European Heart Journal (2014) 35, 1353–1358 doi:10.1093/eurheartj/ehu169

Sharing information on cardiovascular disease prevention across Europe The European Society of Cardiology’s Country of the Month initiative is spreading the good news about cardiovascular disease prevention and highlighting what still needs to be done

Country of the Month map February 2014

Clicking on a country brings up the national coordinator’s name and contact details and their report if available. A short summary provides the essential details about a country and can be read in just a few minutes. Each full report is broken down into sections, for example, health care, risk factors, prevention methods, prevention activities, cardiac rehabilitation, and the future. Details of projects are given along with links and contact information. The reports can be used by specialists in preventive cardiology and by those with a general interest in the field. Practitioners and decision-makers can see a comprehensive overview of the activities and plans in other countries as well as in their own country. The reports are compiled by the NCPCs in each country who typically engage four or five other people from the national heart society and other relevant organizations to provide a full picture of activities in the country. In 3 to 4 years, the map will be light green all over and there will be an overview of cardiovascular prevention in all countries in Europe. Updates are crucial to the utility of the initiative and so a system is in place to remind NCPCs to refresh their country’s data on a yearly basis. ‘The information on this site will never be older than one year’, says Perk. ‘In that way I hope this will be the place where people with an interest in cardiovascular prevention, including decision makers, will go to see what’s going on and to get ideas’. A closer look at the reports published so far shows that countries have emphasized different aspects. The Irish and Dutch reports outline their activities but are also planning documents that describe their vision for what they will do in the future. The Netherlands, for example, has introduced an innovative model that defines cardiovascular prevention at four levels, from the prevention of risk factors at the population level to avoiding further complications in patients who already have health problems. Their report outlines which agencies should take responsibility at the different levels. Iceland has gathered up all of their previous activities and laid them out in a ‘this is where we stand’ report. It is the first time such a document has existed. Turkey’s report is much like Iceland’s and compiles all the previous cardiovascular prevention and rehabilitation activities in one place. Josep Perk says: ‘It’s surprising how much they have been doing already. This complete

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Significant improvements have been made in the treatment of cardiovascular disease (CVD) but the number of people afflicted by it continues to rise. Cardiovascular disease prevention experts are achieving successes too, but until now there was no formal channel for sharing best practice across Europe. The Cardiovascular Prevention Implementation Committee (PIC) of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), a registered branch of the European Society of Cardiology (ESC), decided the time was right to start sharing best practice and established the Country of the Month initiative. The EACPR set up a network of National CVD Prevention Coordinators (NCPCs) several years ago and the current cohort of 59 has been keyed into getting the project off the ground. National CVD Prevention Coordinators are appointed by the presidents of national cardiac societies in ESC member countries. ‘We felt that there are so many exciting projects being done across Europe but we know absolutely nothing about them’, says PIC chairperson Prof. Joep Perk (Sweden). Every other month, two countries provide a report detailing their work in cardiovascular prevention and rehabilitation. An interactive map of Europe was created by a team at the ESC, including Britta Reuter and Camille Pfaff, which allocates each country a colour: orange (most recent reports), light green (report available), and dark green (no report available yet). The map is also an incentive to countries to prepare their reports, so that they too can be coloured light green.

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The next step for Country of the Month is to create a document with up-to-date information on the core components of preventive cardiology in countries that have submitted reports. The core components were set to be agreed during a working meeting at EuroPRevent 2014 in Amsterdam. The aim is to launch the summary document at the ESC Congress in Barcelona. ‘That document will be important for our work at population level, strictly focusing on decision makers such as politicians and healthcare managers’, says Perk. ‘It will be updated every two months as new country reports are published’. After 2 years, reports of 24 countries will be available and the EACPR will measure the impact of the initiative on cardiovascular prevention in Europe. Perk says: ‘We will conduct a survey of the NCPCs and national cardiac societies and ask the gold question of whether this increasing knowledge of each other’s projects has led to more activities’.

