the third millennium should suffer or die from CVD before age 65. After the European Heart Health Charter, the European Parliament adopted a Motion for a Resolution on Action to tackle Cardiovascular Disease. According to latest ESC guidelines on CV prevention, >50% of CV mortality can be eliminated through prevention, and 40% through treatment measures. ( 3 ) CV prevention must start already in pregnancy and last throughout the person’s life. Thus, education programs, continuous action in public health, and individual health programs are all sorely needed. ESC has undertaken many studies on CV prevention, of which EUROASPIRE is among the most significant ones. ( 4 ) It lead to the EUROACTION project in which patients are given advice on healthy lifestyle habits during everyday clinical practice in order to manage risk factors in primary and secondary prevention. ( 5 ) ## The example of the Netherlands One year ago, Prof J. Deckers and R. Kraaijenhagen, MD published a report on CV health in the Nethelands.6 The health system of the Netherlands underwent reform five years ago. There are eight clinics, six large and 15 smaller hospitals, 900 cardiologists, and 10 000 family physicians for a population of 17 million people. Health care is decentralized at local levels. Aging of the population leads to increasing prevalence of CVD, but CV mortality is dropping. In the Netherlands, malignant diseases have become the main cause of mortality, with CVD in second place. Only Spain and France have lower CV mortality. ( 6 ) Lifestyle changes, risk reduction measures, and other individual measures that facilitated CV mortality reduction in the Netherlands are the following: Reduction in the number of smokers Saturated fats were removed from food products Salt intake has been reduced, but the intake of fruit and vegetables is still insufficient 60% of the population is physically active (the Healthy Moving program was started in 2011) 34% have total cholesterol <5.0 mmol/L Diabetes prevalence: 7% in men and 5.5% in women Arterial hypertension: 17% of the population from 30 to 39 years of age, and 71% of the population from 70 to 80 years of age Improved organization of invasive cardiac care. In the Netherlands, prevention is divided into four levels: UNIVERSAL – encompasses the whole population (goals are promoting health, reduction in risk factors, and disease prevention. SELECTIVE – identification of high-risk patients and undertaking targeted preventive measures. INDICATED – prevention of disease progression and complications in high-risk patients (includes medication treatment) PREVENTION THROUGH TREATMENT – preventing complications of CVD. In late 2013, the Netherlands adopted the National Prevention Plan that incorporated local and state authorities, the industry, and social and educational institutions. This preventive plan is comprised of three main goals: Promoting health and disease prevention in areas where people live, work, and learn Prevention is given an important role in health care Securing appropriate health care. This plan promotes universal, individual, selective prevention in communities. Early disease detection and treatment and regulation of risk factors are given high priority, which reduces morbidity. The Netherlands Institute for Prevention and e-Health Development (NIPED) started Personalised Integrated Health Management Support (PIHMS) in 2005, and various medical associations adopted prevention standards for cardiometabolic diseases in 2010. The Netherlands has formed and implemented numerous associations and initiatives for prevention at all levels, including: Healthy Weight, Young People with Healthy Weight, Healthy School, Alliance Smokefree Netherlands, Prevention Consult Alliance, Individual Care Plan for Cardiovascular Risk Management, etc. ( 6 ) ## What we can (and should) do The example of the Netherlands shows the importance of cooperation between all segments of society in CV prevention with the goal of reducing mortality and morbidity from these diseases. The economic recession that has been taking place in Croatia for a number years causes not only the poor social and economic state of the population but poor cardiovascular health as well through a growing tendency towards poor lifestyle habits, without any clear global preventive measure and initiative at the level of the whole society. Thus, our scientific and medical community should, even in these conditions, invest more effort to push for legal and other measures at the local and state levels to actively conduct lifetime CV prevention. The Ministry of Health of the Republic of Croatia adopted the National CVD Prevention Program in 2001. However, this was not followed up by an implementation plan. Every year, we undertake individual preventive initiatives at the level of different medical societies, especially during the World Heart Day. This, however, is not enough. In our everyday practice we engage patients only at the individual level (with advice, education, treatment, etc.). We lack better coordination and cooperation (among specialists and with family physicians) in order to manage patients in creating group preventive initiatives and in treatment and diagnostic procedures. In primary health care, a CV risk assessment table (SCORE, relative risk) should exist for every patient along with CV prevention guidelines (family physicians should perform preventive checkups, CV risk assessment). We should, as much as possible, act at the local level in the promotion of healthy lifestyle habits in order to make those activities available to everyone (educational lectures, promotional material, exercises, relaxation techniques, smoking cessation, etc.). At the state level, legal measures should be introduced to disallow smoking in public places, reduce intake of salt, refined sugar, and saturated fats in food products, and implement preventive programs at all levels, in particular for in early childhood education and in schools. Better cooperation between governmental and non-governmental organizations and medical associations should result in a joint strategy in promoting healthy lifestyle habits and CV risk identification and prevention. This would avoid placing most of the CV prevention burden on physicians, and, unfortunately, mostly on cardiologists who are usually faced with treating already progressed CVD and the resulting complications. Our guiding idea should be the quote from Brown and O’Connor: “We must create a healthy society and incorporate prevention into everyday life”. ## Conclusion In Croatia today, most of the burden of CV prevention rests on the doctors themselves. This achieves only individual prevention. There is no systematic social policy that would affect the whole population. Can the CV prevention initiatives in the Netherlands, implemented at the level of the whole society, serve as an example for us? I think that they would be a good role-model even in this economic recession. We are a Mediterranean country, and France and Spain, Mediterranean countries as well, have the best results in CV mortality and morbidity reduction. The goal of all of us is to extend the average lifetime and reduce premature death from CV diseases.

