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Original article
ASPIRE-2-PREVENT: a survey of lifestyle, risk factor management and cardioprotective medication in patients with coronary heart disease and people at high risk of developing cardiovascular disease in the UK
  1. Kornelia Kotseva1,
  2. Catriona S Jennings1,
  3. Elizabeth L Turner2,
  4. Alison Mead1,
  5. Susan Connolly3,
  6. Jennifer Jones1,
  7. Timothy J Bowker4,
  8. David A Wood1 On behalf of the ASPIRE-2-PREVENT Study Group
  1. 1International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
  2. 2Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Imperial College Healthcare NHS Trust, London, UK
  4. 4Homerton University Hospital NHS Trust, London, UK
  1. Correspondence to Dr Kornelia Kotseva, Cardiovascular Medicine, National Heart and Lung Institute, Imperial College London, St Mary's Campus, International Centre for Circulatory Health, Lower 3rd Floor, 59–61 North Wharf Road, London W2 1LA, UK; k.kotseva{at}imperial.ac.uk

Abstract

Objective To determine in patients with coronary heart disease (CHD) and people at high risk of developing cardiovascular disease (CVD) whether the Joint British Societies' guidelines on CVD prevention (JBS2) are followed in everyday clinical practice.

Design A cross-sectional survey was undertaken of medical records and patient interviews and examinations at least 6 months after the recruiting event or diagnosis using standardised instruments and a central laboratory for measurement of lipids and glucose.

Settings The ASPIRE-2-PREVENT survey was undertaken in 19 randomly selected hospitals and 19 randomly selected general practices in 12 geographical regions in England, Northern Ireland, Wales and Scotland.

Patients In hospitals, 1474 consecutive patients with CHD were identified and 676 (25.6% women) were interviewed. In general practice, 943 people at high CVD risk were identified and 446 (46.5% women) were interviewed.

Results The prevalence of risk factors in patients with CHD and high-risk individuals was, respectively: smoking 14.1%, 13.3%; obesity 38%, 50.2%; not reaching physical activity target 83.3%, 85.4%; blood pressure ≥130/80 mm Hg (patients with CHD and self-reported diabetes) or ≥140/85 mm Hg (high-risk individuals) 46.9%, 51.3%; total cholesterol ≥4 mmol/l 52.6%, 78.7%; and diabetes 17.8%, 43.8%.

Conclusions The potential among patients with CHD and individuals at high risk of developing CVD in the UK to achieve the JBS2 lifestyle and risk factor targets is considerable. CVD prevention needs a comprehensive multidisciplinary approach, addressing all aspects of lifestyle and risk factor management. The challenge is to engage and motivate cardiologists, physicians and other health professionals to routinely practice high quality preventive cardiology in a healthcare system which must invest in prevention.

  • ASPIRE-2-PREVENT
  • coronary patients
  • high cardiovascular risk individuals
  • risk factor management
  • cardiovascular prevention
  • epidemiology
  • screening
  • prevention
  • secondary prevention, hypertension
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Introduction

The main objectives of cardiovascular disease (CVD) prevention in clinical practice are to reduce morbidity, improve quality of life and increase life expectancy. The Joint British Societies' CVD prevention guidelines for clinical practice, first published in 1998 (JBS1) and updated in 2005 (JBS2), defined the following priorities for cardiovascular prevention: (1) people with any form of established atherosclerotic CVD; (2) individuals without established atherosclerotic CVD but who have a combination of risk factors which puts them at high total risk (estimated multifactorial CVD risk ≥20% over 10 years) of developing atherosclerotic CVD for the first time; (3) people with diabetes mellitus (type 1 or 2).1 2

The first ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events) survey was carried out by the British Cardiac Society in 1994–5 in patients with coronary heart disease (CHD) from a stratified random sample of 12 specialist cardiac centres and 12 district general hospitals from 12 geographical areas in the UK.3 The results showed poor lifestyle and risk factor management in patients with established CHD. Previous national and multinational surveys conducted in Europe, the USA and other parts of the world had also reported a high prevalence and inadequate control of cardiovascular risk factors in patients with established CHD.4–7

There is a wealth of scientific evidence from randomised controlled trials and meta-analyses that lifestyle and risk factor management and use of cardioprotective medication can reduce the risk of future cardiovascular events and improve survival in patients with CHD and in those at high risk of developing CVD.8–28

The main objective of ASPIRE-2-PREVENT (A-2-P) was to determine in patients with established CHD and asymptomatic individuals at high risk of developing CVD (HRI) whether the JBS2 guidelines are being followed in everyday clinical practice.

