Skip Navigation

This Article
Right arrow Extract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Rieder, A.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Rieder, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Getting into a healthy `CV success zone': effective strategies to prevent CVD

Anita Rieder

Center for Public Health, Institute of Social Medicine, Medical University Vienna, Rooseveltplatz 3, A-1090 Vienna, Austria

Corresponding author. E-mail address: anita.rieder{at}meduniwien.ac.at

It has been estimated that more than 25% of the world's adult population had hypertension in 2000 and that this figure is expected to increase by 60% to 1.56 billion by 2025.1 The fact that hypertension is one of the biggest public health problems is well known. The WHO European Health Report 2005 points out that the burden of mortality and DALYs (Disability Adjusted Life Years) for the seven leading conditions—ischaemic heart disease, unipolar depressive disorders, cerebrovascular disease, alcohol use disorders, chronic pulmonary disease, lung cancer, and road-traffic injury can be attributed to just seven leading risk factors like tobacco, alcohol, high blood pressure, high cholesterol, overweight, low fruit and vegetable intake, and physical inactivity.2 Of these risk factors hypertension is the top-ranking risk factor in the European region in terms of attributable DALYs (12.8% of total DALYs) and continues to be the most common risk factor for cardiovascular morbidity and mortality.3

While the figures for hypertension are still worryingly high, we have, with the right approach, the potential to be very effective. Hypertension is a modifiable risk factor, which can be prevented or controlled through implementation of medication, adjustment of lifestyle factors, or a combination of both.

The WHO estimates, for example, that modest population-wide and simultaneous reductions in blood pressure, obesity, cholesterol, and tobacco use would more than halve CVD incidence.2


   Where do the challenges lie?
Top
 Where do the challenges...
Where do we go...
 Value of prevention
 Acknowledgement
 References
 
Guidelines
Guidelines are essential in driving treatment, they are, however, dependent on the extent of research that has been done. Hypertension in young people is often not addressed by the guidelines since the research among young people is limited.4 However, raising awareness or treating the initial modest rises in blood pressure could avoid more severe damage at later stages.

Awareness
Although people are often aware that lowering blood pressure would improve health they are frequently unaware of their own blood pressure5,6 and consequently a large proportion are unaware that they are hypertensive. In a screening study of blue collar workers in Austria, undertaken as part of the heart disease prevention programme, ‘A Heart for Vienna’ (Ein Herz für Wien),7 11.4% of subjects assessed were newly diagnosed as hypertensive.8 The prevalence of newly diagnosed hypertension (of total male respondents) ranged from 12.7% in Hungary to 27% in Slovakia.9 Here, socio-economic circumstances are seen to influence awareness.

A rethink in the type and implementation of awareness campaigns is also required. Although public awareness can initially be raised following a ‘one-off’campaign, this increase has been observed to reverse again, once the topic is no longer in the public eye.6 This suggests that although awareness campaigns can be effective, repeated efforts or alternative approaches should be considered to sustain perception and understanding.

Treatment
Unfortunately, studies show that blood pressure is still insufficiently controlled.10 The EUROASPIRE study group concluded that about half of coronary patients require more intensive blood pressure management. Furthermore, Europe has lower levels of blood pressure control than the USA and Canada.11 When using a blood pressure threshold of 140/90 mmHg, almost one-third of patients in the US had their hypertension controlled, compared with 5–10% in the European countries assessed. This discrepancy could possibly be due to less aggressive treatment. Patient non-compliance is another factor which has been reported many times.12 However, poor control of blood pressure has, in part, also been found to be attributable to inadequate management by the physician.13,14 Indeed, in the USA the provider's failure to increase therapy when treatment goals have not been met has been found to contribute to the high prevalence of uncontrolled hypertension and may impede the attainment of the Healthy People 2010 goal of controlling hypertension in 50% of all patients.15

Looking at other aspects of treatment it has been found that the majority of diagnosed hypertensives are treated with medication, relatively few implement lifestyle changes and, alarmingly, there are those who take no action at all.6

Costs
Staggering costs to the health system have been estimated in the US and the UK resulting from untreated hypertension. For the US population with hypertension, inadequate blood pressure control was estimated to result in 39 702 cardiovascular events, 8374 cardiovascular disease deaths, and $964 million in direct medical expenditure. Within the medicated population with cardiovascular disease, the incremental costs of failure to attain blood pressure goals reached approximately $467 million.16 Within in this supplement, Long et al.17 report an estimate that if all untreated patients with stage I or II hypertension had been treated and all achieved normal blood pressures there would have been 89 000 fewer premature deaths from major cardiovascular disease in the US in 2001; 278 000 fewer US hospital discharges for stroke; and 142 000 fewer discharges for myocardial infarctions in 2002 than actually occurred.

