According to the EuroPRevent Conference 2012, which took place in Dublin recently,  Ireland is now reaching the average EU cardiovascular disease (CVD) mortality rate. Ireland had the highest trend of mortality in the 1990s, with alcohol consumption being one of the key factors for CVD. 

Despite major reductions in many countries, CVD remains the main cause of death in Europe and indeed worldwide. The new ESC Guidelines (Joint European Guidelines on the Prevention of CVD) were launched at the conference with the focus being on new risk factor targets as well as new approaches to risk estimation (including risk age) and management. 

“But guidelines are of little use unless implemented,” said Prof Ian Graham, consultant cardiologist and local host at the Conference. “The primary determinants of disease are mainly economic and social, and therefore the remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.”

Minister of State with Responsibility for Primary Care, Roisín Shortall, opened the Prevention Measures Lecture on Ireland Day, the first day of EuroPRevent, setting out the health policies which are currently underway in the Department of Health. 

Government practice

The main focus for the Irish government in terms of healthcare is the need to move from medical curative care to patient self-maintenance. The Government is implementing the Health is your Wealth Policy 2012-2020 to create specific awareness on the importance of heart health. Schemes such as electronic patient information systems and chronic care systems (eg. diabetes and CVD) will be made available to GPs. 

The policy framework will be Ireland’s vision for a healthier population that is protected from public health threats, living in a healthier and more sustainable environment, with increased social and economic productivity and greater social inclusion. 

According to Minister Shortall, this policy will identify practical ways to strengthen cooperation between sectors to promote and protect the health and wellbeing of all sectors in our society. 

It supports ways to keep children healthy; ensure a healthier workforce; and contribute to positive ageing and a greater participation of those with disabilities and mental health issues in society. 

It promotes healthier lifestyles as well as improving the environment where we live and work, addresses the emergence of risk factors and aims to reduce chronic diseases and their burden to families and society. 

The framework policy highlights the achievements of public health policies to date, such as reducing the mortality and morbidity from communicable diseases through vaccination, providing clean water and air, providing safer food, and control of tobacco in workplaces. 

In addition, the framework summarises the growing evidence that supports a public health approach to improving health, and the economic and societal benefits of prevention and early intervention. It also sets out how the public health function will operate over the coming years in order to achieve these goals. 

A working group, chaired by the chief medical officer of the Department of Health has been set up to review and assess the current state of public health in Ireland and internationally.¹

“The plans to introduce free GP care for all by 2015, and universal health insurance the following year, are going ‘full steam ahead’ also as part of the Government’s focus on promoting a healthier Ireland,” Minister Shortall said.

Update on patterns of mortality and morbidity

Continuing with the focus on promoting a healthier Ireland, Dr Siobhan Jennings, consultant in public health medicine, HSE and lead in the Chronic Disease Prevention Programme, presented the varying and worrying trends in CVD mortality rates in Ireland. 

In a recent CVD study of the UK, Ireland and Finland, there was the positive news that mortality rates have greatly decreased since 2005. The rates of MI have also declined as have the rates of ST segment elevation on myocardial infarction (STEMI) patients attending hospital – in 1997 there were approximately 4,000 STEMI patients while in 2012 there were approximately 2,000.

Unfortunately, the number of non-ST segment elevation on myocardial infarction (NSTEMI) patients has increased and the number of stroke cases is increasing also. Out-of-hospital cardiac arrest patients are at a 6.4% rate of survival but only 28% of those who survive are independent of care. Disabilities and overall dependency on carers after cardiac arrest and stroke are on the increase.

The number of prescription drugs for CVD available for the GMS population is on the increase, with the exception of diuretics. 

There was an improvement in CVD rates in Ireland in the early 21st century compared to the 1990s but there has also been a levelling off  since 2005. This means the CVD rates are beginning to rise steadily again and with the high number of our ageing population continuing to increase in Ireland this, in turn, means the incidence of CVD will significantly increase also.

Age-related risk factors

The trends in risk factors in the middle and older years should be examined, says Prof Rose Anne Kenny, consultant in geriatric medicine at St James’s Hospital. “When we think about that in 2030 there will be a 400% increase in those over 100 years old, we understand how important it is to analyse what is occurring now to prevent what will be serious consequences in the future. 

“If we look at the over-80 category in terms of atrial fibrillation, 10.3% of those 80 and over have AF; 19.7% of men over-80 in Ireland have AF; 4.7% of women over-80 have AF; 38.1% of AF patients are undiagnosed; and 2.9% of adults over-50 in Ireland have AF. This translates into 34,771 people in Ireland having AF. These are important statistics because AF is a major risk factor for CVD, Alzheimer’s disease and stroke. As it stands, stroke costs are totalling e500-900 million annually and if the rates of AF continue, these figures will rise significantly.

From these statistics we can see that in 2041 there will be a much higher prevalence of AF because at the moment there is a high portion of AF patients in Ireland who are inappropriately treated or unaware of their condition,” said Prof Kenny.

The Irish LongituDinal Study on Ageing (TILDA) launched in 2008, is the first data on AF prevalence in Ireland.² The research is divided into waves, with the aim to determine the health status and needs of older people (see Table 1).³ The team is working with bioengineers to develop self-help tools for patients to monitor their symptoms or manage their AF conditions. 

