Dr Breda Smyth from the HSE’s Health and Wellbeing Programme addressed the recent NIPC conference on the challenges of CVD prevention in Ireland. She said inequality plays a huge part in terms of risk for chronic disease. Those from lower social classes have a higher risk of disease, and are five times more likely to die from cardiovascular diseases than higher social classes. 

Risk factors overlap for chronic diseases and we need to take a common approach to primary, secondary and tertiary prevention, Dr Smyth said.

“There is no easy solution. We need a top-down approach and a bottom-up approach involving the whole population and our governments and interest groups so they drive initiatives and make them more feasible and achievable.”

She highlighted how the Government’s Future Health strategy document outlines the health and wellbeing of our population as one of the four pillars for reform.

“It outlines that we need good leadership and governance, and partnership. We need to empower people and communities and we need good research and evidence to inform ourselves so we can achieve good health and wellbeing in our population.”

In addition, the Healthy Ireland document, published by the Government recently, is a framework for improved health and wellbeing for the population from 2013-25.

The two reports point to a renewed focus at national and service-wide levels on chronic disease prevention and improved health and wellbeing, including reducing health inequalities, Dr Smyth said.

“Every time we meet a patient it is very important that we address their lifestyle risk factors and talk to them in a way that they understand, not in medical jargon.”

Dr Smyth pointed out that health services have the potential to bankrupt countries, because of increasing age of populations and increasing levels of chronic disease. 

“We need to empower patients so they are aware of their conditions, and increase their awareness of what they can do to manage those conditions, and tackle their lifestyle risk factors.

“If we could move the agenda towards prevention and away from treatment we could perhaps get a better balance in the distribution of health spending.

“We need to reorient our health service from our current delivery system, which is fragmented and focused on episodic care, to a more integrated service, where care is centred on the needs of the patient but also focuses on wellness, prevention and chronic care management,” Dr Smyth said.

Pessimism about targets

Prof David Wood, cardiologist and president-elect of the World Heart Federation, told the conference he would be very pessimistic about the target to halve the global burden of CVD in the next 25 years. 

“The world burden of non-communicable diseases is being exacerbated. It is countries with large populations such as Brazil and India and China that are going through the epidemiological transition and adopting increasingly westernised habits in terms of lifestyle that are driving the overall burden of non-communicable diseases worldwide,” he said.

The WHO was recently charged with developing a global strategy for prevention of non-communicable diseases. Ministers of Health internationally set nine targets, starting with reducing mortality and also including lifestyle, risk factor and therapeutic targets.

These included a 30% reduction in prevalence of current tobacco use in people 15 and over, a 10% relative reduction of insufficient physical activity and a 30% relative in the mean population intake of salt.

Many of the targets, Dr Wood said represent a compromise and may therefore not be regarded as aggressive enough. The risk factor targets are a relative reduction in the prevalence of raised BP; and to halt the rise in diabetes and obesity.

He said whatever view one takes about these targets and what has been omitted, it nonetheless represents an important starting point for worldwide prevention of non-communicable diseases.

The WHO in 2013 published an action plan and the vision of a world free from the burden of non-communicable diseases. This plan contains a number of objectives.

It called on Ministers of Health to develop an action plan for every country - and this has been developed in Ireland.

The action plan, said Dr Wood, called for strengthening of international cooperation, to strengthen national capacity and to reduce exposure to modifiable risk factors through creation of health promoting environments- ‘a big political ask’. 

National societies of cardiology and other professional organisations who are stakeholders in prevention should join forces and be advocates for national policies on issue such as tobacco control, food production and marketing.

Another objective is to strengthen health systems to reorient them toward prevention. “Much of our health budget is spent on the acute management of disease with a small proportion devoted to prevention and this needs to change. Again, national societies have a role to play here.”

“We need to educate and train health professionals in CVD prevention and we need to reorient health systems towards preventive cardiology care.”

Prof Wood said a good example of the reorientation of care for prevention of heart attacks and strokes was the EurAction demonstration project in preventive cardiology. This project in eight countries in 24 centres evaluated a nurse-led MDT programme in prevention.

The results showed that the proportion of patients achieving the European targets for a healthy diet were significantly better in the Euraction programme compared to other settings in terms of saturated fat intake, fruit/veg, and oily fish consumption, including for high risk patients in primary care. The Euraction programme was also more successful in terms of physical activity compared to usual care.

It was this European programme which led to the conception of the successful  MyAction community programme by Croi.

On cardiac rehabilitation, Prof Wood said we should be aiming for 90% of patients having access to prevention and rehabilitation programmes.  He said general practice needs to be looked on as the main deliverer of preventive CVD care.

Problems with implementation

Prof Ian Graham, chair of the Council on CVD prevention with the Irish Heart Foundation, highlighted problems with implementation of CVD prevention guidelines. 

“CVD prevention is a major challenge, particularly in developing countries, where CVD death rates are rising rapidly, as we have transported the Western way of death to other parts of the world.

“The explosion in chronic disease is linked in part to an increasingly ageing population, with the number of over 65s in our population set to double over the next 30 years. While Ireland’s CVD mortality rates have decreased in recent years, there are 8,000 deaths due to CVD per year in Ireland; it is still the biggest cause of death in men and women.”

He said our decrease in CVD deaths since the mid-1980s has been mostly related to risk factor reductions (60%) followed by therapy (40%). However, on the downside, the risk factors of obesity and diabetes are spiralling. 

Prof Graham said underlying atherosclerosis develops slowly, but is usually advanced by the time symptoms emerge; most deaths occur rapidly, before treatment is available. Therefore, treatments are often inapplicable (because the patient is already dead), or palliative, because the disease is too advanced to be reversed. 

“Most CVD, it should be remembered, occurs in apparently healthy people with modest elevations of several risk factors.”

Yet, Prof Graham said, the major causes of CVD are known and there is irrefutable evidence that effective risk factor control reduces CVD mortality.

“Statistics show that most CVD events tend to happen in people with slightly high blood pressure, as there are much more of them; therefore a high risk prevention strategy on its own will fail.”

He outlined the main focus of the latest ESC guidelines, which set specific targets for smoking, diet, BMI, BP, lipids and diabetes. Prof Graham said guidelines, while useful, are a waste of time unless they are implemented properly. “Guidelines are good for the vanity of the authors and bad for rain forests if they are not implemented properly through a defined implementation strategy.”

Key barriers to implementation of guidelines include lack of patient compliance, lack of time, lack of health budget, lack of clarity and lack of Government support.

Prof Graham said Ireland’s outcomes were quite good, but we score badly on waiting times and patient rights and information. He said he believed there had not been significant engagement between Government, HSE, professional bodies and other interested organisations on the implementation of guidelines and recommendations on CVD prevention. However, he believed there were some positive things happening in terms of recommendations and initiatives in the CVD area.