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Cardio-vascular disease in Europe: challenges for the medical profession

Maarten L Simoons
DOI: http://dx.doi.org/10.1016/S0195-668X(02)00751-0 8-12 First published online: 1 January 2002

The European Union has adopted the HeartPlan for Europe, which has been presented by the European Society of Cardiology to the SpanishMinister of Health.

1.1 Heart Plan for Europe

Triggered by our Heart Plan for Europe, thePresidency of the European Union notes on June 12, that cardiovascular disease is a significant cause of mortality and morbidity in the European Union, and results in considerable economic and social costs. For example, in the Netherlands, about 40% of total mortality is related to myocardial infarction, stroke, and other manifestations of cardiovascular disease. This is significantly higher than mortality from cancer, or any other specific disease group.

Early mortality is related to the socio-economic conditions. In Eastern European countries cardiovascular mortality is above nine per 1000 inhabitants per year, which is three times as high as in Western European countries.1 It is a challengefor the politicians, but also a challenge for us cardiologists, to address these inequalities.

The Presidency of the European Union recognizes that health promotion and prevention are costeffective, when applied in a timely and proper manner, and it recognizes that cardiovascular health can be achieved by improving healthinformation to the public, by development of a monitoring system for cardiovascular disease and by development of a scientific database for both health professionals and the general public. These statements illustrate that we have put cardiovascular disease on the political agenda. It is our task to exploit this political awareness for the benefit of the European population and for our patients.

1.2 Trends in management of cardio-vascular disease in Europe

There is no doubt that cardiovascular disease will remain the most frequent cause of death and disability in Europe and in fact throughout the world. Also, there is a wealth of data indicating that better prevention will further delay the onset of cardiovascular disease and that better therapy will provide a better and longer life for our patients. Due to better treatment, more patients will survive. They will need more cardiologists, more nurses and technicians, and more resources: hospital beds, procedures, medication and devices. This requires a major investment in healthcare. However, the type of procedures will change, which may save some costs. Fig. 1depicts the volume of coronarysurgery and percutaneous coronary intervention in 12 European countries over the last decade. The growth in surgical volume stopped in the mid 1990s, and in recent years most countries had a stable or declining volume of coronary surgery. Nowadays, most patients requiring revascularization areoffered a percutaneous intervention, since outcome is equivalent to surgery. Indeed, percutaneous intervention rates are rising in all countries, and in most European countries the volume of percutaneous coronary interventions now exceeds the surgical volume.

Fig. 1

Total volume of procedures in 12 countries over the period 1990–2000. The three-letter codes are presented in the same order as the curves representing each country. DEU, Germany; FIN, Finland; FRA, France; ITA, Italy; HUN, Hungary; CZE, Czech Republic; SWE, Sweden; NLD, the Netherlands; GBR, United Kingdom; ESP, Spain; POL, Poland; ROM, Romania. Data from Boersma et al.1

The results of coronary intervention are improving rapidly, and survival without myocardialinfarction and without reintervention after coronary revascularization has improved. In the CABRI study, which was conducted with support fromthe ESC in the early 1990s, event-free survivalwas 91% with surgery and only 59% with balloon angioplasty.2 Outcome was improved with stents as is evident from the ARTS study.3 Event-free survival with the new sirolimus drug eluting stent is even better, around 95% at 1 year.4 While we have seen major advances in outcome after percutaneousintervention in the last decade, outcome after bypass surgery has stabilized at around 90% without events at 1 year.2,3 It is indeed likely that coronary surgery will be further replaced by percutaneous intervention.

For your information, I have tabulated thetotal number of procedures in 33 countries from which reliable data are available including the 15 countries of the European Union (Table 1). Please appreciate that large populations in Eastern Europe and North Africa are not included. In the European Union, with 370 million inhabitants about 430,000 Percutaneous Coronary Interventions were performed in the year 2000 and about 280,000 bypass operations, 160,000 pacemakers were implanted and only 12,500 Implantable CardiovertorDefibrillators.

View this table:
Table 1

Total number of procedures in 33 countries

  • Estimated number of procedures in the 15 countries in the EU: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxemburg, The Netherlands, Portugal, Spain, Sweden, and United Kingdom.

    And in 18 other countries where adequate data were available in the year 2000: Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Iceland, Israel, Latvia, Lithuania, Macedonia, Norway, Poland, Romania, San Marino, Slovak Republic, Slovenia, Switzerland, and Turkey.

Significant changes may be expected in the next decade particularly an increase in percutaneous revascularization, a decrease in coronary surgery, a modest increase in the use of pacemakers and significant increase in use of implantable cardioverter defibrillators, as well as a significantincrease in use of medication.

1.3 Cardiology practice—area's of expertise

The future will require a different type of cardiologist. Optimal care requires further development and recognition of areas of special expertise within cardiology such as prevention, heart failure, imaging, acute care and intensive care, interventional cardiology, clinical electrophysiology, and congenital heart disease. In the next decade we will see a further shift from the individual physician who takes care of patients with a wide spectrum of disease to networks of specialists, cardiologists, and vascular medicine specialists, as well as nurse practitioners. This should go hand in hand with the development of networks of hospitals and related practices, which together provide high quality care for their population.