    Cardiologia Croatica
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    Reducing Cardiovascular Mortality and Morbidity - What Else Can Be Done?

    Review Article
    Issue7-8
    Published
    Pages190-193
    PDF via DOIhttps://doi.org/10.15836/ccar.2015.190
    cardiovascular diseases
    cardiovascular prevention
    guidelines

    Authors

    Sonja Francula-Zaninovic*ORCIDCroatia

    Abstract

    Since cardiovascular diseases (CVD) are still the leading cause of mortality and morbidity, we have been attempting to increase our efforts to reduce their incidence. In everyday practice we implement cardiovascular (CV) prevention guidelines and educate patients on changing bad lifestyle habits and controling CV risk factors. However, all of that is insufficient without the support of the whole society and public policies. So the question must be asked: what else can we do and how should we act? The example of the Netherlands is used to point out activities, initiatives, associations, and also reforms that have been successful in reducing CV mortality and morbidity.

    Full Text

    ## Introduction Unfortunately, texts on cardiovascular (CV) prevention still start with the fact that cardiovascular diseases (CVD) are the leading cause of mortality and morbidity both globally and in Croatia. It is estimated that by 2030 there will be 23.6 million deaths from CVD per year. There is a weak downward trend in mortality and incidence of CVD in North, West, and South Europe, whereas the mortality and incidence are stable in Central and Eastern Europe. ( 1 ) A significant part of the mortality and morbidity due to CVD can be prevented by applying economical and readily-available interventions. The World Health Organization (WHO) estimates that three quarters of all deaths caused by CVD could be prevented by changing bad lifestyle habits (smoking, poor diet, obesity, lack of physical activity, psychosocial stress) which are closely associated with CVD.2 WHO encourages the implementation of an integrated approach to CVD prevention through preventive programs. CV risk factors (improper diet, lack of physical activity, smoking, arterial hypertension, diabetes, dyslipidemia) contribute to the early development of atherosclerosis, its progression, and the development of CVD (ischemic heart disease, cerebrovascular disease, peripheral artery disease). More than 10 years ago, WHO created cartograms for individual risk estimation as well as guidelines for primary and secondary CV prevention. ( 2 ) The European Society of Cardiology (ESC) published their first guidelines on primary and secondary CV prevention in 1994. They have been revised several times since then, most recently in 2012. In 2007 CV prevention guidelines were incorporated into the European Heart Health Charter. Since 2002, ESC has actively participated in health policies with the stated goal that no child born in the third millennium should suffer or die from CVD before age 65. After the European Heart Health Charter, the European Parliament adopted a Motion for a Resolution on Action to tackle Cardiovascular Disease. According to latest ESC guidelines on CV prevention, >50% of CV mortality can be eliminated through prevention, and 40% through treatment measures. ( 3 ) CV prevention must start already in pregnancy and last throughout the person’s life. Thus, education programs, continuous action in public health, and individual health programs are all sorely needed. ESC has undertaken many studies on CV prevention, of which EUROASPIRE is among the most significant ones. ( 4 ) It lead to the EUROACTION project in which patients are given advice on healthy lifestyle habits during everyday clinical practice in order to manage risk factors in primary and secondary prevention. ( 5 ) ## The example of the Netherlands One year ago, Prof J. Deckers and R. Kraaijenhagen, MD published a report on CV health in the Nethelands.6 The health system of the Netherlands underwent reform five years ago. There are eight clinics, six large and 15 smaller hospitals, 900 cardiologists, and 10 000 family physicians for a population of 17 million people. Health care is decentralized at local levels. Aging of the population leads to increasing prevalence of CVD, but CV mortality is dropping. In the Netherlands, malignant diseases have become the main cause of mortality, with CVD in second place. Only Spain and France have lower CV mortality. ( 6 ) Lifestyle changes, risk reduction measures, and other individual measures that facilitated CV mortality reduction in the Netherlands are the following: Reduction in the number of smokers Saturated fats were removed from food products Salt intake has been reduced, but the intake of fruit and vegetables is still insufficient 60% of the population is physically active (the Healthy Moving program was started in 2011) 34% have total cholesterol <5.0 mmol/L Diabetes prevalence: 7% in men and 5.5% in women Arterial hypertension: 17% of the population from 30 to 39 years of age, and 71% of the population from 70 to 80 years of