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Original scientific paper
Lifestyle and risk factor management in
people at high risk of cardiovascular
disease. A report from the European
Society of Cardiology European Action on
Secondary and Primary Prevention by
Intervention to Reduce Events
(EUROASPIRE) IV cross-sectional survey
in 14 European regions
Kornelia Kotseva
1,2
, Dirk De Bacquer
1,3
, Guy De Backer
1,3
,
Lars Ryde
´
n
1,4
, Catriona Jennings
1,2
, Viveca Gyberg
4
,
Ana Abreu
5
, Carlos Aguiar
6
, Almudena C Conde
7
,
Kairat Davletov
8
, Mirza Dilic
1,9
, Maryna Dolzhenko
10
,
Dan Gaita
1,11
, Borislav Georgiev
12
, Nina Gotcheva
12
,
Nebojsa Lalic
13
, Aleksandras Laucevicius
1,14
, Dragan Lovic
1,15
,
Silvia Mancas
11
, Davor Milic
ˇ
ic
´
1,16
, Raphael Oganov
17
,
Andrzej Pajak
18
, Nana Pogosova
1,17
,Z
ˇ
eljko Reiner
1,16
,
Dusko Vulic
19
and David Wood
1,2
; on behalf of the
EUROASPIRE investigators
Abstract
Background: European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE)
IV in primary care was a cross-sectional survey carried out by the European Society of Cardiology, EURObservational
Research Programme in 2014–2015 in 71 centres from 14 European countries. The main objective was to determine
whether the 2012 Joint European Societies’ guidelines on cardiovascular disease (CVD) prevention in people at high
CVD risk have been followed in clinical practice.
1
European Society of Cardiology, Sophia Antipolis, France
2
International Centre for Circulatory Health, Imperial College London,
UK
3
Department of Public Health, University of Ghent, Ghent, Belgium
4
Department of Medicine Solna, Karolinska Institutet, Sweden
5
Cardiology Department, Hospital Santa Marta, Portugal
6
Cardiology Department, Hospital Santa Cruz, Portugal
7
Cardiac Rehabilitation Unit, Hospital Universitario La Paz, Madrid, Spain
8
Republican Institute of Cardiology and Internal Diseases, Kazakhstan
9
Clinical Centre University of Sarajevo, Bosnia and Herzegovina
10
Department of Cardiology, Shupyk National Medical Academy of
Postgraduate Education, Ukraine
11
Institutul de Boli Cardiovasculare, Universitatea de Medicina si
Farmacie ‘Victor Babes’, Romania
12
Department of Cardiology, National Heart Hospital, Bulgaria
13
Clinic for Endocrinology, Diabetes and Metabolic Diseases, University
of Belgrade, Serbia
14
Clinic of Cardiovascular Diseases, Vilnius University, Lithuania
15
Clinic for Internal Medicine Intermedica, Serbia
16
University Hospital Centre, University of Zagreb, Croatia
17
National Research Centre for Preventive Medicine of the Ministry of
Healthcare of the Russian Federation, Russia
18
Department of Epidemiology and Population Studies, Jagiellonian
University Medical College, Poland
19
Centre for Medical Research, University of Banja Luka, Bosnia and
Herzegovina
Corresponding author:
Kornelia Kotseva, National Hear t and Lung Institute, Imperial College
London, Imperial College Translational Medicine (ICTEM) Building,
Hammersmith campus, 3
rd
Floor, Du Cane Road, London W12 0NN,
UK.
Email: k.kotseva@imperial.ac.uk
European Journal of Preventive
Cardiology
2016, Vol. 23(18) 2007–2018
! The European Society of
Cardiology 2016
Reprints and permissions:
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DOI: 10.1177/2047487316667784
ejpc.sagepub.com
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Methods: Patients without a history of atherosclerotic disease started on either blood pressure and/or lipid and/or
glucose-lowering treatments were identified and inter viewed at least six months after the start of medication.
Results: Medical notes of 6700 patients were reviewed, and 4579 patients (58.7% women; mean age 58.8 (standard
deviation (SD) 11.3) years) interviewed (interview rate 68.3%). Overall, 16.6% were smokers, 39.9% were overweight
(body mass index (BMI)25 and <30 kg/m
2
), 43.5% obese (BMI 30 kg/m
2
) and 63.9% centrally obese (waist circum-
ference of 88 cm for women, 102 cm for men). The medical risk factor control was very poor, with less than half
(42.8%) of the patients on blood pressure lowering medication reaching the target of <140/90 mm Hg (<140/80 mm Hg
in people with self-reported diabetes). Among treated dyslipidaemic patients only 32.7% attained the low-density lipo-
protein (LDL)-cholesterol target of <2.5 mmol/l. Among people treated for type 2 diabetes mellitus, 58.5% achieved the
glycated haemoglobin (HbA1c) target of <7.0%.