1.4 Cardiology and vascular medicine

We realize that our profession is not just about the heart. It is about the heart and the blood vessels, and their interaction with different organs. So perhaps, we should rename our Society to becomethe ‘European Society of Cardiology and Vascular Medicine’. In fact, several of our Working Groupsdo address vascular medicine: atherosclerosis,hypertension, prevention and diabetes, peripheral circulation, and heart failure.

1.5 Information technology

The future will also bring new information systems, for professionals and for the public. To improve the quality of care, cardiologists, vascular medicine specialists, and nurses, will have on-line access to large databases on care in Europe, as well as access to guidelines for prevention, diagnosis, and management of cardiovascular disease (Fig. 2). Hospital information systems will record data on all aspects of cardiology: electrocardiography, imaging, interventions, in hospital, and at the out patient clinic.5 Part of this data will be uploaded to NationalRegistries and to European Surveys of the practice of cardiology.1

Fig. 2

The cardiology information system. Patient dataaccessible through the Hospital Information System on the left, registries to which patient data are uploaded (middle) and the knowledge base on the right.

1.6 Euro Heart Survey

The Euro Heart Survey programme, as well asseveral National Registries already collect systematic data on cardiology practice today.6,7 An example is the existing Swedish Registry of coronary care units which already provides immediate insight in the performance of different hospitals.8 Whenthe participating hospitals are ranked according to the proportion of patients with myocardial infarction who receive reperfusion therapy, there is a wide range, with an average of around 60%, while some hospitals treat only 20–40% of their patients. This warrants investigation, and probably improvement.

Fig. 3

Improving adherence to guidelines in hospitals participating in the Arbeitsgemeinshaft leitende Kardiologische Kliniken in Germany (top). In 2000–2001 patients with myocardial infarction received on average three out of four recommended therapies: reperfusion, aspirin, beta blocker, ACE-inhibitor. Decreasing hospital mortality in the same hospitals in the same registries. Data from Gitt et al.9

In the same registry the proportion ofpatients with myocardial infarction, undergoing revascularization within 14 days was recorded. Again, there was a wide variation from virtually none to about 40% with the higher numbers occurring in those hospitals which have facilities for coronary revascularization procedures. The use of procedures seems to be related as much, or even more to availability of resources than to the need of the patients. Similar patterns are apparent in allcountries and should be addressed by us, cardiologists, and by the governments and health careproviders.

We have collected evidence that evidence based medicine with therapy according to guidelines does improve patient outcome.

Registries in Germany tracked the use ofreperfusion therapy, aspirin, beta blockers, and ACE inhibitors in patients with myocardial infarction.9 Over the last decade the appropriate use of these therapies has significantly increased. In the last survey individual patients received three out of these four recommended therapies. At the same time, in the same hospitals a significant reduction in mortality from myocardial infarction wasobserved (Fig. 3). The message is clear: guideline based therapy should be encouraged. Guideline based patient management will be promoted if physicians have on-line access to guidelines when they see patients in their office or in hospital(Fig. 2). The European Society of Cardiology has taken initiatives to provide on-line access to guidelines, journals, textbooks, drug databases, and other sources of information. In fact, the firstpart of this system is available at this congresshere in Berlin. It is called escardioContent, a joint development of the Society and our publisher,Elsevier.

1.7 Public information on cardiovascular disease

For physicians we have created an informationcycle of guidelines, education programmes, and surveys (Fig. 4). But also the public will request access to information on healthy lifestyle, prevention, and management of cardiovascular disease. Thus, a similar cycle maybe set up for the public (Fig. 5). Together with the Heart Foundations in Europe and the National Societies we shoulddevelop a public education programme about lifestyle, but also provide information on drugs and procedures. I believe that it is also appropriate to inform the public about the actual quality of health care in their environment, if such data is available.

Fig. 4

Information cycle for medical professionals.

Fig. 5

Information cycle for the general public.

At the time of this congress in Berlin the public was informed through our manifestation ‘For Your Hearts Sake, Mehr Herz fürs Herz, at Neues Kranzler Eck’ organised together with the German Societyof Cardiology and the German Heart Foundation. Similar programmes were organised in previous years in Amsterdam (2000) and Stockholm (2001), and will be organised in future congress venues: Vienna (2003) and München (2004).

1.8 The challenge

The Presidency of the European Union hasrecognized that cardiovascular disease results in considerable economic and social costs.

It is our challenge to mobilize the political support to continue to develop optimal proceduresfor prevention, for diagnosis, and for therapy of cardiovascular disease.

It is our challenge in particular to apply inpractice the extensive knowledge which we have gained, in order to improve the quality of life of the European population by reducing the impact of cardiovascular disease, which is the mission of our Society.