New, clearer CVD guidelines

The latest ESC guidelines¹ on cardiovascular disease prevention launched in Dublin recently should prove easier to understand, with a new approach to medical evidence and more emphasis on the importance of patient behavioural change.

These guidelines are the gold standard for Europe and these are the fifth such recommendations. The ESC guidelines have had a direct impact on practice in Ireland, with the third guidelines used as the reference point for Heartwatch, the major secondary prevention programme implemented by the ICGP.

The recommendations launched at EuroPRevent 2012 held in Dublin have been overhauled. The intention was to produce a user-friendly document with concise messages. Greater weight than before has been given to evidence from clinical trials and observational population studies.

Speakers at the launch indicated that the guidelines have been becoming more and more complex and difficult to grasp for medical professionals so steps had to be taken to simplify them. The latest document is one-third shorter than the previous edition.

The guidelines were developed by the Fifth Joint Task Force (JTF) of societies of Cardiovascular Disease Prevention in Clinical Practice, which includes the European Society of Cardiology (ESC) and seven other societies. 

In a radical departure, the Task Force that drew up the guidelines has for the first time introduced the Grading of Recommendations Assessment Development and Evaluation (GRADE) system for assessing medical evidence. This gives increased weight to population studies.

This is in addition to the traditional approach, applied by the ESC in all its guidelines. This approach awards recommendations different classes (I, IIa, IIb, or III) according to the type of trial from where the evidence has been obtained. The GRADE system, developed by the British Medical Journal, takes into account more dimensions than just the quality of the medical evidence. 

The system considers factors such as the degree of uncertainty about the balance of benefits and harms of the intervention, and whether the intervention is a wise use of resources. It allows clear separation between the quality of evidence and strength of the recommendations.

“The traditional approach for grading the quality of the evidence gives predominance to randomised controlled trials (RCTs). This is good science but carries a problem in that drug trials will always outscore lifestyle measures because it’s easy to do RCTs of cholesterol and blood pressure drugs, but hard to do RCTs of smoking cessation or other lifestyle changes,” said Prof Ian Graham, TCD, chairperson of the EACPR Prevention Implementation Committee, and co-chairperson of the EuroPRevent 2012 Programme Committee.
He has also been on the ESC Task Group for many years.

“The GRADE system only uses two categories of recommendation – strong or weak. This encompasses strong recommendations to do something, strong recommendations not to do something, and weak recommendations. The implications of a strong recommendation are that most informed patients would choose the recommended intervention; whereas for weak recommendations some patients would want the intervention, but many would not. 

Getting the message across

“It’s hoped that the GRADE system will allow much clearer interpretation of guidelines by clinicians, patients and policy makers,” Prof Graham said. 

“In the past, implementation of prevention guidelines could undoubtedly have been better”, added Prof Joep Perk, Linnaeus University, Sweden, the Task Force chairperson.

“The change is to help disseminate the information from the guidelines out to where it’s needed – health professionals working in the field, politicians and the general public. We’ve gone back to the first principles of teaching by introducing the what, why, whom, how and where of preventive cardiology,” said Prof Perk.

“The guidelines stress that CVD prevention should be a lifelong effort that starts in the womb and lasts to the end of life. Greater emphasis has been placed on the behavioural aspects of prevention, with discussion of ways to make it easier for patients to change their lifestyles.

The guidelines were launched at the EuroPRevent 2012 meeting in Dublin in May and published simultaneously in the European Heart Journal and European Journal of Preventive Cardiology.

“This was deliberate. It has meant that we could structure the meeting in Dublin around the guidelines with plenty of opportunities for wide-ranging discussions that allow everyone to get up to speed,” explained Prof Graham. 

Special guideline sessions were organised for GPs and practice nurses, with additional training sessions to advise the national co-ordinators, who have been specially appointed from the different European countries, on implementing the guidelines. These sessions focused on how to engage with politicians, the profession and the public.

An electronic, interactive Guideline Learning Tool was launched at the conference. 