Acute cardiovascular events: anger mounts the checklist There is a renewed impulse to search for positive interventions to reduce the impact of anger—especially if intense and repeated—on myocardial infarction, stroke, and other adverse cardiovascular events, reports Barry Shurlock PhD The effects of anger and apoplexy on cardiovascular events are part of folklore in many parts of the world. Not for nothing did the English dramatist William Shakespeare, in the approach to war with France, furnish King Henry V with the words: Once more into the breach, dear friends . . . Stiffen sinews, summon up the blood, Disguise fair nature with hard-favoured rage

This long-held belief in the potential of anger to trigger cardiovascular events has now been strengthened by a new meta-analysis of all studies carried out between 1996 and June last year, which is published in this issue.1 The new study was carried out by Dr Elizabeth Mostofsky MPH, ScD and others at the Cardiovascular Epidemiology Research Unit (CVERU), Beth Israel Deaconess Medical Center, Boston, MA, USA. It builds on earlier work from the same centre by Dr Murray A. Mittleman MD and others based on 3886 patients. The CVERU study used a custom-devised Onset Anger Scale, structured and phrased in a manner to ask whether there were ‘anger events’ during the 2 h previous to the cardiovascular event and to

compare, in a case-crossover design, such findings with each patient’s individual usual frequency of anger episodes at other times. This measure was used in most of the subsequent studies included in the meta-analysis, which shows that the major conclusions of the new study, which is by far the largest of its kind, are broadly supported by other similar, but smaller studies from Sweden, the UK, and Israel. In the 2 h following outbursts of anger, compared with other times, there was a higher rate of myocardial infarction, acute coronary syndrome ischaemic and haemorrhagic stroke, and arrhythmia. Commenting on the use of anger scales in assessing cardiovascular risks in the clinic, Dr Mittleman said: ‘The Onset Anger Scale is a brief measure to assess levels of anger that has proved useful in the research setting, but its utility in the clinical setting has not been studied’. Different forms of anger may have different implications for CVD, according to Dr Mostofsky, who said: ‘In the study we were aware of different cultural norms for anger – for example, in some cultures it may acceptable to “lose control” when you are angry, whilst in others it is necessary to be more

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overview will really encourage them to continue the excellent work they are doing’. Israel and Germany, while also describing current activity, have highlighted that too little is being done. ‘It’s also a bit of an accusation to decision makers and cardiologists that they should be able to do more’, says Perk. ‘Israel believes the national cardiac society is so interested in interventional cardiology that it neglects prevention. Germany has a lot going on in cardiac rehabilitation but there is a feeling that the government has given up the battle against smoking’. At home the reports form the basis for a state-of-the-art discussion on current practice and where the gaps are, while ideas from other countries are there to be copied. Country-specific issues come out in the reports and there are similarities too. Israel, for example, is trying to reach out to the non-US population, which has many cardiovascular risk factors. In Ireland, there are pockets of less affluent people at risk of CVD. Iceland’s lipid levels are deteriorating due to legislation that requires fishermen to sell their catch to a fish factory for processing. Perk says: ‘People in Iceland can’t buy fish directly from the fishing boats anymore, making it unaffordable. The result is that young people’s lipid levels are going up’.

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associated with anger (increased blood pressure, heart rate, and vascular resistance) are strongly suggestive of physiological mechanisms likely to trigger acute cardiovascular events. The search is therefore on for interventions that may reduce risks, especially in people with trait anger. Dr Mostofsky said: ‘There are a number of studies underway, including work on the use of beta-blockers and aspirin by a colleague Dr Geoffrey Tofler at the University of Sydney, Australia. It has been found that the SSRI antidepressant paroxetine may lower risks of episodes of anger, possibly because, as psychologists have found, it helps with impulse control and thereby lowers the number of outbursts. Psychosocial interventions may also help. Recent work has shown that these may reduce anxiety and depression, but there is no evidence yet that they can reduce the effects of anger on the risk of heart attacks or strokes’.

