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Reducing Premature Cardiovascular Morbidity and Mortality in People with Atherosclerotic Vascular Disease Dr j WORLD HEART FEDERATION ROADMAP gRECS Reducing Premature Cardiovascular Morbidity and Mortality in People With Atherosclerotic Vascular Disease Dr. Perel lead several The World Heart Federation Roadmap for Secondary studies on preventive car- diology for which his insti- Prevention of Cardiovascular Disease tution has received grants. He has no conflicts related y z x k { # to this particular article. Dr. Pablo Perel*, Alvaro Avezum , Mark Huffman , Prem Pais , Anthony Rodgers , Raj Vedanthan , David Wood , Huffman received grant Salim Yusuf** support from the World Heart Federation for its Geneva, Switzerland; London, United Kingdom; São Paulo, Brazil; Chicago, IL, USA; Bangalore, India; Sydney, Emerging Leaders program, New South Wales, Australia; New York, NY, USA; and Hamilton, Ontario, Canada which has been supported by unrestricted educational grants from AstraZeneca, 1. BACKGROUND BOX 2. Secondary prevention interventions Boehringer Ingelheim, and Bupa. Dr. Rodgers’s 1.1. The importance of secondary cardiovascular employer The George prevention Priority secondary prevention medications: Institute for Global Health Aspirin obtained an exclusive Every year, around 35 million people have an acute ACE inhibitors global license in December coronary or cerebrovascular event. About one quarter of Statins 2012 for polypills used in clinical trials it conducted, these events occur in individuals with known athero- Beta-blockers* sclerotic vascular disease. The number of people with following a decision by Dr. Reddy’s Ltd. not to proceed prevalent cardiovascular disease (CVD) worldwide is Lifestyle interventions (cardiac rehabilitation, or preven- tive cardiology) with taking the products to likely to be around 100 million [1e3].Thefive-year rate market because of uncer- of recurrent myocardial infarction, stroke, heart failure or Smoking cessation tainty in regulatory re- cardiovascular death among patients with known CVD is Physical activity quirements. Dr. Wood lead between 20% and 30%, which has been estimated to be Healthy diet several studies on preven- fi Stress management tive cardiology for which four to ve times greater than the rate among moderate- his institution has received and high-risk individuals without known CVD [4]. Such *Beta-blockers are recommended for patients with grants from both peer re- individuals are eligible for secondary preventive therapies ischemic heart disease. For patients with other types of view organizations as well (Box 1). vascular disease, such as prior ischemic stroke or as from a number of phar- prevalent peripheral artery disease, recommendations maceutical companies. He are similar with regard to statin, aspirin, and 1 blood has also received honoraria for lectures and travel ex- pressure-lowering agent (often an ACE inhibitor or penses for talks. He has no BOX 1. What is secondary prevention? ¼ angiotensin receptor blocker). ACE angiotensin conflicts related to this converting enzyme. particular article. Dr. Yusuf Secondary cardiovascular prevention can be defined as lead several trials with a any strategy aimed at reducing the probability of a range of drugs as well as recurrent cardiovascular event in patients with known lifestyle interventions atherosclerotic CVD, including coronary artery disease, involving CVD prevention cerebrovascular artery disease, peripheral artery disease, 1.2. Effect of secondary cardiovascular prevention for which his institution has and atherosclerotic aortic disease. interventions received grants from both Secondary prevention of CVD consists of both medication peer review organizations as well as from a number use and behavioral strategies for risk factor management. of pharmaceutical com- panies. He has also Pharmacotherapy received honoraria for lec- Medications proven to reduce recurrent events and death tures and travel expenses Individuals with clinical vascular disease (ischemic include antiplatelet agents, renineangiotensinealdosterone for talks. He has no con- heart disease, cerebrovascular disease, or peripheral fl system antagonists, beta-blockers, and lipid-lowering ther- icts related to this partic- vascular disease) can be readily identified. Treatment with ular article. The remaining apy with statins [6e8]. four proven drugs and smoking cessation will prevent or authors report no postpone as many as 75% to 80% of recurrent vascular Behavioral interventions relationships that could be construed as a conflict of events and their complications, including death and Additionally, tobacco cessation among individuals who use interest. disability [1] (Box 2) tobacco, moderate levels of physical activity, healthy diet, From the *World Heart Secondary prevention can also