EURObservational Research Programme Clinical reality of primary prevention in people at high cardiovascular risk in Europe A comparison of EUROASPIRE III and IV surveys in general practice Kornelia Kotseva National Heart and Lung Institute, Imperial College London, UK on behalf of EUROASPIRE IV Investigators

Disclosure Statement of Financial Interest Within the past 12 months, I have had a financial interest/arrangement or affiliation with the healthcare related company listed below. European Society of Cardiology Grant/Research Support

European recommendations and surveys on cardiovascular disease prevention 1994 First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention 1995–96 EUROASPIRE I 1998 Second Joint Task Force Recommendations 1999–2000 EUROASPIRE II 2000 Joint European Societies CVD Prevention Committee Third Joint Task Force Guidelines Joint European Societies CVD Prevention Committee 2006–2007 EUROASPIRE III 2007 Fourth Joint Task Force Guidelines Fifth Joint Task Force Guidelines –15 EUROASPIRE IV – European survey of CVD prevention and diabetes References: First joint task force recommendation: Pyörälä K et al. Heart J 1994;15:1300–1331 Second joint task force recommendation: Wood DA et al. Eur Heart J 1998;19:1434–1503 Third joint task force recommendation: De Backer G et al. Eur Heart J 2003;24:1601–1610 Fourth joint task force recommendation: Graham I et al. Eur Heart J 2007;28:2375–2414 Fifth joint task force recommendation: Perk J et al. Eur Heart J 2012;33:1635–1701 EUROASPIRE I and II: Wood DA et al. Lancet 2001;357:995–1001 EUROASPIRE II, III and IV: Press release from escardio.org dated 03.01.2013 entitled ‘EUROASPIRE IV: Adverse lifestyle trends counter improvements in CV risk factor management’, accessed 25.11.13

EUROASPIRE Surveys The EUROASPIRE surveys identifies risk factors in high risk individuals describes their management through lifestyle and use of drug therapies providing objective assessment of clinical implementation of current knowledge

Objective To describe 8-year time trends in lifestyle and risk factor management use of cardioprotective drug therapies In people at high cardiovascular risk Between the EUROASPIRE III and IV surveys in general practice

Methods Consecutive patients, men and women <80 years No history of coronary or other atherosclerotic disease Prescribed one or more of the following medications ≥6 months and ≤3 years prior to the interview 1. Blood pressure lowering and/or 2. Lipid lowering and/or 3. Glucose lowering (diet, oral drugs and/or insulin) Interview and examination ≥6 months later

Data Collection Height, weight Waist circumference Blood pressure Breath CO Fasting venous blood sample for serum total cholesterol, HDL-cholesterol, triglycerides, glucose and HbA1c

Outcome Measures Proportions of high CVD risk individuals achieving the European lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention defined in the Joint European Societies Guidelines on CVD prevention

EUROASPIRE III & IV Countries Study Population EUROASPIRE III & IV Countries Bulgaria, Croatia, Poland, Romania, UK Survey Time period Patients Women n (%) Age (years) mean±SD EUROASPIRE III 2007-2008 1985 1194 (60) 58±10 EUROASPIRE IV 2014-2015 1842 1002 (54) 59±12

Prevalence of smoking* at interview (%) Bulgaria Croatia Poland Romania UK Overall P +17.2% +3.4% -9.0% -8.7% +0.0% +0.4% P=0.90 * Self-reported smoking or CO in breath > 10 ppm

No intention to quit smoking* (%) Bulgaria Croatia Poland Romania UK Overall P -0.5% +16.1% +8.0% +13.3% +2.9% +10.6% P=0.004 * Among current smokers

Prevalence of overweight* (%) Bulgaria Croatia Poland Romania UK Overall P -5.2% -6.1% +1.9% +10.7% -2.8% -0.7% P=0.85 * Body mass index ≥25 kg/m2

Prevalence of obesity* (%) Bulgaria Croatia Poland Romania UK Overall P -15.3% +2.8% +2.6% +10.0% -5.8% -0.7% P=0.88 * Body mass index ≥30 kg/m2

Prevalence of central obesity* (%) Bulgaria Croatia Poland Romania UK Overall P +4.7% +7.7% +11.8% +1.5% -1.0% +5.8% P=0.053 * Waist circumference ≥88/102 cm women/men

Obese patients ever been told by a health care professional that their diet is unhealthy (%) Bulgaria Croatia Poland Romania UK Overall P -7.6% +0.9% +1.5% -6.0% -11.3% -3.7% P=0.24 * Body mass index ≥30 kg/m2

Obese patients ever been told by a health care professional that they are overweight (%) Bulgaria Croatia Poland Romania UK Overall P -6.5% -5.6% +4.9% -15.4% -4.3% -4.5% P=0.20 * Body mass index ≥30 kg/m2

Obese patients actively trying to lose weight in the last month (%) Bulgaria Croatia Poland Romania UK Overall P +6.3% -5.4% +4.8% -5.6% +13.0% +3.6% P=0.34 * Body mass index ≥30 kg/m2