Methods

Study design

A cross-sectional survey was undertaken of medical records, patient interviews and examinations using standardised instruments and a central laboratory for measurement of lipids and glucose.

Setting

The A-2-P survey was undertaken in a stratified random sample of hospitals and general practices. In 12 geographical regions (nine English health regions and one each in Northern Ireland, Wales and Scotland), a random sample of two hospitals (one specialist cardiac centre and one district general hospital) was identified from a national list of specialist cardiac centres (n=38) and district general hospitals (n=235). In addition, two Primary Care Trusts (PCTs) from each region were randomly drawn from a list of PCTs and three general practices with ≥4 full time general practitioner equivalents from each PCT were randomly selected. A total of 24 hospitals and 72 general practices were selected and invited to participate but, because of the low response rate, 14 more hospitals and 72 more general practices had to be randomly selected from the same geographical areas to obtain the sample size required.

Participants

Within each hospital, consecutive patients (men or women aged ≥18 years but <80 years at the time of diagnosis) with new or recurrent CHD were retrospectively identified from diagnostic registers, hospital discharge lists or other sources. Patients had to fulfil one or more of the following diagnostic criteria: (1) elective or emergency coronary artery bypass graft (CABG); (2) elective or emergency percutaneous coronary intervention (PCI); (3) acute myocardial infarction (AMI: ST elevation or non-ST elevation); (4) unstable angina; and (5) exertional angina.

Within each general practice, all men and women (aged ≥18 years but <80 years) without a history of coronary or other atherosclerotic disease who had been prescribed one or more of antihypertensive and/or lipid-lowering and/or antidiabetes treatments in the last 3 years were identified retrospectively from the general practice register.

The survey was approved by National Research Ethics Committee (REC reference number 08/H0301/33) and written informed consent was obtained from every participant.

Variables

The main outcome measures were the proportions of patients with CHD and HRI achieving at interview the lifestyle, risk factor and therapeutic targets defined in the JBS2 guidelines.

The definitions for risk factors were as follows:

  • Current smoking: self-reported smoking or carbon monoxide test ≥10 ppm.

  • Persistent smoking: smoking at interview as a proportion of those who reported smoking in month prior to recruiting event (patients with CHD) or at the start of medication (HRI).

  • Overweight: body mass index (BMI) ≥25 kg/m2 (non-Asian); BMI ≥23 kg/m2 (Asian).

  • Obesity: BMI ≥30 kg/m2 (non-Asian); BMI ≥25 kg/m2 (Asian).

  • Central obesity: waist circumference (WC) ≥102 cm (non-Asian men); WC ≥90 cm (Asian men); WC ≥88 cm (non-Asian women); WC ≥80 cm (Asian women).

  • Not at physical activity target: individual does not perform moderate/intense physical activity at least 30 min/5 times per week assessed by the Godin Leisure-Time Exercise Questionnaire.29

  • Elevated blood pressure: patients with CHD and self-reported patients with diabetes ≥130/80mm Hg; HRI ≥140/85 mm Hg.

  • Elevated total cholesterol (TC): ≥4 mmol/l and ≥5 mmol/l.

  • Elevated LDL-cholesterol (LDL-C): ≥2 mmol/l and ≥3 mmol/l.

  • Low HDL- cholesterol (HDL-C): <1.2 mmol/l (women); <1 mmol/l (men).

  • Elevated triglycerides (TG): fasting serum TG ≥1.7 mmol/l.

  • Newly diagnosed diabetes: fasting glucose ≥7.0 mmol/l among those with no self-reported diabetes.

