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
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
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.
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
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. (276th
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.