reduce healthcare costs, weight management and diabetes control are all beneficial Federation, Geneva, increase economic productivity and improve quality of for vascular disease prevention. Switzerland, and the fi London School of Hygiene life. These interventions are highly cost-effective (de ned Smoking is an established risk factor for CVD. Among & Tropical Medicine, as cost per disability-adjusted life year [DALY] saved less patients with known CVD, smoking cessation is associated London, United Kingdom; than three times GDP per capita) [5]. with a substantial reduction in all-cause mortality [9]. yDante Pazzanese Institute GLOBAL HEART, VOL. 10, NO. 2, 2015 99 June 2015: 99-110 j gRECS of Cardiology, São Paulo, Box 3 summarizes some of the most effective smoking and statins), as well as lifestyle interventions like smoking z Brazil; Northwestern Uni- cessation strategies. WHO has developed a training pack- cessation, physical activity and healthy diet. versity Feinberg School of Medicine, Chicago, IL, USA; age to assist countries to provide tobacco dependence Programs that provide comprehensive management of xSt. John’s Research Insti- treatment by integrating brief tobacco interventions (brief patients with known CVD are called ‘cardiac rehabilitation, tute, Bangalore, India; kThe advice) into primary care (www.who.int/tobacco/ or preventive cardiology programs’ and consist of a George Institute for Global publications/building_capacity/training_package/treating multidisciplinary approach of exercise, education and Health, Sydney, New South tobaccodependence/en/). behavioral modification. They are designed to return the Wales, Australia; {Icahn School of Medicine at patient to full physical, emotional, psychosocial and Mount Sinai, New York, NY, vocational function by stabilizing and stopping the un- USA; #International Centre BOX 3. Individual smoking cessation strategies derlying atherosclerotic process. for Circulatory Health, Im- These comprehensive preventive cardiology programs perial College London, Brief advice from healthcare workers are also important but the challenges of their imple- London, United Kingdom; Telephone support mentation are complex, particularly in limited resource and the **Population Text messaging Health Research Institute, Printed self-help materials settings and alternative models for these settings are McMaster University, needed to improve health behaviors. Hamilton, Ontario, Canada. Community support Further discussion on behavioral interventions for Correspondence: P. Perel Multi-session, face-to-face counselling (Pablo.Perel@worldheart. Behavioral support secondary CVD prevention is beyond the scope of this org). Pharmacologic support (varenicline, buproprion or Roadmap but is an area of active interest within the World nicotine replacement therapy) Heart Federation (WHF). GLOBAL HEART © 2015 World Heart Federation (Geneva). Published by Elsevier Ltd. 1.3. The CVD secondary prevention care gap Most major cardiology societies and international All rights reserved. A care gap refers to a discrepancy between best practice VOL. 10, NO. 2, 2015 health organizations have published guidelines recom- (based high-quality evidence) and the care provided in ISSN 2211-8160/$36.00. mending evidence-based interventions for secondary CVD http://dx.doi.org/10.1016/ e usual clinical practice. Care gaps include those situations in prevention [6 8]. These interventions include the use of fi j.gheart.2015.04.003 four proven medications (aspirin, angiotensin-converting which proven ef cacious interventions are under-utilized. enzyme [ACE] inhibitors (or angiotensin receptor They are seen in practically all countries, including those blockers if ACE inhibitors are not tolerated), beta-blockers that are wealthy, but they are most marked in poorer countries, particularly in rural and under-resourced set- tings. Recently, the Population Urban Rural Epidemiology A No drug (PURE) cohort study assessed the use of secondary pre- Coronary heart disease One drug 100 Two drugs vention drugs across high-, middle-, and low-income Three or more drugs countries, in both rural and urban settings [10]. The use 75 of proven medications (aspirin, statins, and recommended blood pressure drugs) in patients with coronary heart 50 disease or stroke is low, particularly in low-income coun- cipants (%) Ɵ tries, where 80% took no drugs (Figure 1). PURE also 25 Par reported low rates of lifestyle changes in patients with 0 CVD, as well as low rates of adherence to diet, physical Overall High-income Upper middle- Lower middle- Low-income countries income countries income countries countries activity and smoking cessation, particularly in low- and B middle-income countries [11]. Stroke 100 The economic status of the country accounted for about two-thirds of the variance in
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