In this study we assessed the proportions of patients who reported non-smoking, making healthy food choices and achieving physical activity, BMI, waist, blood pressure, lipids and glucose targets for CVD prevention at interview.

Data sources/measurements

Data collection was conducted by centrally trained nurses. They retrospectively reviewed all individual medical notes and interviewed and examined the patients at least 6 months and at most 3 years after (1) recruiting coronary event or procedure (in hospital) or (2) being prescribed antihypertensive, lipid-lowering or hypoglycaemic therapy (in general practice).

Information on personal and demographic details, family history of coronary or other atherosclerotic disease, reported medication and lifestyle advice in relation to smoking, diet, physical exercise, weight, blood pressure, lipids and diabetes was obtained at interview by administered questionnaire.

The following measurements were performed:

  • (a) Breath carbon monoxide was recorded in ppm (Micro+Smokerlyser, Bedfont Scientific, Kent, UK).

  • (b) Height and weight were measured in light indoor clothes without shoes using locally available measuring sticks and scales.

  • (c) Waist circumference was measured by metal tape measures midway between the lower rib margin and the iliac crest.

  • (d) Blood pressure was measured twice on the right upper arm in a sitting position after rest for at least 5 min using automatic digital sphygmomanometers (Omron M6; Omron Healthcare, Kyoto, Japan).

  • (e) Venous blood was drawn for serum total cholesterol, HDL-cholesterol (HDL-C), triglycerides (TG) and plasma glucose. Fasting time was recorded. LDL-cholesterol (LDL-C) was calculated using the Friedewald formula.

The central laboratory was the School of Clinical and Laboratory Sciences, Faculty of Medical and Human Sciences, University of Manchester, UK. Venous blood samples were transported to the laboratory within 24 h where all measurements were performed on a Cobas MIRA clinical chemistry analyser (Horiba-ABX, Shefford, UK). The following methods were used: CHOD-PAP method for measuring the serum total cholesterol; an enzymatic clearance method with reagents from Horiba ABX Diagnostics for direct measurement of serum HDL-cholesterol; GPO-PAP method for measuring serum triglycerides; glucose oxidase-PAP method for plasma glucose using reagents from Randox Laboratories (Crumlin, UK). The laboratory takes part in the Lipid Standardisation Program organised by CDC (Atlanta, Georgia, USA). During the course of the study the coefficient of variation (CV) (mean±SD) and systematic error (bias) (mean±SD) were 3.9±0.1 and 0.05±0.01 for TC, 4.2±0.2 and −0.04±0.01 for HDL-C, 4.4±0.2 and 0.09±0.02 for TG and 4.1±0.2 and 0.06±0.02 for glucose (all measurements in mmol/l).

Data management

Data management was undertaken by the Euro Heart Survey department of the European Society of Cardiology (Nice, France). All data were collected electronically using a unique identification number for country, centre and patient and were submitted via the internet. The data management centre checked the data for completeness, internal consistency and accuracy. All data were stored under the provisions of the UK Data Protection Regulations.

Statistical methods

Sample size calculations required a sample of 390 patients per subgroup attending interview to estimate the prevalence of single risk factors with a 95% CI of width 10%. The prevalence and associated 95% CI of lifestyle and risk factors changes made after the qualifying event (patients with CHD) or starting therapy (HRI) were calculated separately for patients with CHD and HRI. Differences between these two groups with associated CI were obtained with adjustment for age and sex performed by binomial regression. Where numbers were too small the Fisher exact test was used. Additional tables of results are available online only. All statistical analyses were undertaken using STATA V.11 (StataCorp LP).

Results

A random sample of 38 hospitals (20 specialist cardiac centres and 18 district general hospitals) and 144 general practices was drawn across the UK. A total of 19 (50%) hospitals (eight (40%) specialist cardiac centres and 11 (61%) district general hospitals) and 19 (13.2%) general practices participated. Figure 1 shows the flow of individuals through the recruitment process for both CHD and HRI groups and their demographic and diagnostic characteristics. Overall, 1522 hospital medical records were retrospectively identified of which 1474 patients with CHD were eligible for interview and 676 (25.6% women) were interviewed (participation rate 47.2% after excluding 43 patients who had moved away or died). Those who did not participate in the interview were younger and more likely to have had a PCI (see table 1 in online supplement). Patients were interviewed at a median interval of 13 (IQR 10–16) months after a clinical diagnosis of new or recurrent CHD.