Conclusion: The EUROASPIRE IV survey shows that large proportions of patients at high CVD risk have unhealthy
lifestyle habits and uncontrolled blood pressure, lipids and diabetes. The present data make it clear that more efforts
must be taken to improve cardiovascular prevention in people at high CVD risk.
Keywords
EUROASPIRE, primary prevention, cardiovascular risk factors, guideline implementation
Received 20 February 2016; accepted 16 August 2016
Introduction
The main objectives of cardiovascular disease (CVD)
prevention are to reduce morbidity and premature mor-
tality, improve quality of life and increase longevity.
1
The European Society of Cardiology (ESC) together
with other partner societies has engaged in a compre-
hensive programme of CVD prevention in clinical prac-
tice for many years.
2
Guidelines on this important topic
have been developed and updated at regular intervals
over the last 20 years: 1994, 1998, 2003, 2007 and
2012.
1,3–6
It is emphasised that the highest clinical pri-
ority for prevention should be directed towards patients
with coronary or other atherosclerotic disease, and
those at high risk of developing CVD. Guideline imple-
mentation in daily practice has been evaluated with
four cross-sectional surveys called European Action
on Secondary and Primary Prevention by Intervention
to Reduce Events (EUROASPIRE) conducted under
the auspices of ESC Euro Heart Survey programme
in patients with coronary heart disease in 1995–1996,
1999–2000, 2006–2008 and in 2013–2015 through the
EURObservational Research Programme.
7–15
For the
first time, the two most recent surveys included individ-
uals free from any manifestations of CVD but living
with a high risk of developing CVD because of arterial
hypertension, dyslipidaemia or type 2 diabetes.
12
The
aim of the primary care arm of EUROASPIRE IV was
to determine whether the 2012 Joint European Societies
(JES) guidelines on CVD prevention in people at high
cardiovascular risk are being followed in clinical
practice.
Study population and methods
Study design
The primary care arm of EUROASPIRE IV was
a cross-sectional survey carried out from January
2014–April 2015 in 71 primary care centres in Bosnia
and Herzegovina, Bulgaria, Croatia, Kazakhstan,
Lithuania, Poland, Portugal, Romania, Russian
Federation, Serbia, Spain, Sweden, Ukraine and the
UK. Within each country one or more geographical
areas with a defined population were selected and a
sample of one or more general practices or health cen-
tres serving that population were identified according
to the structure of the local health services. Not all
countries that participated in the hospital arm of
EUROASPIRE IV were able to join the primary care
study due to logistics issues and differences in the
organisation of primary care.
Study population
Within each general practice men and women 18 to
<80 years at the time of identification, without a
history of coronary or other atherosclerotic disease,
who had been prescribed one or more of the following
treatments: (a) blood pressure lowering drugs and/or
(b) lipid-lowering drugs and/or (c) glucose-lowering
(diet and/or oral drugs and/or insulin), 6 months to
<3 years prior to the date of interview, were identified
retrospectively from practice records. Patients sampled
by each of these treatments might have been using one
or more of the other drug therapies.
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Data collection
Centrally trained research staff undertook data collec-
tion using standardised methods and the same instru-
ments in all centres. They reviewed patient medical
notes and interviewed and examined the patients at
the general practice or home at least six months after
the prescription of blood pressure, lipid or glucose-
lowering therapy.
Height and weight (scales 701 and measuring stick
model 220; SECA Medical Measuring Systems and
Scales, Birmingham, UK) and waist circumference
16
(metal tape applied horizontally at the point midway
in the mid-axillary line between the lowest rim of the rib
cage and the superior iliac crest) were recorded. Being
overweight was defined as a body mass
index (BMI)25 to <30 kg/m
2
and obesity as
BMI30 kg/m
2
. Abdominal overweight was defined as
a waist circumference 94 cm in men, 80 cm in
women and central obesity as a waist circumference
of 88 cm for women and 102 cm for men.
Blood pressure was measured twice on the right upper
arm in a sitting position using an automatic digital sphyg-
momanometer (Omron M6; OMRON Corporation,
Kyoto, Japan) and the mean was used for the analyses.
