Out of the six global regions divided by the World Health Organization (WHO), Europe has the most significant burden of cardiovascular risk factors. Smoking, estimated to cause about 10% of the cardiovascular diseases worldwide, had the highest prevalence in this region (29%). Hypertension is present in almost a third (28.1%) and elevated blood glucose can be found in 10.1% of the population. Obesity represents a major health issue in Europe as 23% of adults aged over 18 have a BMI greater than 30kg/m2. Of further concern, according to WHO statistics on non-communicable diseases (NCDs), hypercholesterolaemia is noted in half of the population (53.7%).1
In light of this evidence, as well as the rapidly increasing burden of cardiovascular disease (CVD) in low and middle income countries the WHO has set a global target to reduce the premature mortality from NCDs by 25% by 2025 and the World Heart Federation (WHF) is pursuing a reduction in premature mortality from cardiovascular disease of 25% by 2025. In order to achieve this target, goals include to reduce physical inactivity by 10%, high levels of salt intake by 30%, tobacco use by 30%, prevalence of raised blood pressure by 25% and to prevent heart attack and stroke through secondary prevention in 50% of eligible populations.2 A number of European countries are well on their way to accomplishing this objective and in order to promote their examples the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) has been publishing monthly reports focusing on the ‘Country of the Month’ elaborated by National Coordinators of Cardiovascular Prevention.3
Prevention in Europe
The European Heart Network (EHN)4 operates alongside the professional societies in Europe. Based in Brussels, EHN focuses on structural changes through EU-wide regulation. EU regulation tends to also have an impact in European countries that are not members of the EU. EHN is a founding member of the EU Platform for Diet, Physical Activity and Health (the Platform), which endeavours to set the pace for reformulation of food and drink products and standards for restricting marketing of high fat, salt and sugar foods (HFSS) to children. Salt reduction was singled out by the High Level Group (of EU member states) on Diet and Physical Activity working in tandem with the Platform. EHN is a member of the European Chronic Disease Alliance (ECDA).5 ECDA advocates for an EU strategy on chronic diseases, which should adopt the global targets. ECDA has recently published its policy recommendations on alcohol. The EHN is a founding member of the Smoke Free Partnership (SFP). Active lobbying led to the adoption of an EU directive on tobacco with world-class standards. The EHN is actively lobbying the European Commission with a view to have an EU regulation mandating maximum levels of industrially produced trans fatty acids.6
© World Heart Federation.
Country of the month
Germany’s main risk factor is hypertension (55%), followed by being overweight (36%) and smoking (30%). Each year in November the German Heart Foundation launches a national educational campaign highlighting one specific topic: cardiovascular risk factors, prevention and early recognition of myocardial infarction (MI), or symptoms of heart failure, valvular heart diseases or of rhythm disturbances (in particular atrial fibrillation with its associated risks). Its aims for the future include achieving comprehensive smoking bans and developing risk stratification by a scoring system that will become part of the routine comprehensive evaluation at age 35 years.3
Iceland is afflicted by physical inactivity (46%), which highly correlates with being overweight (43%), as well as hypertension (28.8%) and smoking (14.3%). The main prevention strategies are a tobacco point of sale ban introduced in 2001 and a total ban of smoking in public spaces introduced in 2007. The Directorate of Health led a nationwide campaign for a reduction in total salt and saturated fat consumption. Its aims for the future include interventions aimed at the increasing prevalence of obesity and diabetes, interventions against recruitment of smokers, and smoking cessation.3
As with other European countries, Ireland struggles with being overweight and obesity (61–64% of its population) and smoking (22%). That is why it has launched a tobacco-free society aligned with the 2025 programme, in addition to a childhood obesity campaign. It aims to increase the proportion of people who are healthy at all stages of life and to achieve a smoking rate of less than 5% by 2025.3
The Netherlands is combating hypertension in 33% of its male population and 20% of its female population, smoking (25%) and diabetes mellitus (14% men and 11% women). Universal prevention is aimed at the general population, with the goal to promote health by reducing the burden of risk factors. Selective prevention identifies groups (of subjects) at high risk with the provision of targeted and tailored preventive measures to all individuals with risk factors.3
