5.2.5. Control tools and policies

Results from the WHO MONICA Project, which measured IHD mortality trends between the early 1980s and 1990s, showed that in the populations with decreasing mortality, two-thirds of the decline was due to the incidence decrease and the remaining one-third to improvements in survival linked to better treatments. This highlights the importance of decisions such as stop smoking, adopting healthy diet and making regular physical activity. This is also confirmed by a recent study looking at the decline in IHD mortality over a 20-year period in England and Wales. The authors found that between 1981 and 2000, 58% of the decline was attributable to reductions in major risk factors, mainly smoking, whereas treatment of individuals including secondary prevention explained only the remaining 42% of the mortality decline (Unal et al, 2005).

The falling rates have resulted in longer life spans; however, it has been recognized that trends do not change equally across countries. For this reason, it is important to monitor disease trends, treatments and risk factors in order to improve public health through planning and implementing preventive actions. Prospective epidemiological studies have emphasized that known risk factors account for more than ¾ of IHD cases; these studies have demonstrated that most individuals with IHD have at least one or more previous risk factors (Greenland et al, 2003), and optimal levels of known risk factors are associated with very low CVD risk (Palmieri et al, 2006; Giampaoli et al, 2006; Hozawa et al, 2007; Daviglus et al, 2007). Low risk individuals live longer and are eligible for low medical care expenditures in the last years of life (Daviglus et al, 2005). It is commonly believed that risk factors increase with age, but severe atherosclerosis, although part of normal ageing, is avoidable.

5.2.5.1. Prevention

In 1982, the WHO report on Prevention of coronary heart disease distinguished (WHO, 1982) three strategies: a population strategy, a high risk strategy and a secondary prevention strategy. Since then, many epidemiological studies have demonstrated that risk is a continuum, many asymptomatic high risk individuals exist and the terms ‘primary’ and ‘secondary’ prevention are artificial. Risk assessment, based on age, sex, smoking habit, systolic blood pressure, cholesterol and diabetes considered simultaneously, is the first step to identify people at risk to develop the disease, help those at high risk to reduce it and those at low risk to maintain this favourable level during their life. Therefore, the ‘population strategy’ and ‘individual strategy’ should be performed together.

An established concept in CVD prevention is that individual risk factors (such as hypertension and hypercholesterolemia) must be treated with increasing intensity as the CVD risk increases; treatment targets for LDL cholesterol and blood pressure in individuals with different risk profiles have been set in the most recent international guidelines (Grundy SM et al, 2004, Graham I et al, 2007)

Within this context, blood lipid and blood pressure control are the milestones of CVD prevention. The preferential use of fats with favourable effects on the lipid profile (mono-and polyunsaturated, of vegetal or marine origin), a reduced intake of foods rich in preformed cholesterol, a moderate intake of salt and of salty foods, an increased intake of fruit, vegetables and fibre rich foods are the first step of the nutritional control of these risk factors (Poli A et al, 2008; Sacks F et al, 2001); the hypolipidemic effect of such an healthy nutrition can be enhanced through a regular use of foods supplemented in phytosterols, soy protein, fibres (Poli A et al, 2008). In high risk subjects, if these interventions fail to bring the patient’s blood lipids or blood pressure to the appropriate target, a life-long pharmacological treatment with drugs must be considered.

For prevention approaches of CVD risk factors related to the lifestyles including obesity (body weight) or the environment see Sections 5.1. or 5.2.; for diabetes mellitus see Section 3.1.5. Annex 1 is also relevant within this context.

High-level EU documents, particularly the Council Conclusion from 2004 (Council of the European Union - 950/04 – 2586 Council Meeting – 1 and 2 June 2004) on promoting cardiovascular health, emphasize the importance of acting both at population and individual level, notably by identifying individuals at high-risk in a multisector cooperation and action.

Finland provides one of the best-documented examples of community intervention. In 1972, Finland had the world’s highest CVD mortality rate. Planners examined the policy and environmental factors contributing to CVD and sought appropriate changes, such as increased availability of low-fat dairy products, antismoking legislation and improved school meals. They used the media, schools, worksites, sports, education and agricultural to educate residents. After five years, significant improvements were documented in smoking, cholesterol and blood pressure. By 1992, CVD mortality rates for men aged 35-64 had dropped by 57%. The programme was so successful that it was expanded to include other lifestyle-related disease. Twenty years later, major reductions in CVD risk factor levels, morbidity and mortality were also attributed to the Project (Puska et al, 1998).

Experience in CVD control, spelt out in the European Heart Health Charter and its working programme, suggests that these strategic approaches are likely to include disease management programmes, population-based registers and screening programmes. These approaches will foster disease (including CVD) control and will help reduce inequalities in health and in accessing healthcare. The existence of a strategic framework will help to identify best practices in Europe and ensure solidarity among EU Member States.

The majority of cardiology studies suggests that improvements in treatment (thrombolysis; aspirin; angiotensin-converting-enzyme inhibitors; statins etc) explain less than half of the mortality decline; the major contribution to mortality decline comes from risk factors reduction.

5.2.5.2. Policy

·          In 2002, the Spanish Presidency issued a Presidency note on promoting cardiovascular health in the Health Council conclusions

·          The European Union Council Conclusions, adopted under the Irish Presidency, called upon the European Commission as well as the Member States to ensure that appropriate action is taken to address CVD.

·          The Luxembourg Declaration (Luxembourg Declaration – 29 June 2005), adopted under the Luxembourg Presidency, established an agreement among representatives of National Ministries of Health, European and National representatives of Cardiac Societies and Heart Foundations, present at the Luxembourg meeting, to pursue vigorously the initiation or strengthening of comprehensive CVD prevention plans and to ensure that effective measures, policies and interventions are in place in all European countries.

·          Several WHO resolutions and charters (EUR/RC56/R2; WHA53.17; EUR/RC52/R12; EUR/RC55/R1; EUR/RC54/R3; EUR/RC55/R6) have been adopted to combat CVD and other major non-communicable diseases.

·          In 2006, a large conference organised by the European Society of Cardiology and the European Heart Network, with a special focus on “Women and CVD” was held in Brussels under the auspices of the Austrian Presidency.

·          The purpose to protect health and improve the quality of life in the European population by reducing the impact of CVD is fully reported in the EU Treaty (Article 152 of the EU Treaty) and in the objectives of the EU’s Lisbon Agenda and the prospects of the integration of health in all policies expressed by the conclusions of the European Council of the 30 November 2006 under the Finnish Presidency. (276^th Employment, Social Policy, Health and Consumer Affairs Council Meeting - Brussels – 30 November and 1 December 2006)

·          The European Heart Health Charter was developed with the support of the European Commission, the World Health Organization (WHO-Europe), the European Heart Network and the European Society of Cardiology.

·          The European Heart Health Charter was officially launched on 12 June 2007 before the European Parliament in Brussels.