age Improved organization of invasive cardiac care. In the Netherlands, prevention is divided into four levels: UNIVERSAL – encompasses the whole population (goals are promoting health, reduction in risk factors, and disease prevention. SELECTIVE – identification of high-risk patients and undertaking targeted preventive measures. INDICATED – prevention of disease progression and complications in high-risk patients (includes medication treatment) PREVENTION THROUGH TREATMENT – preventing complications of CVD. In late 2013, the Netherlands adopted the National Prevention Plan that incorporated local and state authorities, the industry, and social and educational institutions. This preventive plan is comprised of three main goals: Promoting health and disease prevention in areas where people live, work, and learn Prevention is given an important role in health care Securing appropriate health care. This plan promotes universal, individual, selective prevention in communities. Early disease detection and treatment and regulation of risk factors are given high priority, which reduces morbidity. The Netherlands Institute for Prevention and e-Health Development (NIPED) started Personalised Integrated Health Management Support (PIHMS) in 2005, and various medical associations adopted prevention standards for cardiometabolic diseases in 2010. The Netherlands has formed and implemented numerous associations and initiatives for prevention at all levels, including: Healthy Weight, Young People with Healthy Weight, Healthy School, Alliance Smokefree Netherlands, Prevention Consult Alliance, Individual Care Plan for Cardiovascular Risk Management, etc. ( 6 ) ## What we can (and should) do The example of the Netherlands shows the importance of cooperation between all segments of society in CV prevention with the goal of reducing mortality and morbidity from these diseases. The economic recession that has been taking place in Croatia for a number years causes not only the poor social and economic state of the population but poor cardiovascular health as well through a growing tendency towards poor lifestyle habits, without any clear global preventive measure and initiative at the level of the whole society. Thus, our scientific and medical community should, even in these conditions, invest more effort to push for legal and other measures at the local and state levels to actively conduct lifetime CV prevention. The Ministry of Health of the Republic of Croatia adopted the National CVD Prevention Program in 2001. However, this was not followed up by an implementation plan. Every year, we undertake individual preventive initiatives at the level of different medical societies, especially during the World Heart Day. This, however, is not enough. In our everyday practice we engage patients only at the individual level (with advice, education, treatment, etc.). We lack better coordination and cooperation (among specialists and with family physicians) in order to manage patients in creating group preventive initiatives and in treatment and diagnostic procedures. In primary health care, a CV risk assessment table (SCORE, relative risk) should exist for every patient along with CV prevention guidelines (family physicians should perform preventive checkups, CV risk assessment). We should, as much as possible, act at the local level in the promotion of healthy lifestyle habits in order to make those activities available to everyone (educational lectures, promotional material, exercises, relaxation techniques, smoking cessation, etc.). At the state level, legal measures should be introduced to disallow smoking in public places, reduce intake of salt, refined sugar, and saturated fats in food products, and implement preventive programs at all levels, in particular for in early childhood education and in schools. Better cooperation between governmental and non-governmental organizations and medical associations should result in a joint strategy in promoting healthy lifestyle habits and CV risk identification and prevention. This would avoid placing most of the CV prevention burden on physicians, and, unfortunately, mostly on cardiologists who are usually faced with treating already progressed CVD and the resulting complications. Our guiding idea should be the quote from Brown and O’Connor: “We must create a healthy society and incorporate prevention into everyday life”. ## Conclusion In Croatia today, most of the burden of CV prevention rests on the doctors themselves. This achieves only individual prevention. There is no systematic social policy that would affect the whole population. Can the CV prevention initiatives in the Netherlands, implemented at the level of the whole society, serve as an example for us? I think that they would be a good role-model even in this economic recession. We are a Mediterranean country, and France and Spain, Mediterranean countries as well, have the best results in CV mortality and morbidity reduction. The goal of all of us is to extend the average lifetime and reduce premature death from CV diseases.