Estonia has one of the highest rates of hypercholesterolaemia (59.2%), followed by hypertension (47.3% in men and 33.2% in women) and smoking (46% men, 23% women). It aims to extend the healthy life years (or disability-free life) expectancy and average life expectancy for women and men by three years by 2020.3
Reports from Sweden show a high rate of hypertension (46%) and physical inactivity (47%), followed by smoking (22%) and obesity (19.9% men and 17.3% women). That is why all undergraduate programmes leading to a healthcare profession at university level develop competence in preventive medicine. At the residency level there are also compulsory goals on preventive and health promoting competences at both the individual patient and group level for all specialties including cardiology. Sweden aims to see more use of national quality registers in the preventive strategies and new individualised models of cardiac rehabilitation.3
Bulgaria’s main concerns are smoking (36%) and hypertension (42.8% in men and 39.7% in women). A National Health Care Strategy has been adopted for the period 2014–2020, in which the reduction of cardiovascular diseases takes a central place. It aims at educating individual patients as well as the general population to restrict the increasing prevalence of hypertension, promote physical activity and combat being overweight especially among children and young people.3
Poland has one of the highest prevalence rates of hypercholesterolaemia (61%), followed by hypertension (32%) and smoking (27%). It has undertaken a wide range of activities concerning prevention such as ‘schools in movement’, which promotes physical activity and healthy food choices in schools and kindergartens. The Polish Forum for Prevention of Cardiovascular Disease advocates for harmonisation and dissemination of guidelines on prevention of cardiovascular disease, and educates policy makers, physicians and patients.3
Slovakia is also one of the top ranking European countries in the prevalence of hypercholesterolaemia (49%), followed by hypertension (32%) and obesity (26%). It developed several major projects including “I am 65+, I live healthy”, which is designed for seniors. It aims at strengthening the primary care system by focusing on cardiovascular health promotion, including smoking cessation, increase in physical activity and obesity prevention.3
Slovenia struggles with being overweight, which affects almost three quarters of its population (71%), hypercholesterolaemia (66.2%) and hypertension (32.5%). Its prevention activities include a nation-wide programme on primary prevention of CVD through screening launched in 2000. Slovenia aims to create a national registry for secondary prevention, modernise cardiac rehabilitation and run a national prevention campaign predominantly for patients post-myocardial infarction.3
Latvia is among the countries with highest rates for hypercholesterolaemia (72%), followed by hypertension (52.9%) and smoking (52% men and 18% women). Their main CVD prevention activities are officially published in the “Public Health Strategy for 2011–2017” and “Action plan of improvement of CV health for 2013–2015”. The goal on the national level is to decrease the premature CVD mortality of men by x% to 220/100,000 and by y% to 60/100,000 for women.3
Lithuania mostly toils with hypertension (33%), hypercholesterolaemia (23%) and smoking (17%). The key document, the National Health Concept (Supreme Council of the Republic of Lithuania, 1991), developed new approaches to healthcare, including introduction of the concept of health insurance, prioritising disease prevention and developing primary care. The Lithuanian High Cardiovascular Risk (LitHiR) programme, aimed at estimation and aggressive managing of cardiovascular risk factors, was launched in 2006. However, the primary care system needs strengthening so that more patients are treated instead of being referred to a specialist.3
In Russia, the prevalence of smoking has declined in men over the past 10 years but is still high at 44%; conversely, it has increased in women and is now at 14%. However, the incidence of obesity and hypertension has increased significantly in recent years. In 2012 the Russian Ministry of Healthcare stipulated procedures for the organisation of medical rehabilitation. The goal is to provide cardiac rehabilitation for 25% of those in need by the end of 2015. Russia is aiming to ensure complete elimination of tobacco use.3
Kazakhstan has a high prevalence of hypercholesterolaemia (50%), followed by hypertension (36%) and smoking (24%). Led by the Ministry of Health, a screening programme is the main element of prevention with primary care centres implementing it in practice. This active national screening programme covers the entire population aged 25–64 for early detection of CVD and diabetes. Kazakhstan’s primary and immediate goal is to introduce a contemporary system of epidemiological surveillance of the main NCDs and start a broad research programme.3
Portugal is among the European countries that has the highest rates of hypercholesterolaemia (63%), followed by hypertension (42%) and smoking (18%). The average life expectancy at birth in Portugal in 2012 was 80.6 years, which is slightly above the EU28 average. Their main aims for the future include implementing four national priority programmes incorporating new recommendations and accepting the Diabetes Challenge proposed by the Calouste Gulbenkian Foundation.3