In a UK study, it was estimated that 5.7 million adults (12% of the population aged > 16 years) have blood pressure above 160/95 mmHg, and a further 10.3 million (21%) have blood pressure in the range of 140/90–160/95 mmHg. An estimated 58 000 major cardiovascular events per year would be avoided if their blood pressure was at target levels. The cost to the NHS of managing major cardiovascular events would fall by £97.2 million per year (2000–01 prices) if all patients had blood pressure controlled at target levels. Thus, Lloyd et al.18 concluded that failure to achieve blood pressure targets contributes substantially to avoidable National Health Service costs and to the number of cardiovascular events in the UK.

Similarly, in other parts of Europe, high costs due to hypertension have been reported. In a study of five European countries (France, Germany, Italy, Sweden, and the UK) it was estimated that 29 million adults in the five countries (13% population) have blood pressue levels above 160/95 mmHg, and an additional 46 million (21% population) have blood pressure ranging between 140/90–160/95 mmHg. The model estimated that healthcare system costs of 1.26 billion euros could be avoided if hypertension management were to achieve blood pressure targets.19

These results reflect the importance of adequate blood pressure control, in reducing cardiovascular morbidity, mortality, and overall health care expenditure among patients with hypertension, although it should be noted that the cost of interventions required to reduce the risk of cardiovascular disease must also be considered.


   Where do we go from here?
Top
 Where do the challenges...
 Where do we go...
Value of prevention
 Acknowledgement
 References
 
The evidence shows that there are a number of factors, which need to be addressed if we are to achieve successful prevention of the many diseases connected with elevated blood pressure. An innovative and multifaceted public health approach, which incorporates gender, special risk groups, and socio-economic circumstances is required if the burden of hypertension is to be reduced. Figure 1 shows the key areas and stakeholders which form the scope for the formation of effective public health strategy.


Figure 1
View larger version (22K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Aspects to be considered by public health.

 
While hypertension is a major public health priority, the responsibility should lie with all members of society to actively participate in the control and management of this health threat. Public awareness must be raised and the information provided to empower the individual to take control of his/her own health. Primary prevention strategies and programmes should be devised to encourage patients to make lifestyle changes which can have a positive impact on their health. General practitioners who are frequently the first point of contact should have clear guidelines and the tools necessary to evaluate and support their patients with the appropriate treatment for their condition and should ensure that the progress is monitored. In Austria, the yearly precautionary health examination, which is a service provided free of charge by the health system and is available to everyone resident in Austria, is a means of screening and identifying health problems such as hypertension at an early stage and thus offering the opportunity of timely intervention.20

Integrated intervention packages appear to be the way forward towards increasing knowledge of blood pressure and medical compliance; these have already been shown to have increased success in the treatment of hypertension. As Wood21 demonstrates, by means of results from the Euro Action programme, significant lifestyle improvements and risk factor reductions in coronary patients and patients at risk of developing cardiovascular disease may be achieved through the implementation of a comprehensive, multi-disciplinary preventive cardiology programme. The integrated, patient-focused approach used in the Manage it Well programme for blood pressure control including education programmes for patients and physicians, close follow-up with frequent office visits, and regular home blood pressure measurements was found to significantly increase the success of treatment in a ‘real-world’ setting.22 Another multifactorial intervention including patient education improved blood pressure control compared with provider education alone.23 In Durham County, NC, USA, a community-care programme has recently been started endeavouring to reduce disparities by providing low-cost care in the community (including schools, churches, and homes). This programme will obtain more frequent blood pressure measurements, transmit them electronically, and allow all providers access to the same records in the community, thus aiming to improve patient management and establish and maintain better blood pressure control.24 The results of such local programmes will be extremely interesting.

A major stumbling block is the effective communication and dissemination of knowledge to the general public. As a result education programmes for doctors as well as patients have been called for and introduced.25 A new initiative involving a broad and evolving dissemination strategy was recently launched in Canada, which also includes the training of health professionals to speak to the public and patients on the subject of hypertension, coupled with opportunities to speak in forums organized in their local communities.26 In this journal issue, Glasspool presents the ongoing CV Success Zone programmes, which are country-specific compliance programmes, incorporating, among other things, patient education programmes and materials, as well as, continued dialogue and support by the medical professional through direct mail, e-mail, or the internet.27

New initiatives approaching the problem at a number of different levels are the key. Schaefer28 argues that blood pressure awareness and self-monitoring could and should start at a young age and become a regular preventive activity. Furthermore, greater empowerment of diagnosed patients, encouraging them to take greater responsibility for their own disease could lead to improvements in compliance.


   Value of prevention
Top
 Where do the challenges...
 Where do we go...
 Value of prevention
Acknowledgement
 References
 
There is a large population at risk and therefore a large preventive potential. As indicated in Figure 2, to quantify the value of prevention it is necessary to set clear and attainable targets and continually evaluate whether these targets have been met. There is a clear need to examine the potential of and devise incentive systems to encourage and motivate doctors, patients, and the health system as a whole to actively deal with the problem of high blood pressure.