Reference 1. Mostofsky E, Anne Penner E, Mittleman MA. Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis. Eur Heart J 2014;35: 1404–1410.

Brain responses to stress and their effects on the cardiovascular system Juan Carlos Kaski discussed the latest evidence at the International Conference on Heart and Brain

Juan Carlos Kaski Both chronic and acute stress modalities are associated with cardiovascular disease. Stress in early life, anger, depression, and socio-economic adversity can trigger cardiac events or exacerbate pre-existent cardiovascular conditions. Recent work by Steptoe et al. in the UK has shown an increased relative risk of acute coronary syndrome onset being preceded by stress in case-crossover studies. Loneliness, social isolation, and stress at work have also been associated with increased cardiovascular morbidity. Stress (Takotsubo) cardiomyopathy, a condition mimicking acute myocardial infarction, has been shown to be triggered by acute emotional or physical stress. Takotsubo cardiomyopathy appears to be caused by increased sympathetic activity and the release of catecholamines that directly affect the myocardium causing LV stunning.

Diffuse epicardial and microvascular spasm have also been implicated in the pathogenesis of stress cardiomyopathy. Transient myocardial ischaemia in subjects with coronary disease can be triggered by stress. Angiographic studies have documented the occurrence of coronary vasospasm during mental stress. A relationship between stress and major risk factors for cardiovascular disease, including hypertension, dyslipidaemia, insulin resistance, and endothelial dysfunction, has been established. Moreover, inflammatory mechanisms and platelet activation also appear to play a pathogenic role in both stress and cardiovascular disease. In the context of population-level stressors, such as earthquakes or equivalent catastrophes, studies have reported substantial increases in the incidence of sudden cardiac death or acute myocardial infarction immediately following these events compared with control periods. Complex links exist between brain responses to stress and their effects on the cardiovascular system. Increased sympathetic activity and a sympatho-vagal imbalance can trigger coronary vasomotor changes and arrhythmias. The activation of the hypothalamus– pituitary –adrenal axis is vital in the response to stress and results mainly in cortisol secretion. Circulating cortisol raises the concentration of adrenaline in blood.

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reserved. These differences may have some importance for heart disease. For example, previous studies have shown that destructive anger, in which you keep getting angry and don’t move on, is associated with higher cardiovascular risk whereas constructive anger, in which the person attempts to deal with the situation that is annoying them, is associated with lower risk. ‘It is important to keep in mind that although the risk of a heart attack or stroke in any given hour is very low, the absolute impact of anger outbursts will be higher among individuals with known risk factors such as smoking or hypertension. Therefore, the same number of anger episodes per month is associated with a higher risk among high-risk people than those with fewer risk factors. In addition, the short-term effects of anger can accumulate, leading to a larger clinical impact for people with more frequent episodes of anger. ‘In my view the clinician should certainly take account of the anger profile of patients. It’s been known and shown, for example, that trait anger is associated with long-term increased cardiovascular risks, and we are now examining whether the anger immediately prior to a heart attack is associated with long-term prognosis’. Although the researchers point out that the meta-analysis is not proof of cause—only of association—the haemodynamic changes

1356 Two major and mutually interconnected brain systems are recruited during the stress reaction: the hypothalamic paraventricular nucleus (PVH), which governs the neuroendocrine stress response, and the extended amygdala, which regulates most of the autonomic and behavioural stress reactions. Sympathetic output from the locus coeruleus and from the PVH activate the adrenal medulla and peripheral sympathetic nerves during stress. Cardiovascular autonomic dysregulation due to forebrain lateralization occurs in patients with ischaemic and haemorrhagic stroke. Insular cortex involvement, in particular, is associated with a pronounced autonomic imbalance leading to QT prolongation, lifethreatening arrhythmias, and sudden death.

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Further research is needed in this area. Understanding the molecular mechanisms underlying brain responses to stress and their effects on the cardiovascular system is a major challenge confronting researchers in neurocardiology at present.

