Family Practice Vol. 21, No. 3, 304-306
Family Practice Vol. 21, No. 3 © Oxford University Press 2004, all rights reserved.
Secondary prevention of coronary heart disease is disappointing among patients of working age
Kangasala Health Centre, a Department of Public Health, University of Turku, b Raisio District Hospital, Department of Public Health, University of Turku and c Medical School, University of Tampere and Department of General Practice, Hospital District of Pirkanmaa, Finland
Correspondence to Markku Sumanen, Marhamintakuja 6, 36240 Kangasala, Finland; E-mail: markku.sumanen{at}kolumbus.fi
Received 7 May 2003; Revised 29 August 2003; Accepted 7 January 2004.
Sumanen M, Koskenvuo M, Immonen-Räihä P, Suominen S, Sundell J and Mattila K. Secondary prevention of coronary heart disease is disappointing among patients of working age. Family Practice 2004; 21: 304–306.
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Abstract |
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Background. The risk factors underlying coronary heart disease (CHD) are well known.
Objective. The purpose of this study was to evaluate risk factors related to secondary prevention of working-age CHD patients.
Methods. CHD patients with (n = 139) and without (n = 203) myocardial infarction were selected from a postal questionnaire study (n = 21 101) of randomly selected Finns aged 20–54 years (HeSSup study). Four age- and sex-matched controls were chosen for every patient.
Results. CHD patients still smoke, are obese and suffer hangovers more frequently than the control population.
Conclusion. The health care system has not succeeded in the secondary prevention of CHD.
Keywords. Angina pectoris, coronary heart disease, myocardial infarction, risk factors, secondary prevention.
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Introduction |
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The risk factors underlying coronary heart disease (CHD), i.e. high cholesterol, elevated blood pressure, diabetes mellitus, smoking and middle-body obesity, are well known. Therefore, the prevention of the condition has become substantially more effective; in particular, the use of statins has increased throughout the West since the 1990s.1 In Finland, acute coronary events have been considerably reduced with lipid-lowering drugs.2 Smoking has been regulated by legislation, and health education is available to all. The care of hypertension has been steadily reinforced, and the role of dieting is widely understood. People also expect doctors to pay attention to the life habits of their patients and the prevention of CHD.3 The extent of awareness of risk factors in the population of working age is thus a matter of interest.
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Methods |
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The Health and Social Support (HeSSup) study is a prospective postal follow-up survey and involves a random sample of 52 739 individuals of working age stratified in equivalent shares according to age brackets 20–24, 30–34, 40–44 and 50–54 years. The sample was drawn from the Finnish Population Register Centre. Baseline questionnaires of 21 101 individuals (40% response) were used for this study. Careful non-response analysis indicated that differences in physical conditions between the study participants and the whole population were small.4
There were 110 items in the questionnaire concerning the most central areas of life, including health habits, medication and diagnosed illnesses. The subjects were asked whether or not a doctor has told them that they have or have had angina pectoris or a myocardial infarction.
Risk factors were mapped by asking whether or not a doctor had ever said that the study participant had a high cholesterol level, diabetes or high blood pressure. Smoking was examined by asking whether the participant had ever smoked regularly, and whether he or she still smoked regularly. Height, current weight, maximal weight during lifetime and weight at the age of 20 were also established. The corresponding body mass indices (BMIs) were calculated. The consumption of alcohol was mapped by asking the frequency of hangovers during the last 12 months. A hangover at least once a month was considered frequent. Study participants were also asked whether or not they had been abstinent throughout their life. They were asked how much and how exhausting exercise they took, and the exercise variable was then calculated according to how strenuous the exercise had been. For volume of activity, an activity metabolic equivalent (MET) index5 was used. Finally, the index was divided into two classes, the limit being two MET hours of exercise daily.
For interpretation of the results, the CHD patients were divided into two groups. The first comprised coronary patients not having had an infarction (angina group) and the second patients having had an infarction (infarction group). The proportions were compared with control groups formed by giving every patient four randomly selected age- and sex-matched controls. Statistical significance was tested with the chi-square test. The analyses were made using the SAS System for Windows, release 8.2/2000.
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Results |
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Among the study participants there were 203 CHD patients who had not experienced a myocardial infarction and 139 who had.
Risk factors
In the angina group, one-third and in the infarction group two-thirds had elevated cholesterol (Table 1). Half of the angina group and two-thirds of the infarction group had elevated blood pressure. Diabetes was not common in the angina group, but concerned one in five in the infarction group. All of these risk factors were not as common among controls. In the angina group, every one in three and in the infarction group almost every one in two subjects was obese. In the angina group, more than half and in the infarction group two-thirds had had a BMI of at least 27 kg/m2. Among controls, about one-third were obese. In both CHD groups, the present average BMI and the average maximal BMI were higher than in the control groups, but only the differences in the average maximal BMI were statistically significant.
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More than half in the angina group and almost three-quarters in the infarction group had smoked (Table 1). In both groups, half had stopped smoking. In this respect, they did not differ from the controls. In both CHD groups, one in five reported frequent hangovers. In the control groups, about one in six suffered from frequent hangovers. In both CHD groups, one in 20 reported lifelong sobriety. Among controls this was rarer. Lack of exercise was also more common among CHD patients than among controls. The difference, however, was statistically significant only between the infarction group and their controls.
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Discussion |
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The chief finding in this study was that CHD patients, despite having survived a life-threatening clinical event, appear to have continued adverse behaviours such as smoking, being obese and having frequent hangovers more than the control population. Clearly the health care system has not succeeded in secondary prevention of CHD, when the issue is considered from the people's point of view.
The findings reflect the respondents' own conception of their risk factors and CHD. This must be considered important since according to findings from a 3-year follow-up of 4000 men, self-reported CHD predicts a new coronary event.6 An individual's own conception of risk factors has an influence on their actions and lays the foundation for guidance.
It is highly likely that there are persons who were not aware of their risk. It is also likely that many of them who had reported elevated blood pressure and high cholesterol already had been treated for these risk factors. Thus they had had their blood pressure and lipid levels under at least some kind of control.
There are European consensus and national guidelines on ideal risk factor levels and treatment procedures. According to our findings, however, secondary prevention of the disease has been disappointing. The implication of guidelines for a reasonable everyday practice constitutes a great challenge to doctors in primary health care.
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References |
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1 EUROASPIRE I and II Group; European Action on Secondary Prevention by Intervention to Reduce Events. Clinical reality of coronary prevention guidelines: a comparison of EURO-ASPIRE I and II in nine countries. Lancet 2001; 357: 972–973.[CrossRef][Web of Science][Medline]
2 Heinonen OP, Huttunen JK, Manninen M et al. The Helsinki Heart Study: coronary heart disease incidence during an extended follow-up. J Intern Med 1994; 235: 41–49.[Web of Science][Medline]
3 Danielsson B, Åberg H, Strender LE. Evaluation of changes in public interest concerning lipids and other cardiovascular risk factors between 1990 and 1995. Scand J Prim Health Care 2000; 18: 183–187.
4 Korkeila K, Suominen S, Ahvenainen J et al. Non-response and related factors in a nation-wide health survey. Eur J Epidemiol 2001; 17: 991–999.[CrossRef][Web of Science][Medline]
5 Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. J Am Med Assoc 1998; 279: 440–444.
6 Koskenvuo M, Kaprio J, Rose RJ et al. Hostility as a risk factor for mortality and ischaemic heart disease in men. Psychosom Med 1988; 50: 330–340.
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