Figure 2
View larger version (18K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 The value of prevention.

 
In his review, Heinz Redwood29 takes a closer look at the public policy implications of hypertension control and the potential role and impact of incentive systems.

It has been suggested that there is too much focus on the treatment of hypertension rather than the prevention of blood pressure-related diseases and that the prevention of many blood pressure-related diseases will not be resolved by the treatment of hypertension alone.30 The fact is that many health risks are inter-related and positive lifestyle changes can have a beneficial impact on a wide variety of health problems. Adjustment of lifestyle factors, such as weight loss, more exercise, lower alcohol intake, and lower sodium intake have been shown to have positive effects on blood pressure. This coupled with the relatively small percentage of people who undertake lifestyle changes to help control their blood pressure offers an enormous potential for the implementation of public health interventions that focus on lifestyle factors. Not only that, but the health gains to be made through improving diet, exercising more, stopping smoking, and drinking less alcohol are potentially far-reaching. Chiuve et al.31 found that those probands who adopted a combination of healthy lifestyle characteristics had a reduced risk of coronary heart disease even among those taking anti-hypertensive medication and adopting additional lifestyle factors further reduces this risk. This supports the view that medication should complement rather than replace healthy lifestyle practices. A further significant aspect of health promotion strategy is the involvement of the food industry and the development of nutritional policy, which should investigate the possibility of lowering the salt content of convenience foods and encourage the consumption of fruit and vegetables, an approach strongly advocated by He and MacGregor32 in a discussion of the significant reductions achievable in stroke and heart attacks through a small reduction in salt intake.32

Ultimately, the aim of comprehensive public health policy and programmes should be to reduce incidence, postpone CVD and diseases associated with hypertension, reduced disability, increase quality of life, and increase healthy life expectancy. Bearing in mind the burden of disease, ‘Failure is not an option’ (Gene Kranz, Apollo13).


   Acknowledgement
Top
 Where do the challenges...
 Where do we go...
 Value of prevention
 Acknowledgement
References
 
I would like to express my thanks to Kitty Lawrence for her assistance in the preparation of the manuscript.

Conflict of interest: none declared.


   References
Top
 Where do the challenges...
 Where do we go...
 Value of prevention
 Acknowledgement
 References
 