Margaret Cupples presented the different strategies to generate motivation in the smoker, the obese, the sedentary, and the depressed patient at EuroPRevent 2014

Prof. Margaret Cupples, Clinical Professor of General Practice, UKCRC Centre of Excellence for Public Health Research (NI), Queen’s University, Belfast, Northern Ireland Optimal cardiovascular prevention requires the collaborative engagement of individuals. Investment in lifestyle change, as well as appropriate therapeutic interventions, is required in order to achieve maximal effectiveness in reducing cardiovascular risk. Strategies to motivate individuals to adopt healthy lifestyle behaviours should be underpinned by a bio-psychosocial framework that integrates primary and secondary prevention, including cardiac rehabilitation. Individualized assessment is a core component of cardiac rehabilitation and effective prevention.1 Other core components include smoking cessation, weight control, physical activity, and psychosocial management, including the management of depression. Individual patients vary in their motivation to address these aspects of their lifestyles and, indeed, not all aspects are directly relevant to everyone. Likewise, individuals may have different priorities and face different barriers or facilitators which influence their motivation to adhere to medication or lifestyle advice. For each individual, involvement of a partner or significant other person is an important source of support. ‘Important others’ in social networks also act as ‘subjective norms’, influencing specific health behaviours.

The Behaviour Change Wheel courtesy Michie et al. Implementation Science 2011, 6(42) The ‘behaviour change wheel’2 is a framework that has been used to identify how physical and social conditions, including government policies, may work for or against motivational factors. Motivation, together with capability and opportunity, is one of the three essential components at the centre of this framework. Behaviour change requires not only motivation but also the necessary knowledge and psychological and physical capacity to perform the behaviour, and the opportunity to make it possible. Thus, strategies that seek to motivate individuals should ensure that they provide access to information that is clearly understood and, to the best possible conditions, promote the uptake of advice. Ensuring that services linked to smoking cessation, avoidance of obesity, and promotion of physical activity are supported in the community offers the best potential to help generate individual motivation.

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interventions to address contributory psychosocial factors. Identifying and treating depression can be a major challenge: patients often have difficulty communicating problems with their mental health to others. These patients should be managed by trained staff and their significant others should be included in management plans to ensure effective social support.1 Frank discussions of their concerns, fears, and health beliefs are helpful in motivating them to adopt healthy lifestyle behaviours, participate in social activities, and adhere to medical therapy.

Conclusion Key health behaviours relevant to cardiovascular prevention include the avoidance of smoking, obesity, and physical inactivity. Shared understanding, between professionals and individuals, of barriers that adversely influence motivation to engage with effective prevention measures is important, particularly for depressed patients. Strategies to prevent cardiovascular disease should be tailored to individuals’ needs: their successful implementation depends on multidisciplinary professional teams working collaboratively within the context of local communities.

References 1. Piepoli MF, Corra` U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B, Cupples M et al. Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery. Eur J Prev Cardiol 2047487312449597, first published online June 20, 2012 PMID: 22718797. 2. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011;6:42. 3. Cole JA, Smith SM, Hart N, Cupples ME. Do practitioners and friends support patients with coronary heart disease in lifestyle change? A qualitative study. BMC Fam Pract 2013;14:126.

Common analgesics ‘pose cardiac risk’ Data suggest ibuprofen and diclofenac can slightly increase the risk of cardiac problems if taken in high doses for a long time People with severe arthritis often take ibuprofen and diclofenac which are also anti-inflammatories to go about daily life. A study, published last year in the Lancet,1 showed that the abovementioned two drugs posed even greater risks for smokers and the overweight. The researchers said some patients would deem the risk acceptable, but they should be given the choice. The risks have been reported before, but a team of researchers at the University of Oxford analysed the issue in unprecedented detail in order to help patients make an informed choice.

