Prevention of cardiovascular diseases in clinical practice: is it possible to achieve improvement?

Czech version

Authors: Tomáš Štulc; Michaela Šnejdrlová; Richard Češka
Authors‘ workplace: III. interní klinika 1. LF UK a VFN Praha, přednosta prof. MUDr. Štěpán Svačina, DrSc., MBA
Published in: Vnitř Lék 2014; 60(11): 931-936
Category: Reviews

Overview

Prevention through evaluation and treatment of cardiovascular risk factors is an efficient approach to reduce the risk of cardiovascular events, however, the problem remains that the available treatment options are underused. Implementation of cardiovascular disease prevention guidelines into clinical practice is therefore important for decreasing the burden of cardiovascular disease in general population. However, there are many barriers to this process, including questionable relevance of scientific results for clinical practice, personal preferences and expertise of the doctors, patient attitudes, lack of time, and economical factors. All these factors need to be taken into account for any change in the clinical practice to be successful. With respect to cardiovascular disease prevention, insufficient screening for risk factors, inappropriate risk estimation and hesitation to keep to the guidelines-based treatment targets contribute most to inadequate control of risk factors, and this has been repeatedly demonstrated to be difficult to improve. In this context, our studies demonstrate that the emphasis on systematic application of the principles of cardiovascular prevention results in improved control of cardiovascular risk factors. Adequate support for transforming the guidelines-based knowledge into practicable habit appears therefore important for successful prevention of cardiovascular disease in clinical practice and may translate into substantial reduction of cardiovascular risk in general population.

Key words:
cardiovascular risk – cardiovascular risk reduction – dyslipidemia – guidelines implementation – hypertension

Sources

1. Sever PS, Dahlöf B, Poulter NR et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial – Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003(9364); 361: 1149–1158.

2. Hsia J, MacFadyen JG, Monyak J et al. Cardiovascular event reduction and adverse events among subjects attaining low-density lipoprotein cholesterol < 50 mg/dl with rosuvastatin. The JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin). J Am Coll Cardiol 2011; 57(16): 1666–1675.

3. Teo K, Yusuf S, Sleight P et al. Rationale, design, and baseline characteristics of 2 large, simple, randomized trials evaluating telmisartan, ramipril, and their combination in high-risk patients: the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial/Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease (ONTARGET/TRANSCEND) trials. Am Heart J 2004; 148(1): 52–61.

4. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010; 376(9753): 1670–1681.

5. Czernichow S, Zanchetti A, Turnbull F et al. Blood Pressure Lowering Treatment Trialists’ Collaboration. The effects of blood pressure reduction and of different blood pressure-lowering regimens on major cardiovascular events according to baseline blood pressure: meta-analysis of randomized trials. J Hypertens 2011; 29(1): 4–16.

6. Perk J, De Backer G, Gohlke H et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012; 33(13):1635–1701.

7. Nichol MB, Knight TK, Wu J et al. Transition probabilities and predictors of adherence in a California Medicaid population using antihypertensive and lipid-lowering medications. Value Health 2009; 12(4): 544–550.

8. Graham IM, Stewart M, Hertog MG. Factors impeding the implementation of cardiovascular prevention guidelines: findings from a survey conducted by the European Society of Cardiology. Eur J Cardiovasc Prev Rehabil 2006; 13(5): 839–845.

9. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362(9391): 1225–1230.

10. van Steenkiste B, van der Weijden T, Timmermans D et al. Patients’ ideas, fears and expectations of their coronary risk: barriers for primary prevention. Patient Educ Couns 2004; 55(2): 301–307.

11. Zwolsman S, te Pas E, Hooft L et al. Barriers to GPs’ use of evidence-based medicine: a systematic review. Br J Gen Pract 2012; 62(600): e511-e521.

12. Eichler K, Zoller M, Tschudi P et al. Barriers to apply cardiovascular prediction rules in primary care: a postal survey. BMC Fam Pract 2007; 8: 1.

13. Kotseva K, Wood D, De Backer G et al. Cardiovascular prevention guidelines in daily practice: a comparison of EUROASPIRE I, II, and III surveys in eight European countries. Lancet 2009; 373(9667): 929–940.

14. Cífková R, Skodová Z, Bruthans J et al. Longitudinal trends in major cardiovascular risk factors in the Czech population between 1985 and 2007/8. Czech MONICA and Czech post-MONICA. Atherosclerosis 2010; 211(2): 676–681.