Obese patients considering trying to lose weight in the next month (%) Bulgaria Croatia Poland Romania UK Overall P +11.7% -7.4% +2.0% -19.6% +14.4% +1.1% P=0.86 * Body mass index ≥30 kg/m2

Vigorous physical activity outside work for ≥ 20 min at least three times a week (%) Bulgaria Croatia Poland Romania UK Overall P -11.6% +2.2% -1.5% +17.1% +1.7% +1.9% P=0.68

Proportion of patients not doing regular exercise Proportion of patients not doing regular exercise* to increase physical fitness (%) Bulgaria Croatia Poland Romania UK Overall P -29.3% +0.1% -8.0% +38.1% -4.4% -1.4% P=0.91 * Regular exercise is any planned physical performed to increase physical fitness. The activity should be performed 3-5 times/week for 20-60 minutes/session.

Proportion of patients advised to follow a CVD prevention programme over the last 3 years (%) Bulgaria Croatia Poland Romania UK Overall P -0.6% +4.5% -6.4% -0.9% -6.9% -2.1% P=0.37

Therapeutic control of blood pressure* (%) Bulgaria Croatia Poland Romania UK Overall P +23.5% +6.3% +0.9% +0.7% +7.0% +8.5% P=0.12 * SBP/DBP <140/90 mmHg in patients using blood pressure lowering drugs 140/80 mmHg in diabetes

Therapeutic control of total cholesterol* ( %) Bulgaria Croatia Poland Romania UK Overall P +14.8% +19.6% +8.1% +20.5% -3.5% +9.9% P=0.11 * Total cholesterol <4.5 mmol/L in patients using lipid lowering drugs

Therapeutic control of LDL-cholesterol* ( %) Bulgaria Croatia Poland Romania UK Overall P +10.2% +16.2% +8.4% +20.3% -15.0% +6.7% P=0.38 * Total cholesterol <2.5 mmol/L in patients using lipid lowering drugs

Prevalence of undetected diabetes at interview* (%) Bulgaria Croatia Poland Romania UK Overall P +21.4% +7.9% +2.6% +6.7% +1.4% +6.6% P=0.09 * Fasting glucose ≥7 mmol/L in patients not reporting a history of diabetes

Prevalence of impaired fasting glycaemia*(%) Bulgaria Croatia Poland Romania UK Overall P +1.0% -2.1% +2.0% -3.8% +10.5% +0.5% P=0.84 * No self-reported or newly detected diabetes and fasting glucose ≥6.1 but <7 mmol/L

Therapeutic control of diabetes - HbA1c <7% Bulgaria Croatia Poland Romania UK Overall P +3.8% -6.6% -6.8% +18.6% -3.8% -1.2% P=0.75

Conclusions Cause for concern No change in prevalence of smoking, obesity and central obesity with more then 80% of high CVD risk patients being overweight or obese No improvement in therapeutic control of blood pressure, LDL-cholesterol and diabetes Large heterogeneity between countries Call for action There is a pressing need for modern preventive cardiology programme integrating lifestyle and medical risk factor management adapted to medical and cultural settings in each country Urgent need of health care systems that invest in prevention

EUROASPIRE IV Steering Committee Executive Committee Kornelia Kotseva (Chair Scientific Steering Committee) (UK) Guy De Backer (Chair Executive Committee) (Belgium) Philippe Amouyel (France) Dirk De Bacquer (Belgium) Stephan Gielen (Germany) Aldo Maggioni (Italy) Lars Ryden (Sweden) Oliver Schnell (Germany) Jouko Sundvall (Helsinki) Jaakko Tuomilehto (Finland) David Wood (Principal Investigator) (UK) Speaker

EUROASPIRE IV Steering Committee National coordinators Bulgaria: Nina Gotcheva Croatia: Željko Reiner, Davor Milicic Poland: Andrzej Pajak Romania: Dan Gaita, Silvia Mancas United Kingdom: David Wood Speaker

EUROASPIRE IV Steering Committee Data management centre Coordinating centre Cardiovascular Medicine, International Centre for Circulatory Health Imperial College, London, UK David Wood Kornelia Kotseva Catriona Jennings Agnieszka Adamska Data management centre EURObservational Research Programme, European Heart House, Sophia-Antipolis, France Thierry Ferreira Myriam Glemot Marème Konte Statistical Centre Department of Public Health, Ghent University, Belgium Dirk De Bacquer Speaker

EUROASPIRE IV Steering Committee Diabetes centre Cardiology unit, Department of Medicine, Karolinska Institutet, Stockholm Sweden Lars Rydén Viveca Gyberg Jaakko Tuomilehto Oliver Schnell Central Laboratory Laboratory of Analytical Biochemistry, National Public Health Institute Helsinki, Finland Jouko Sundvall Laura Lund Speaker

EUROASPIRE Sponsors The EUROASPIRE survey as an ESC initiative was supported by: EUROASPIRE III: AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck/Schering-Plough, Novartis, Pfizer, Sanofi-Aventis, and Servier EUROASPIRE IV Amgen, AstraZeneca/Bristol-Myers Squibb, F. Hoffman-La Roche, GlaxoSmithKline, and Merck Sharp & Dohme