How should we reduce deaths from ischemic heart disease? At the XVIIIth Congress of the European Society of Cardiology, the most radical proposal was for a general redistribution of income to narrow the gap between richest and poorest—the example before us being Japan, with its low rate of heart disease. This idea generated barely a flicker of interest. In Europe, as in the United States, most cardiologists have decided that their preventive activities should be focused on patients and their families; population aspects are for others to deal with. But even at patient level, the average physician offers scant support on matters such as diet, exercise, and smoking. Acute interventions generate more enthusiasm, and the presentation that caused the biggest stir at the Congress was a report from Dr Arthur J. Moss (University of Rochester Medical Center, Rochester, NY) on the Multicenter Automatic Defibrillator Implantation Trial.
MADIT is the first large randomized study comparing implantable cardioverter-defibrillators (ICDs) with conventional medical treatment. All the patients had had myocardial infarction and were at high risk of sudden cardiac death as judged by clinical features and electrophysiological testing—inducibility of monomorphic ventricular tachycardia not suppressible by standard agents. Randomization was to ICD (CPI/Guidant) or conventional treatment, usually amiodarone. The investigators used sequential analysis, and the trial was stopped after recruitment of 196 patients, when there was a clear advantage for the ICD group—only 15 of 95 had died, compared with 39 of 101 on conventional therapy (a 54% reduction in all-cause mortality).
Extrapolating from these results, Dr Moss estimated that about 10% of myocardial infarction survivors might benefit from implantation of a defibrillator—80 000 per year in the United States alone, to say nothing of the million or so who have had infarcts in the past. The current price of an ICD is about $100 000.
After multiplying these numbers, we might reflect anew on less costly means of postponing death. In 1994, a European task force1 issued guidelines for secondary prevention, and the 1996 recommendations of an American group, at the 23rd Bethesda Conference,2 are closely similar. How well are European physicians performing in secondary prevention? At the congress, Dr David Wood, of the Royal Brompton Hospital, London, UK, reported the results of EuroASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events), a 10-country study of day-to-day practice. The investigators secured the case notes of more than 7400 patients treated in-hospital for coronary heart disease and saw 5551 of the patients 6 months after discharge. At that time, 53% had mild or moderate hypertension (systolic >140, diastolic >90 mm Hg), 44% were hypercholesterolemic (serum cholesterol >5.5 mmol/L), and 20% were still smoking; 86% were taking aspirin but only 54% a β-blocker and 32% a lipid-lowering agent; just 1 in 5 had been advised to have the family screened for risk factors. In the words of Dr Kalevi Pyo¨ra¨la¨ (University of Kuopio, and principal investigator in Finland), “We aren't doing what is necessary.”
Failure to apply secondary prevention is not a uniquely European phenomenon. For example, a task force at the 23rd Bethesda Conference estimated that aspirin was used in just 70% of myocardial infarction survivors, β-blockers in 40%, and lipid-lowering drugs in 25%. Everywhere cardiologists recognize that motivation of patients demands supplementary skills, and many have set up clinics where physicians, special nurses, nutritionists, and others offer a multifactorial approach. In Sweden, a more ambitious scheme is soon to be under way in which motivation acts in reverse. In that country, almost half of all health districts already have programs of shared care between cardiologists and primary care physicians, and Dr L. Erhardt (Malmo¨ University Hospital) described to the congress a project to be launched by the Swedish Societies of Cardiology and Family Medicine. Every patient treated in-hospital for a coronary event will receive a booklet listing all relevant risk factors, will decide with the physician on targets for modification (blood pressure, cholesterol, body weight, smoking, etc), will monitor the results, and will send these personal data regularly to a central computer. Part of the aim is to determine the quality of secondary care in the health system as a whole. More important, the scheme is meant to give patients control over their medical care and generate demand for good services. Perhaps only Scandinavians could succeed in a scheme that involves reporting to a central database, but the other element, self-motivation, should be applicable everywhere. As in primary prevention, bottom-up is likely to work better than top-down.
- Copyright © 1996 by American Heart Association
Pyo¨ra¨la¨ K, De Backer G, Graham I, Poole-Wilson P, Wood D, on Behalf of the Task Force. Prevention of coronary heart disease in clinical practice: recommendations of the Task Force of the European Society of Cardiology, European Atherosclerosis Society and European Society of Hypertension. Eur Heart J.. 1994;15:1300-1331.