  1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He Jiang. Global burden of hypertension: analysis of worldwide data. Lancet (2005) 365:217–223.[ISI][Medline]
  2. WHO, World Health Organisation. European Health Report (2005).
  3. Kaplan NM, Opie LH. Controversies in hypertension. Lancet (2006) 367:168–176. (Ezzati et al. PloS Med 2005;2:e133).[CrossRef][ISI][Medline]
  4. Williams B. Evolution of hypertensive disease: a revolution in guidelines. Lancet (2006) 368:6–8.[CrossRef][Medline]
  5. Oliveria SA, Chen RS, McCarthy BD, Davis CC, Hill MN. Hypertension knowledge, awareness, and attitudes in a hypertensive population. Gen Intern Med (2005) 20:219–225.[CrossRef][ISI][Medline]
  6. Schmeiser-Rieder A, Kunze U. Blood pressure awareness in Austria. A 20-year evaluation, 1978–1998. Eur Heart J (2000) 21:414–420.[Abstract/Free Full Text]
  7. Rieder A, Dorner T, Hübel U, Antes G, Strunz B, Schmidl H. Ein Herz für Wien’—eine Stadt widmet sich der Herzgesundheit ihrer Bewohner. Weißbuch Prävention Herzgesund? (2004) Jahresreport der Kaufmännische Krankenkasse.
  8. Dorner T, Fodor JG, Allichhammer D, Kiefer I, Lawrence K, Slovinec D'angelo M, Huebel U, Strunz B, Ohnoutka A, Antes G, Schmidl H, Kunze M, Rieder A. A heart for Vienna’—the prevention program for the big city. Blue-collar workers as a special target group. Wien Med Wochenschr (2006) 156:552–557.[CrossRef][Medline]
  9. Fodor J, Lietava J, Rieder A, Sonkodi S, Emmons T, Turton P. Work-site hypertension prevalence and control in three central European countries. J Hum Hypertens (2004) 18:581–585.[CrossRef][ISI][Medline]
  10. Boersma E, Keil U, De Bacquer D, De Backer G, Pyorala K, Poldersmans D, Leprotti C, Pilotto L, de Swart E, Deckers JW, Heidrich J, Sans S, Kotseva K, Wood D, Ambrosio GB, EUROASPIRE I II Study Groups. Blood pressure is insufficiently controlled in European patients with established coronary heart disease. J Hypertens (2003) 21:1831–1840.[CrossRef][ISI][Medline]
  11. Wolf-Maier K, Cooper RS, Kramer H, Banegas JR, Giampaoli S, Joffres MR, Poulter N, Primatesta P, Stegmayr B, Thamm M. Hypertension treatment and control in five European countries, Canada and the United States. Hypertension (2004) 43:10–17.[Abstract/Free Full Text]
  12. Fodor GJ, Kotrec M, Bacskai K, Dorner T, Lietava J, Sonkodi S, Rieder A, Turton P. Is interview a reliable method to verify the compliance with antihypertensive therapy? An international central-European study. J Hypertens (2005) 23:1261–1266.[ISI][Medline]
  13. Hyman DJ, Pavlik VN, Vallbona C. Physician role in lack of awareness and control of hypertension. J Clin Hypertens (2000) 2:324–330.
  14. Banegas JR, Segura J, Ruilope LM, Luque M, Garcia-Robles R, Campo C, Rodriguez-Artalejo F, Tamargo J, CLUE study group investigators. Blood pressure control and physician management of hypertension in hospital hypertension units in Spain. Hypertension (2004) 43:1338–1344.[Abstract/Free Full Text]
  15. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension (2006) 47:345–351.[Abstract/Free Full Text]
  16. Flack JM, Casciano R, Casciano J, Doyle J, Arikian S, Tang S, Arocho R. Cardiovascular disease costs associated with uncontrolled hypertension. Manag Care Interface (2002) 15:28–36.[Medline]
  17. Long G, Cutler DM, Berndt ER. Antihypertensive drugs: a perspective on the value of improved blood pressure control in the USA. Eur Heart J Suppl (2007) 9:B19–B22.[Abstract/Free Full Text]
  18. Lloyd A, Schmieder C, Marchant N. Financial and health costs of uncontrolled blood pressure in the United Kingdom. Pharmacoeconomics (2003) 21(Suppl. 1):33–41.[CrossRef][ISI][Medline]
  19. Hansson L, Lloyd A, Anderson P, Kopp Z. Excess morbidity and cost of failure to achieve targets for blood pressure control in Europe. Blood Press (2002) 11:35–45.[CrossRef][ISI][Medline]
  20. Vorsorgeuntersuchung NEU. http://www.sozialversicherung.at/esvapps/page/page.jsp?p_pageid=110&p_id=3&p_menuid=59337.
  21. Wood D. The concept of doctor targets based on quality guidelines: focus on blood pressure. Eur Heart J Suppl (2007) 9:B29–B36.[Abstract/Free Full Text]
  22. Szirmai LA, Arnold C, Farsang C. Improving control of hypertension by an integrated approach—results of the ‘Manage it well!’ programme. J Hypertens (2005) 23:203–211.[CrossRef][ISI][Medline]
  23. Roumie CL, Elasy TA, Greevy R, Griffin MR, Liu X, Stone WJ, Wallston KA, Dittus RS, Alvarez V, Cobb J, Speroff T. Improving blood pressure control through provider education, provider alerts, and patient education—a cluster randomized trial. Ann Intern Med (2006) 145:165–175.[Abstract/Free Full Text]
  24. Califf RM. The cycle of quality as a model for improving health outcomes in the treatment of hypertension. Eur Heart J Suppl (2007) 9:B8–B12.[Abstract/Free Full Text]
  25. Liau CS, Fujita T, Shimamoto K, Wu Z, Zhu J, Chung NS, Park JB, Lee YT, Chen MF. What are the education programmes needed for doctors and patients in the promotion of blood pressure control? Int J Clin Pract Suppl (2006) 150:23–25.
  26. Campbell NR, Petrellea R, Kaczorowski J. Public education on hypertension: a new initiative to improve the prevention, treatment and control of hypertension in Canada. Can J Cardiol (2006) 22:599–603.[ISI][Medline]
  27. Glasspool J. Adherence: a major unmet meed. CV success zone programme. Eur Heart J Suppl (2007) 9:B37–B41.[Abstract/Free Full Text]
  28. Schaefer C. Quality of life and self monitoring: CVD prevention in practice. The role of patient organizations in CVD prevention. Eur Heart J Suppl (2007) 9:B42–B44.[Abstract/Free Full Text]
  29. Redwood H. Hypertension, society and public policy. Eur Heart J Suppl (2007) 9:B13–B18.[Abstract/Free Full Text]
  30. MacMahon S, Neal B, Rodgers A. Hypertension—time to move on. Lancet (2005) 365:1108–1109.[ISI][Medline]
  31. Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation (2006) 114:160–167.[Abstract/Free Full Text]
  32. He FJ, MacGregor G. Blood pressure is the most important cause of death and disability in the world. Eur Heart J Suppl (2007) 9:B23–B28.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Extract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Request Permissions
Google Scholar
Right arrow Articles by Rieder, A.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Rieder, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?