Figure 1

Flow chart of patients with coronary heart disease and high-risk individuals (HRI) through all phases of data collection.

In the general practice arm, 943 HRI were retrospectively identified of whom 920 were eligible and 446 (47.5% women) were interviewed (participation rate 48.5% after excluding two participants who had died or moved away). In general practice, 39.0% of patients were enrolled because of antihypertensive therapy, 36.6% lipid-lowering therapy and 32.7% diabetes therapy but many patients were taking more than one class of treatments. Those who did not participate in the interview were younger, less likely to be prescribed antihypertensive therapy and more likely to be on lipid-lowering therapy (see table 1 in online supplement). Patients were interviewed at a median interval of 8 (IQR 4–12) months after the start of antihypertensive, lipid-lowering or glucose-lowering medication.

The reported lifestyle changes made by patients with CHD and HRI to reduce their risk of cardiovascular disease are shown in table 2 in the online supplement.

The prevalence of risk factors at interview is shown in table 1 and online supplementary figure 1. Overall, patients with CHD had better lifestyle and risk factor control than HRI. Although the prevalence of current smoking at interview was very similar in both groups, persistent smoking was significantly lower in patients with CHD. The proportions of patients who were overweight, obese, had elevated TC or LDL-C or with diabetes were significantly higher in the HRI group than in the CHD group. There were no significant differences between these two patient groups with regard to achieving physical activity and blood pressure targets.

Table 1

Prevalence of lifestyle and risk factors at interview

Table 2

Therapeutic control of blood pressure, cholesterol and glucose at interview

There was no evidence of any differences in the therapeutic control of blood pressure, cholesterol and glucose in those who were on blood pressure, lipid-lowering or diabetes medication, respectively (table 2), with the exception of the TC target of <4 mmol/l which was achieved by a significantly higher proportion of patients with CHD. The proportions of patients on antiplatelets, lipid-lowering medication, beta-blockers, ACE inhibitors and anticoagulants were all significantly higher in patients with CHD, while calcium channel blockers and diuretics were used more often in HRI (table 3).

Table 3

Cardioprotective drug therapies at interview

Discussion

The ASPIRE-2-PREVENT survey shows a large majority of patients with CND and HRI in the UK are still not achieving the lifestyle, risk factor and therapeutic targets set by the JBS2 guidelines on CVD prevention.2 Unhealthy lifestyles were associated with correspondingly high prevalences of obesity and central obesity, inadequate blood pressure, cholesterol and glucose control, and these disappointing results are consistent with comparable survey data from other European countries.4–7 Patients with CHD tended to make greater efforts to achieve a healthier lifestyle, particularly for smoking cessation, but therapeutic control of blood pressure, lipids and diabetes was similar with the exception of the TC target of <4.0 mmol/l which was achieved in a higher proportion of patients with CHD.

About half of the patients with CHD who were smoking at the time of their diagnosis were still smoking at interview and persistent smoking in HRI was substantially higher. A meta-analysis of smoking cessation after a myocardial infarction shows that those who stop smoking have a 46% reduction in risk of coronary mortality compared with those who continue to smoke,8 yet only one-fifth of current smokers attended a smoking cessation clinic following their event. Encouragingly, pharmacological support was used in nearly half the patients with CHD who were current smokers, almost entirely nicotine replacement therapy, with only a very small proportion using other evidence-based therapies. In HRI the use of nicotine replacement therapy was similar to that of patients with CHD.