Spain has a prevalence of hypertension in 43% of the population, closely followed by hypercholesterolaemia (41%) and obesity (29%). The Spanish Society of Cardiology and the Spanish Heart Foundation are involved in many cardiovascular prevention programmes such as Mimocardio and R-EUReCa (Spanish Registry of Cardiac Rehabilitation Units). Spain aims to improve adherence to the Mediterranean diet and to achieve a wider implementation of cardiac rehabilitation programmes all over the country.3
Malta has a high prevalence of hypercholesterolaemia (68% in men and 56% in women), followed by hypertension (33%) and obesity (22%). Malta was one of the first countries to ban smoking in public buildings, leading to a decline in smoking prevalence, and is a signatory to the charter on counteracting obesity, and the Vienna Declaration (2013). Prevention activities include The Healthy Eating Lifestyle Plan and Healthy Weight of Life Strategy with interventions such as ‘walking buses’. Malta aims to make healthy living the “natural choice”, facilitated through education, intuitive tools and collaborative communities within a supportive environment ‘nudging towards health’.3
The United Kingdom faces an important threat represented by obesity in 18.9% of children aged 10–11 years old. There is also hypertension (31%) and smoking (21%). NHS Health Checks (England) have the objective to deliver five-yearly free health checks to everyone between 40 and 74 who has not previously been diagnosed with a cardiovascular disease. The UK aims to encourage senior cardiologists to be more involved in prevention.3
Greece occupies a leading position regarding smoking (51% men, 39% women), followed by hypercholesterolaemia (46% men, 40% women) and hypertension (37% men and 25% women). Education of the medical profession in primary and secondary prevention, press conferences and publications, tobacco control activities, collaboration between the Civil Servants’ Confederation (ADEDY), the Hellenic Labor Inspectorate (SEPE) and the Public Health doctors of the Ministry of Health and Social Solidarity (Security) aim to define laws prohibiting smoking, to implement actions for anti-tobacco initiatives and to raise awareness in both public and private sector workplaces.3
Physical inactivity represents one of the main risk factors in Italy (46.1% women, 32.3% men), followed by hypercholesterolaemia (34.3% men and 36.6% women) and hypertension (27.4% women and 25.9% men). The main prevention activities include ‘Progetto Cuore’, which since 1988 provides important information about CVD epidemiology, risk factors and risk stratification, having collected data from more than 4500 primary care physicians. Italy aims to decrease the percentage of obese people, and those with overweight and metabolic syndrome, improve access to cardiac rehabilitation and advise the general population regarding smoking cessation, healthy eating and increasing physical activity.3
Israel’s greatest risk factor is hypertension that affects 31% of the population, obesity (25%) and smoking (24%). The Forum for Preventing Cardiovascular Diseases provides educational and medical screening projects in workplaces, schools and other public settings. The aims for the future include enhancing activities related to ‘neglected’ risk factors such as smoking, physical inactivity and targeting high-risk populations (35–60 year old individuals and certain ethnic groups).3
Turkey is challenged mostly with obesity (36%), hypertension (31.4%) and hypercholesterolaemia (25%). The Ministry of Health leads the main influential projects for cardiovascular health, like the National Tobacco Control Program and the recently started Obesity Prevention and Control Program.3
Romania has a high prevalence of hypercholesterolaemia (45.8%),7 hypertension (31.8%),7 smoking (26.7%)8 and obesity (20.5%).9 Important efforts have been made to stimulate physical activity through Athletic Cardio Club, an increasing group of medical professionals attempting to set an example for their patients, which has evolved into a club for all sports enthusiasts trying to live a healthy life. The Romanian Heart Foundation, a member of the European Heart Network, has a mission to reduce cardiovascular disease for all people in Romania through various activities such as The Heart Promenade each year on 29 September, World Heart Day.
The European Association for Cardiovascular Prevention and Rehabilitation (EACPR) has issued as early as 2008 a call to action for all member countries in order to achieve the targets set for 2025 by creating multidisciplinary national task forces which will develop national strategic plans for cardiovascular prevention. Importantly, the information summarised in this article is an example of this effort.
We would like to give thanks for the immense help offered by Joep Perk, Ian Graham, Britta Ettelt and all EACPR National CVD Prevention Coordinators.