“We’re really excited about this because it will allow doctors, students and other healthcare professionals to engage interactively with the guidelines through case histories and other new learning techniques,” said Prof Graham. 

In addition, pocket guidelines, an A4 page with all the essential information and a slide-set for teaching purposes are in development. 

“Our ultimate aim is to get an A4 summary of the guidelines on the desk of every single family doctor in Europe. It will be the bible of health prevention,” said Prof Perk.

The latest guidelines highlight the overwhelming need to promote CVD prevention. This is underlined by grim statistics showing CVD to be the leading cause of premature death worldwide. Each year in Europe over 4.3 million people will die of CVD, according to the European Heart Network. 

Of all the deaths occurring before the age of 75 years, CVD is estimated to be responsible for 42% of deaths in women and 38% in men. But the vast majority of these deaths might have been prevented through the widespread adoption of simple interventions such as smoking cessation, improved diets and increased exercise. 

Most heart attacks could be prevented

Evidence that CVD is caused by modifiable risk factors and is preventable comes from clinical trials and observational community studies. For instance, in the INTERHEART study,² a case-controlled study comparing the lifestyles of around 15,000 patients who had suffered an acute MI and 15,000 controls, it was found that nine modifiable risk factors accounted for 90% of the attributable risk in men and 94% in women.

The risk factors were dyslipidaemia, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors and alcohol consumption. Lack of consumption of fruits, vegetables, and physical activity were also factors.

“The INTERHEART study results suggest that 90% of heart attacks worldwide may be prevented and that the majority of heart attacks are a direct result of the personal lifestyle choices made by individuals,” said Professor Guy De Backer, Ghent University, Belgium, a member of the Task Force. 

“But the good news is that it’s never too late for people to make modifications to lifestyle, even after they’ve suffered an event.”

Evidence for this comes from a 2010 study published in Circulation³ where Clara Chow and colleagues asked 19,000 patients who had undergone PCI after MI questions about lifestyle. The study, which took place in 41 countries, showed that patients who continued to smoke and did not adhere to diet and exercise regimens were 3.8 times more likely to suffer an MI, stroke, or death within six months than non-smokers who modified diet and increased exercise. Both groups complied with their medications. 

“The challenge for CVD guidelines lies in translating this evidence into effective preventive care, and in persuading the public to lead healthy lifestyles,” said Prof De Backer.

The 2012 guidelines explore wide ranging issues such as total CV risk estimation, diseases with increased risk for CVD, methods of CVD prevention, smoking cessation interventions, dietary habits, physical activity, psychosocial factors, body weight, blood pressure, type 2 diabetes,  lipids,  and anti-thrombotic therapies. 

Increased emphasis has been placed on the principles of behavioural change, with a section exploring why patients do not adhere to medications. Each section has been clearly signposted including the key messages and recommendations, the most important new information, and the remaining gaps in evidence. “This section is intended for researchers seeking inspiration,” explains Prof Perk.

A new addition is the “where” chapter that looks at prevention in different healthcare settings, and explores the contributions of nurse co-ordinated prevention programmes, family doctors, cardiologists working in general practice and specialised hospital based rehabilitation services.

New for legislative change

The final chapter focuses on the ‘new era’ of political engagement in preventive cardiology, showing how in addition to clinical prevention activities, healthcare professionals should extend their remit to include political lobbying activities that influence healthy behaviour in the wider population. 

“Although we’ve already made gains at the clinical level to have a really big impact on CVD, we need to engage politicians. Changing human behaviour is a political issue,” said Prof Perk. 

“We need to create a healthier environment and this requires changes in the law, such as reducing the amount of salt and trans fatty acids in food, providing more cycle lanes and getting school curriculums to include more movement.” 

References

1. The Fifth Joint Task Force. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (version 2012). EHJ 2012, doi:10.1093/eurheartj/ehs092
2. Yusuf S, Hawken S, Ounpu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952
3. Chow CK et al. Association of diet, exercise and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010:121: 750-758