A large majority of patients self-reported changes to their diet and increasing physical activity levels to reduce their risk of heart disease. In an observational analysis of contemporary patients with acute coronary syndrome optimally managed therapeutically, those receiving a combined dietary and physical activity intervention had a substantial reduction in the subsequent risk of recurrent myocardial infarction, stroke and coronary death.9 Similar observational data in medically treated HRI demonstrates the benefits of a healthy lifestyle score on the subsequent risk of myocardial infarction, in addition to the benefits of drug therapies.10

A large majority of patients were overweight or obese and most were also centrally obese, yet about one in three had not taken any action to lose weight. Weight loss is associated with a significant reduction in acute cardiovascular events in patients with CHD participating in cardiac rehabilitation.11

Blood pressure control was far from optimal with nearly half of the CHD and HRI groups not reaching the blood pressure target of <140/85 mm Hg (<130/80 mm Hg in patients with coronary disease and diabetes mellitus) at the time of interview. Meta-analyses of randomised controlled trials have shown that blood pressure reduction in hypertensive subjects substantially reduces CVD morbidity and mortality.12–14

Overall, about half of the patients with CHD and four-fifths of the HRI group had total and LDL cholesterol above the recommended targets of <4.0 mmol/l and <2 mmol/l, respectively. Meta-analyses show that cholesterol reduction, mainly with statins, reduces cardiovascular morbidity and mortality and prolongs survival in both patients with established CHD and in asymptomatic individuals at high risk of developing atherosclerotic disease.15–18

About one-fifth of patients with CHD and more than two-fifths of HRI had self-reported or newly diagnosed diabetes. Glucose control in patients with previously diagnosed diabetes was poor. Just one in three of patients with CHD and HRI with self-reported diabetes achieved the glucose target of ≤6.0 mmol/l. The long-term prognosis after myocardial infarction, unstable angina, CABG and PCI is worse in diabetic patients than in non-diabetic patients.19 20

Overall, cardioprotective drugs were more commonly prescribed in patients with CHD than in HRI. More than nine of 10 patients with CHD were on antiplatelets/P2Y12 inhibitors, antihypertensive or lipid-lowering medications (almost entirely statins). Less than one-third of HRI reported taking aspirin or other antiplatelet drugs and, given the recent meta-analysis of aspirin in primary prevention, this is likely to fall substantially.21 In view of the poorer control of lipids in HRI compared with patients with CHD, the use of lipid-lowering medications is too low. One reason for not reaching the blood pressure and lipid targets in high-risk patients is that general practitioners may be using the Quality Outcomes Framework audit targets of a blood pressure of <150/90 mm Hg and a total cholesterol target of <5.0 mmol/l.22 The evidence from randomised controlled trials has demonstrated benefit from treatment below these audit levels. Remuneration for achieving audit standards should not be confused with the need for optimal preventive care.2

A comparison with the first ASPIRE survey of patients with CHD shows that the prevalence of smoking has decreased from 19.0% in the first survey to 14.1% in the second survey. However, the prevalence of overweight and obesity both increased, from 72.0% and 27.9% in the first survey to 78.4% and 38.0%, respectively, in the second survey. This reflects similar trends in the general population and contributes to the prevalence of other risk factors such as raised blood pressure, dyslipidaemia and diabetes. The comparison of blood pressure and cholesterol management should be interpreted with caution due to the differences in blood pressure measuring devices and central laboratories in the two surveys and different risk factor targets in JBS1 and JBS2. In ASPIRE, elevated blood pressure was defined as systolic (SBP) ≥160 mm Hg and diastolic (DBP) ≥90 mm Hg and 17.5% and 26.4% of patients with CHD were above these respective targets. The JBS2 guidelines recommended a lower blood pressure target of <130/80 mm Hg in patients with established atherosclerotic disease, yet 18.3% of patients with CHD in this second survey had SBP ≥160 mm Hg and 19.2% had DBP ≥90 mm Hg. However, there has been a substantial improvement in TC management with the proportion of patients with cholesterol ≥5 mmol/l decreasing substantially from 82.0% in the first survey to 16.3% in the second survey, almost entirely because of statins. The use of other cardioprotective drug therapies (antiplatelets, beta-blockers, ACE inhibitors) also increased in the second survey.