The electrocardiogram (ECG) has been shown through the research to improve treatment and prevent strokes. The study has already shown that 50% of people who have hypertension are unaware that they have high blood pressure. If by 2030 one in five people will be 65 years and older in this country, the challenges are there to “prepare for successful population ageing and to ensure that some of the lessons learned in societies that aged at an earlier stage are taken on board here – but to do this we urgently require accurate and representative health and socio-economic data.

Causal factors in middle-age Ireland

Over 90% of middle-aged Ireland have more than three serious risk factors which attribute to CVD. Obesity, hypertension, and hypercholesterolaemia are just some of these risk factors. Smoking, alcohol intake (11.9l on average per person in 2010), diet, saturated fat intake, gene markers and calorie excess are also contributors with men being the least healthy of the sexes, the conference was told. 

Between 2002 and 2007 alone, the mortality rate for circulatory systems diseases such as heart attack and stroke decreased by 25%. There are also new service developments including chest pain clinics, enhanced pre-hospital care and cardiac rehabilitation across the country. 

However, looking at the Slán study of 2007, which focused on the lifestyles of 10,364 adults from 400 clusters nationally, Prof Ivan Perry, professor of public health and head of the Department of Epidemiology and Public Health, University College Cork, said that since the survey was conducted, diabetes and obesity have been increasing at alarming rates because of middle-aged Ireland’s daily lifestyle. 

“In 2010, 36.5% of men in Ireland were obese while 29.2% of women were obese. This is not surprising according to the Slán survey because in 2007 in relation to body weight, 39% of those examined (ages 18+) were medically overweight with a further 25% classified as obese. 

“If the average child is consuming 4kg of salt a year now, this will lead to a major increase in chronic disease such CVD and diabetes cases will only get higher,” he said.

The Special Action Group on Obesity (SAGO) will be targeting these issues to promote healthy eating guidelines and revise the food pyramid; restrict food marketing for children; encouraging calorie posting on fast food outlet menus; and enforcing nutritional labelling signs, says Dr John Devlin, Department of Health.

“The main steps which need to be taken for a positive future are ongoing public debates; development of action plans; and focusing on wellbeing and health policies,” he said.

Points of action for primary care

The Changing Cardiovascular Health: National Cardiovascular Health Policy 2010-2019 was launched to develop a policy framework for the prevention, detection and treatment of cardiovascular diseases, including stroke, which would ensure an integrated and quality assured approach in their management.

The policy, structure and recommendations of the Cardiovascular Health Policy were presented by Professor Hannah McGee, chair of the Department of Psychology at the Royal College of Surgeons in Ireland (RCSI) and founding director of the RCSI’s Health Services Research Centre. 

• The main 10-year targets of the policy are:
• To reduce smoking by 1% annually
• To reduce salt consumption by 16%
• To bring alcohol consumption down from 11.9l to 9.2l per person
• Emphasis on healthy body weight.

“Bringing primary care into the fold as a major factor in public awareness is essential and is an opportunity for GPs to apply a chronic disease management strategy. Those who go to secondary care health professionals for help are actually healthier than those who don’t. This is why risk identification management begins with GPs. 

“Stroke prevention, heart failure management, clinical management for stroke, cardiac rehabilitation and monitoring should be adapted into step-down strategies for hospitals to primary care services. This means that patients can be referred and monitored early on to prevent more serious problems arising when referred to secondary care.

“The report’s key areas of success will be the clinical programmes for heart failure and stroke, while the challenges will be overall prevention. Patients will be assessed individually and a risk factor profile should be monitored. 

“An overall Cardiovascular Health Policy Monitoring Group has been established with a full format review planned at five years (2015),” Prof McGee said.

The primary care section of the report focuses on prevention of stroke in primary care; peripheral arterial disease; prevention of CVD in those with diabetes mellitus and management of high risk in established disease. Multidisciplinary teams should facilitate shared care strategies which will promote a continuity of care where patients are educated in treatment, management, expected outcomes and follow-up support. 

“The idea would be that the cycle of chronic disease management should go in tandem with ongoing support needed for patients with CVD conditions when transferred from hospital rehabilitation programmes to continuing care in the community. Pharmacies as well as GPs would play an important role in chronic disease management and the establishment of specific ‘prevention services’ in communities needs to be examined,” she said.

According to the report: “Increasing obesity and diabetes with high rates of hypertension signals a need for ongoing rehabilitation and prevention to achieve recommended lifestyle, risk factor and therapeutic targets”.

“At the moment the new policy is timely given the pace of scientific discovery and related changes in medical practice, changes in health service structures, and patterns and influences on population health behaviours in Ireland over the decade. 

“Cardiovascular health and its maintenance is a microcosm of health more generally and will have beneficial effects for the whole healthcare system and population” said Prof McGee.

References

1. http://healthupdate.gov.ie/current-topics/your-health-is-your-wealth-developing-a-new-public-health-policy-framework-for-ireland.html
2. Finucane C et al. Low awareness of atrial fibrillation in a nationally representative sample of older adults. Circulation 2011; 124 (21)
3. www.tcd.ie/tilda/events/.../Tilda_Master_First_Findings_Report.pdf