15. Keller H, Hirsch O, Kaufmann-Kolle P et al. Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis. BMC Public Health 2013; 13: 623. Dostupné z DOI: <http://doi: 10.1186/1471–2458–13–623>.

16. van de Steeg-van Gompel CH, Wensing M et al. Implementation of a pharmacist-led intervention to enhance statin prescribing for secondary prevention in primary care: a cluster randomized trial. Eur J Prev Cardiol 2012; 19(2): 169–176.

17. Smidth M, Christensen MB, Olesen F et al. Developing an active implementation model for a chronic disease management program. Int J Integr Care 2013; 13: e020.

18. Bernhardsson S, Larsson ME, Eggertsen R et al. Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial. BMC Health Serv Res 2014; 14: 105. Dostupné z DOI: <http://doi: 10.1186/1472–6963–14–105>.

19. Sackett DL, Rosenberg WM, Gray JA et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312 (7023]: 71–72.

20. Mayer J, Piterman L. The attitudes of Australian GPs to evidence-based medicine: a focus group study. Fam Pract 1999; 16(6): 627–632.

21. Jacobson LD, Edwards AG, Granier SK et al. Evidence-based medicine and general practice. Br J Gen Pract 1997; 47(420): 449–452.

22. Hannes K, Leys M, Vermeire E et al. Implementing evidence-based medicine in general practice: a focus group based study. BMC Fam Pract 2005; 6: 37.

23. Bruckert E, Hayem G, Dejager S et al. Mild to moderate muscular symptoms with high-dosage statin therapy in hyperlipidemic patients – the PRIMO study. Cardiovasc Drugs Ther 2005; 19(6): 403–414.

24. Stone NJ, Intwala S, Katz D. Statins in very elderly adults (debate). J Am Geriatr Soc 2014; 62(5): 943–945.

25. Freeman AC, Sweeney K. Why general practitioners do not implement evidence: qualitative study. BMJ 2001; 323(7321): 1100–1102.

26. Carlsen B, Norheim OF. “What lies beneath it all?” an interview study of GPs’ attitudes to the use of guidelines. BMC Health Serv Res 2008; 8: 218. Dostupné z DOI: <http://doi: 10.1186/1472–6963–8–218>.

27. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidence-based medicine. BMC Med Educ 2006; 6: 59.

28. Wyatt JC, Sullivan F Keeping up: learning in the workplace. BMJ 2005; 331(7525): 1129–1132.

29. Ghandehari H, Kamal-Bahl S, Wong ND. Prevalence and extent of dyslipidemia and recommended lipid levels in US adults with and without cardiovascular comorbidities: the National Health and Nutrition Examination Survey 2003–2004. Am Heart J 2008; 156(1): 112–119.

30. Berthold HK, Gouni-Berthold I, Böhm M et al. Patterns and predictors of statin prescription in patients with type 2 diabetes. Cardiovasc Diabetol 2009; 8: 25. Dostupné z DOI: <http://doi: 10.1186/1475–2840–8–25>.

31. Conroy R, Pyorala K, Fitzgerald AP et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24(11): 987–1003.

32. Anderson KM, Wilson PWF, Odell PM et al. An updated coronary risk profile: A statement for health professionals. Circulation 1991; 83(1): 356–362.

33. Persson M, Carlberg B, Tavelin B et al. Doctors’ estimation of cardiovascular risk and willingness to give drug treatment in hypertension: fair risk assessment but defensive treatment policy. J Hypertens 2004; 22(1): 65–71.

34. Sheridan SL, Crespo E. Does the routine use of global coronary heart disease risk scores translate into clinical benefits or harms? A systematic review of the literature. BMC Health Serv Res 2008; 8: 60. Dostupné z DOI: <http://doi: 10.1186/1472–6963–8–60>.

35. Hradec J, Bultas J, Kmínek A et al. How are statins used in the Czech Republic? STEP survey – results. Cor Vasa 2011; 53(10): 527–534.

36. Vrablik M, Freiberger T, Lanska V et al. The Atractiv project: improvement of cardiovascular prevention in primary care in the Czech Republic. Vnitř Lék 2008; 54(12): 1131–1139.

37. Ceska R, Snejdrlova M, Prusikova M et al. Complex Approach in the Decrease of Cardiovascular Risk in Daily Practice, the Varo Study. Circulation 2013; 128(22 Suppl): A11969.

38. Hatzitolios AI, Athyros VG, Karagiannis A et al. Implementation of strategy for the management of overt dyslipidemia: the IMPROVE-dyslipidemia study. Int J Cardiol 2009; 134(3): 322–329.