Raised blood pressure was defined as systolic blood pres-
sure (SBP)140 mm Hg and/or diastolic blood pressure
(DBP)90 mm Hg (140/80 mm Hg in patients with
diabetes).
Breath carbon monoxide (CO) was measured in ppm
using a smokerlyser (Model Microþ Bedfont Scientific,
Harrietsham, UK). Smoking was defined as self-
reported smoking, and/or a breath CO exceeding
10 ppm.
17
Habitual physical activity was assessed with the fol-
lowing question:
Which of the following four alternatives describes your
level of activity outside work in the best way?
a. No physical activity weekly,
b. Only light physical activity in most weeks,
c. Vigorous physical activity at least 20 minutes
once or twice a week,
d. Vigorous physical activity for at least 20 min-
utes three or more times a week.
Fasting (10 h) venous blood samples were taken in
the sitting position with light stasis into a tube contain-
ing clot activator (Venosafe, Terumo Europe, Leuven,
Belgium) for lipid assays and into a potassium
Ethylenediaminetetraacetic acid (EDTA) tube
(Venosafe) for glycated haemoglobin (HbA1c) assay.
Serum was separated by centrifuging at 2000 g for
10 min at room temperature and aliquoted into two
bar-code-labelled tubes that were stored locally together
with whole EDTA blood tubes at a minimum of –70
C
for subsequent transportation to the central laboratory
at the Disease Risk Unit, National Institute for Health
and Welfare, Helsinki, Finland where all measurements
were performed on a clinical chemistry analyser
(Architect c8000; Abbott Laboratories, Abbott Park,
Illinois, USA). The laboratory has been accredited by
the Finnish Accreditation Service and fulfils the require-
ments of the standard SFS-EN ISO/IEC 17025:2005.
Total and high density lipoprotein cholesterol
(HDL-C) and triglycerides were analysed in serum,
and HbA1c in whole blood with the following methods:
enzymatic method for total cholesterol, a homogenous
method for direct measurement of HDL-C, an enzym-
atic glycerol phosphate oxidase method for triglycer-
ides, and an immunoturbidimetric method for
HbA1c. LDL cholesterol (LDL-C) was calculated
according to Friedewald’s formula.
18
Elevated LDL-C
concentration was defined as 2.5 mmol/l. Elevated
HbA1c was defined as 7.0% (Diabetes Control and
Complications Trial (DCCT)).
The laboratory takes part in the Lipid
Standardization Program organized by Centers for
Disease Control and Prevention (CDC), Atlanta,
Georgia, USA and External Quality Assessment
Schemes organized by Labquality, Helsinki, Finland.
During the course of the study, comprising two
months in 2013, the coefficient of variation
(meanstandard deviation (SD)) and systematic error
(bias) (mean SD) were 1.3% 0.2 and 1.7% 1.1 for
total cholesterol, 1.6% 0.5 and –1.5% 1.6 for HDL-
C, 2.3% 0.1 and –1.2% 2.6 for triglycerides, and
1.9% 0.1 and 1.4% 0.2 for HbA1c, respectively.
Data management
The EURObservational Research Programme at the
European Heart House (Nice, France) was in charge
of data management. All data were collected electron-
ically through web-based data entry using a unique
identification number for country, centre and individ-
ual. The data were submitted via the Internet to the
data management centre where checks for complete-
ness, internal consistency and accuracy were run. All
data were stored under the provisions of the National
Data Protection Regulations.
Statistical analyses
Sample size calculations indicated that a sample of 400
patients attending interview was sufficient to estimate
prevalence of risk factors with precision of at least 5%
and with a confidence interval of 95%. Descriptive
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statistics were used to estimate the prevalence of risk
factors and medication use by country, gender and age
at interview. All statistical analyses were undertaken
using SAS statistical software (release 9.4) in the
Department of Public Health, Ghent University,
Belgium.
Ethical procedures
The local ethics committees of all participating coun-
tries approved the EUROASPIRE IV protocol.
Written, informed consent was obtained from each
participant.
Outcome measures
The main outcome measures were the proportions of
high CVD risk individuals achieving the lifestyle and
risk factor targets defined in the 2012 JES guidelines on
CVD prevention in clinical practice: not smoking,
healthy food choices and be physically active; a
BMI<25 kg/m
2
; blood pressure<140/90 mm Hg
(<140/80 mm Hg in patients with diabetes), LDL-
C<2.5 mmol/l, and appropriate use of cardioprotective
drug therapies for treatment of elevated blood pressure,
lipids and glucose.