The group investigated .353 000 patient records from 639 separate clinical trials to assess the impact of non-steroidal antiinflammatory drugs. They looked at high-dose prescriptions levels of 150 mg diclofenac or 2400 mg ibuprofen per day, rather than over-the-counter pain relief. They showed that, for every 1000 people taking the drugs, there would be three additional myocardial infarctions, four more cases of heart failure, and one death, as well cases of gastro-intestinal bleeding— every year as a result of taking the medications. So the number of

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For the smoker, within the context of healthcare provision, motivation to stop smoking is best generated by ‘brief intervention’ and using the ‘5 A’s’ strategy.1 This involves asking patients about their smoking habit, advising them of the benefits of stopping, assessing their motivation to do so, assisting them by providing appropriate counselling and pharmacotherapy, and arranging review of their progress. A non-smoking ‘norm’ within their family and community network will encourage their maintenance of non-smoking behaviour. The introduction of national legislation to prohibit smoking in public places has been an effective strategy to help motivate smoking cessation for both individuals and populations. The obese patient’s motivation to lose weight is very dependent on their cultural beliefs and social support. Any strategy designed to motivate them to change their eating habits requires an initial assessment of their personal circumstances,1 and of barriers they may face in losing weight.2 Unhealthy eating behaviour is strongly influenced by a wide range of issues such as food availability, cooking habits, food policies, and cost, as well as personal dislikes and taste preferences.3 Health professionals’ attitudes and personal health beliefs and illness perceptions are also important factors that can impact either negatively or positively on individuals’ motivation for change.3 Collaborative working across all sectors of society, including environmental planning, transport, and education as well as health and social care, is essential to help sedentary patients to become physically active. Both social and professional support is needed to help make ‘the healthier choice the easier choice’. It is important to help individuals to understand the health benefits of physical activity and provide accessible and attractive opportunities, giving consideration to their location, the availability of professional support for exercise training, opening hours, support facilities such as childcare, availability of public transport, parking, the ‘walkability’ of areas and, within buildings, positioning stairways in more convenient locations than lifts. Reasons for patients not engaging in physical activity are complex, reflecting the value of using a framework2 to design interventions to motivate them to change. Patients with cardiovascular disease and depression are at an increased risk of adverse outcomes. They should be considered for referral for psychological counselling, medication, and other

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Prof Alan Silman, medical director of Arthritis Research UK, said the drugs were a ‘lifeline’ for millions of people with arthritis and were ‘extremely effective in relieving pain’. He added: ‘However, because of their potential side-effects, in particular the increased risk of cardiovascular complications which has been known for a number of years, there is an urgent need to find alternatives that are as effective, but safer’. Prof Donald Singer, member of the British Pharmacological Society and from the University of Warwick, said: ‘The findings underscore a key point for patients and prescribers - powerful drugs may have serious harmful effects. It is therefore important for prescribers to take into account these risks and ensure that patients are fully informed about the medicines they are taking’. Andros Tofield

Reference 1. Coxib and traditional NSAID Trialists’ (CNT) Collaboration. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials.The Lancet 2013;382:769 – 779.

CardioPulse contact: Andros Tofield, Managing Editor. Email: [email protected]

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myocardial infarctions would increase from 8 per 1000 people per year normally to 11 per 1000 people per year with the drugs. Prof Colin Baigent the lead researcher stated ‘three per thousand per year sounds like it is quite a low risk, but the judgement has to be made by patients. If you’re a patient and discuss it with your doctor, you are the one who should be making the judgement, whether three per thousand per year is worth it to allow you, potentially, to go about your daily life’. He said this should not concern people taking a short course of these drugs, for example, for headaches. However, he did warn that those already with cardiac risks would be at even greater risk as a result of the high-dose drugs. A similar drug, rofecoxib (Vioxx), was voluntarily taken off the market by its manufacturer in 2004 after similar concerns were raised. There are .17 million prescriptions of non-steroidal antiinflammatory drugs in the UK each year. Two-thirds are either ibuprofen or diclofenac. A third drug, naproxen, had lower risks of heart complications in the study and some doctors are prescribing this to higher-risk patients. The drug is similar to aspirin as an anti-thrombotic and this also increases the risk of gastro-intestinal bleeding.

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