Strengths and limitations of the study

The findings of this survey must be considered within the context of the study strengths and limitations. An important strength of the A-2-P survey is that participating centres were randomly selected from a geographically stratified sample of hospitals and general practices in order to obtain a representative sample of UK clinical practice. However, in contrast to the first ASPIRE survey of patients with CHD where 79% of hospitals participated, only about half did so in A-2-P with district general hospitals having a higher participation rate than specialist cardiac centres. The participation of general practices was even lower at 13.2%. There was no primary care arm in the first ASPIRE survey. In addition, only about half of eligible patients with CHD and HRI came to interview compared with a response rate of 83% in the original ASPIRE survey. The A-2-P results are therefore potentially biased because of low participation rates by centres, especially in general practice, and low response rates of both groups of patients. However, it is likely that participating centres will be biased towards better care, and patient responders will have a better lifestyle and risk factor profile than non-responders. These biases will therefore result in a more optimistic picture of risk factor management than the everyday reality of clinical practice.

An important strength of this survey is that data collection was not just based on medical record information but also on face-to-face interviews and examinations using the same protocol and standardised methods and instruments, including central laboratory analyses of lipids and glucose.

The results of the A-2-P survey demonstrate some real improvements compared with the first survey, especially for lipids, but there is a continuing gap between the current guidelines and everyday clinical practice. There is a wealth of scientific evidence that cardiac rehabilitation and secondary prevention programmes of patients with CHD, with or without exercise, reduce both cardiac and total mortality.23–25 In primary prevention the principle of total CVD risk assessment is embodied in the form of health checks as recommended by the Department of Health,26 but the evidence from randomised controlled trials for multifactorial programmes is less compelling.27 However, the recent EUROACTION trial has shown that it is possible to achieve a higher standard of preventive care for patients with CHD and HRI and their families with a nurse-led multidisciplinary comprehensive preventive cardiology programme.28 We need such programmes for both patients with atherosclerotic vascular disease and those at high risk of developing this disease. The MyAction programme for the NHS is an innovative development which integrates secondary and primary prevention in a community setting and addresses all aspects of lifestyle through a behavioural approach in families, together with more effective management of blood pressure, lipids and glucose.30 The challenge is to engage and motivate cardiologists, physicians and health professionals to routinely practice high quality preventive cardiology in a healthcare system which invests in prevention.

Key messages

  • A large majority of patients with coronary heart disease and those at high risk of developing cardiovascular disease (CVD) in the UK do not achieve the lifestyle, risk factor and therapeutic targets.

  • CVD prevention needs a comprehensive multidisciplinary approach, addressing all aspects of lifestyle and risk factor management.

  • The challenge is to engage and motivate cardiologists, physicians and other health professionals to routinely practice high quality preventive cardiology in a healthcare system which is increasingly investing in prevention.

Acknowledgments

The ASPIRE-2-PREVENT Study Group is grateful to all the hospitals and general practices in which the study was carried out. Their administrative staff, physicians, nurses and other personnel helped us in many ways and we very much appreciate this (see Appendix available online only). We are also grateful to all the patients who participated in the study.

References

View Abstract

Supplementary materials

Footnotes

  • Funding The ASPIRE-2-PREVENT survey was supported by Merck Sharp & Dohme (MSD) with an unrestricted educational grant to Imperial College London and is part of a wider international survey called DYSIS (Dyslipidaemia International Survey). The sponsor had no role in the ASPIRE-2-PREVENT design, data collection, data analysis, data interpretation and writing of this report. The authors had full access to all data and had final responsibility for the decision to submit the manuscript for publication.

  • Competing interests DW serves on a Merck Sharp & Dohme Steering Committee for DYSIS and has received unrestricted research grants from MSD to Imperial College. KK and CSJ are employed by Imperial College. All other authors declare that they have no conflict of interest with regard to the work submitted for publication.

  • Ethics approval Ethics approval was obtained from Essex 1 Research Ethics Committee (REC: 08/H0301/33).

  • Provenance and peer review Not commissioned; internally peer reviewed.

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