Results
Patient characteristics
A total of 6700 medical notes were reviewed and 4579
patients interviewed after the start of drug treatment
(interview rate 68.3%). The comparison of patients
interviewed with those who were not, showed that
women and patients older than 60 years were signifi-
cantly more likely to attend the interview. Of those
interviewed, the mean (SD) age was 58.8 (11.3) years
and 2647 (57.8%) were women (Table 1).
Study outcomes
Lifestyle. The prevalence of smoking, obesity and central
obesity is presented in Table 2. The overall prevalence
of smoking (self-reported and/or CO in breath
>10 ppm) was 16.6% (men 22.0%, women 12.7%)
and higher in patients <60 years of age. Less than
half of current smokers (42.2%) reported having the
intention to quit smoking within the next six months.
Although the majority of smokers had been offered
personal advice by a health professional to stop smok-
ing (73.5%), only 11.1% had been referred to smoking
cessation clinic. Advice to use nicotine replacement
therapy (NRT) had been given to 11.6% of the smokers
Table 1. Distribution of study population by country, age and gender.
Female, % (n) Age, mean (SD) Age60 years, % (n)
Centre
Bosnia and Herzegovina
d
53.2 (118/222) 62.3 (8.9) 58.1 (129/222)
Bulgaria 49.5 (93/188) 60.0 (12.2) 60.6 (114/188)
Croatia 57.9 (232/401) 62.7 (10.1) 64.1 (257/401)
Kazakhstan 68.3 (285/417) 57.2 (9.1) 39.8 (166/417)
Lithuania 55.8 (223/400) 54.0 (9.1) 28.3 (113/400)
Poland 55.8 (261/468) 56.8 (10.5) 42.9 (201/468)
Portugal 53.8 (211/392) 65.9 (9.4) 75.5 (296/392)
Romania 60.2 (239/397) 55.5 (12.5) 39.5 (157/397)
Russian Federation 71.6 (290/405) 56.0 (10.1) 30.4 (123/405)
Serbia 57.2 (103/180) 51.0 (14.2) 30.6 (55/180)
Spain 46.6 (75/161) 66.9 (8.9) 76.4 (123/161)
Sweden 51.3 (77/150) 64.9 (9.0) 72.7 (109/150)
Ukraine 64.1 (263/410) 56.8 (11.4) 43.4 (178/410)
United Kingdom 45.6 (177/388) 61.0 (11.5) 55.9 (217/388)
Reasons for inclusion
Blood pressure lowering therapy 59.2 (1920/3243) 58.9 (11.0) 48.5 (1574/3243)
Lipid-lowering therapy 57.0 (676/1186) 60.8 (10.7) 56.2 (667/1186)
Glucose-lowering therapy 52.1 (570/1094) 59.7 (11.7) 52.7 (577/1094)
All 57.8 (2647/4579) 58.8 (11.3) 48.9 (2238/4579)
SD: standard deviation.
2010 European Journal of Preventive Cardiology 23(18)
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and bupropion and varenicline had been prescribed to
2.6% and 2.9% of them, respectively.
Overall, 39.9% of patients (men 45.6%, women 35.9%)
were overweight and 43.5% (men 40.4%, women 45.7%)
were obese. The prevalence of abdominal overweigh t was
84.9%, higher in women (89.8%) than in men (78.1%) an d
63.9% (men 52.3%, women 72.3%) wer e centrally obese.
One in five of obese patients (20.1%) have never been told
by a health professional that they were overweight and just
over half (52. 2%) planned to lose weight in the next
month. About two-thirds (65.2%) of obese patients had
received a personal dietary recommendation by a health
professional and 59.0% were ad vised to participate in
regular physical activity but less than half of them took
steps to lose weight by increa sing physical activity (39.3%).
In this survey, less than a fifth (18.4%) of patients (men
23.6%, women 13.0%) performed vigorous physical activ-
ity during at least 20 min on three or more times/week . In
addition, less than one in five patients (14.1%) had been
advised to attend some form of CVD prevention pro-
gramme. The reported lifestyle changes are presented in
Table 3.
Blood pressure. Just over half of patients not using blood
pressure lowering medication had a normal blood pres-
sure (total 53.8%, men 44.0%, women 62.0%). Overall,
82.7% of patients were on blood pressure lowering medi-
cation at the time of interview. However, less than half
(42.8%, men 35.0%, women 48.4%) reached the target of
<140/90 mm Hg (<140/80 mm Hg in people with dia-
betes) (Table 4). Four of five patients (85.4%) on blood
pressure lowering medication were aware of their blood
pressure level and 67.9% of the recommended blood pres-
sure target. The most commonly prescribed medication
were inhibitors of renin angiotensin systems (angiotensin-
converting-enzyme (ACE) inhibitors/ angiotensin recep-
tor blockers (ARBs); 79.8%), followed by beta-blockers
(36.8%), diuretics (38.3%) and calcium channel blockers
(29.1%).
