We know how to prevent repeat heart attacks and strokes. So why aren’t we better at it?
30 June 2021
Heart attack and stroke are among Europe’s biggest killers, and a leading cause of unplanned hospitalisations. Secondary prevention is key to reducing this burden.
More people now survive major cardiovascular events than ever before; 17 million people in the EU are living with coronary heart disease or have experienced a stroke. Governments across Europe still haven’t grasped the importance of focused prevention efforts among these high-risk groups.
Slow progress in cardiovascular disease is holding our societies back
Remember when life expectancy kept going up? How inevitable the march of societal progress in health then seemed. Yet after years of consistent growth, the uncomfortable truth is that the trend of increasing life expectancy is slowing across Europe, and in some cases even halting. COVID-19 has played its part, but it is not the sole reason; the trend pre-dates 2020. One of the major causes of this slowdown is the growing prevalence of cardiovascular disease, which includes Europe’s biggest killers: heart attack and stroke.
How can repeat heart attacks and strokes be prevented?
Most governments, and indeed people, grasp the need to reduce the most common lifestyle causes of heart disease and stroke, such as obesity, smoking, poor diet, lack of exercise and, increasingly, pollution and stress. In recent years, many ministries of health have woken up to the need to improve early identification and treatment of common underlying conditions that can lead to a heart attack or stroke, such as high blood pressure, high cholesterol, abnormal heart rhythm (such as atrial fibrillation) and type 2 diabetes. It’s work in progress, true, but you can see clear movement for the better.
Data from Sweden show that one in five people who survive a heart attack has another heart attack, a stroke, or dies of other cardiovascular illness within the first year.
There is much less understanding, however, that many of the worst outcomes come from the highest risk groups. The number of people who now survive a heart attack or stroke continues to rise, and many will experience more than one. In fact nearly half of all major coronary events (such as a heart attack) occur in people who are known to have coronary heart disease, and between a quarter to a third of strokes are repeat events. Data from Sweden show that one in five people who survive a heart attack has another heart attack, a stroke, or dies of other cardiovascular illness within the first year. This is what is meant by secondary prevention: preventing a second or subsequent heart attack or stroke, as opposed to primary prevention – stopping them from occurring in the first place.
In theory, vast numbers of repeat heart attacks or strokes can be prevented. People who have experienced one should be ‘on the radar’ of their health systems, and duly prioritised for more intensive prevention efforts, particularly after discharge. Multi-component disease management programmes can reduce the chance of a repeat heart attack by one third and of a repeat stroke by two thirds.
The reality check: gaps in prevention and care, and people left at risk
In reality, if you had a heart attack or stroke today, the odds of receiving the care needed to avoid a second one are not good. Prevention should be initiated immediately in hospital, but this doesn’t routinely happen. When discharged, fewer than half of heart attack patients are referred to crucial preventive cardiac rehabilitation programmes, and lifestyle management programmes post-stroke are only available in half of European countries.
What does this mean for the heart attack or stroke survivor? It means that they don’t get effective help to give up smoking, exercise more or lose weight (in fact, obesity rates in people who have had a heart attack have increased), nor are they supported to fully understand and engage in their medical treatment, rehabilitation or follow-up care, leaving them ultimately at risk of another debilitating and possibly fatal event.
Governments have the care models to improve secondary prevention in cardiovascular disease, but analysis has shown that policies lag behind most other non-communicable diseases in European countries.
What can governments do to improve secondary prevention?
Governments have the care models to improve secondary prevention in cardiovascular disease, but they appear hesitant to push health systems to achieve consistent success in this area. Analysis has shown that policies lag behind most other non-communicable diseases in European countries. This is perhaps all the more baffling as failures in cardiovascular disease prevention cost our societies a lot of money, and create inequality. In many European countries, stroke, heart attack and other types of cardiovascular disease take up a large, if not the biggest, proportion of healthcare spending.
How did we get here? There are several possible explanations, but most commentators agree that progress from primary prevention and lifestyle changes, particularly reducing smoking, has been widely seen as ‘good enough’ by ministries of health. It is also clear that policymakers still do not understand the role of cardiovascular disease a as major cause of hospital admissions.
This has to change, and fast. No central plan or strategy makes a difference purely on its own, but it can give a clear framework to understand the scale of opportunity, where to invest, and what societies expect to see achieved. It would also send a clear message of intent to health systems in need of leadership and vision.
A message, then, to every government across Europe promising to rebuild, invest in sustainability and resilience, and secure greater fairness in health and wellbeing:
Start with cardiovascular disease, and think big.