Lipids. One third of the patients (35.6%) were on lipid-
lowering drug therapy. Of these patients 96.1% were on
statins, 4.6% on fibrates, 1.4% on ezetimibe and 0.4%
on other lipid-lowering drugs. Only a minority of those
prescribed lipid-lowering drugs reached the LDL-C
target of <2.5 mmol/l (total 32.7%, men 39.9%,
women 27.0%) (Table 5). Less than half (47.1%) of
patients on lipid-lowering medication had been
informed of their cholesterol levels and 38.7% were
aware of their target. Only one in 10 (10.7%) of the
patients without any lipid-lowering medication had a
LDL-C<2.5 mmol/l (men 12.3%, women 9.6%).
Table 2. Prevalence of smoking, obesity and central obesity by country, age and gender.
Smoking
a
%(n) Obesity
b
%(n) Central obesity
c
%(n)
Men Women Men Women Men Women
Centre
Bosnia and
Herzegovina
20.2 (21/104) 5.9 (7/118) 14.5 (12/83) 20.2 (20/99) 18.3 (11/60) 73.5 (61/83)
Bulgaria 29.5 (28/95) 15.1 (14/93) 60.0 (57/95) 39.8 (37/93) 82.1 (78/95) 89.2 (83/93)
Croatia 20.7 (35/169) 21.1 (49/232) 45.0 (76/169) 44.4 (103/232) 57.4 (97/169) 69.8 (162/232)
Kazakhstan 33.3 (44/132) 14.0 (40/285) 45.5 (60/132) 44.2 (126/285) 56.8 (75/132) 79.9 (227/284)
Lithuania 26.0 (46/177) 10.8 (24/223) 54.2 (96/177) 55.5 (122/220) 65.5 (116/177) 74.1 (163/220)
Poland 26.1 (54/207) 19.2 (50/261) 42.7 (88/206) 37.5 (98/261) 46.4 (96/207) 68.2 (178/261)
Portugal 12.7 (23/181) 7.6 (16/211) 33.5 (60/179) 42.2 (89/211) 57.9 (103/178) 76.3 (161/211)
Romania 13.9 (22/158) 5.9 (14/239) 40.5 (64/158) 51.9 (124/239) 39.9 (63/158) 71.1 (170/239)
Russian Federation 31.3 (36/115) 12.4 (36/290) 48.7 (56/115) 59.6 (171/287) 44.1 (49/111) 70.6 (199/282)
Serbia 46.8 (36/77) 34.0 (35/103) 24.3 (17/70) 22.5 (23/102) 48.5 (16/33) 62.7 (37/59)
Spain 12.8 (11/86) 16.0 (12/75) 40.7 (35/86) 64.0 (48/75) 70.9 (61/86) 80.0 (60/75)
Sweden 12.3 (9/73) 6.5 (5/77) 35.6 (26/73) 29.9 (23/77) 57.5 (42/73) 63.6 (49/77)
Ukraine 25.9 (38/147) 4.2 (11/263) 36.1 (53/147) 54.0 (142/263) 41.5 (61/147) 68.4 (180/263)
United Kingdom 10.9 (23/211) 13.0 (23/177) 32.2 (68/211) 40.7 (72/177) 44.1 (93/211) 65.9 (116/176)
Age
<60 years 29.5 (305/1035) 17.5 (228/1306) 42.9 (440/1026) 44.7 (581/1299) 51.0 (503/986) 70.4 (884/1255)
60 years 13.5 (121/897) 8.1 (108/1341) 37.5 (328/875) 46.7 (617/1322) 53.8 (458/851) 74.0 (962/1300)
All 22.0 (426/1932) 12.7 (336/2647) 40.4 (768/1901) 45.7 (1198/2621) 52.3 (961/1837) 72.3 (1846/2555)
a
Self-reported smoking or carbon monoxide (CO) in breath >10 ppm;
b
body mass index 30 kg/m
2
;
c
waist circumference 88/102 cm for women/
men;
d
the percentage of missing values in waist circumference in Bosnia and Herzegovina makes gender comparisons difficult.
Kotseva et al. 2011
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