Dirk De Bacquer

Observational studies and intervention trials provide the evidence base for developing strategies for primary and secondary prevention of cardiovascular disease (CVD). The Joint European Society of Cardiology recommendations on prevention of coronary heart disease published in 1994 was the first European guideline to summarize this evidence and propose prevention strategies for clinical practice with regular updates since. The implementation of these recommendations, and subsequent guidelines, was evaluated from 1996 onwards through the EUROASPIRE programme of surveys, which have evolved over a 30-year period, involving thousands of coronary and high-risk patients from hundreds of medical centres across 30 countries. This cycle of surveys over six iterations is described in this historical review, informing the need for quality improvements in real-life practice, both to prevent the development of atherosclerotic disease in high-risk individuals (primary prevention) and in those with established CVD (secondary prevention).

Background and Aims: We investigated whether patients with coronary heart disease (CHD) in Europe are achieving the standards set by prevention and rehabilitation guidelines. Variability in achieved standards was also studied: (i) between countries, (ii) between geographical risk regions, and (iii) according to attendance at cardiac rehabilitation (CR). Methods: EUROASPIRE VI is an observational study conducted between September 2024 and February 2026 in 160 hospitals across 27 countries. Geographical risk regions were defined as high, moderate, or low based on World Health Organization cardiovascular mortality data. Results were standardized by age and sex. Results: Among 8590 patients with CHD (23.7% female), 17.1% were current smokers, 32.0% were obese, and 33.5% reported low physical activity. 59.8% were above blood pressure target (systolic ≥130 and/or diastolic ≥80 mmHg), 82.7% were above LDL-cholesterol target (≥1.4 mmol/L), 32.8% had known diabetes of whom 42.2% had HbA1c ≥7%, and 30.6% had chronic kidney disease. Prevalences of these risk factors were all highest in countries from high-risk regions. 29.1% of patients attended at least one CR session, with country variability ranging from 0% to 79% and differing by risk region (55.9% low risk, 29.7% moderate risk and 10.2% high risk; P < .001). Attendance at CR programmes was associated with significantly better lifestyles, risk factor control, and use of cardioprotective drugs. Conclusions: Most European patients are not achieving targets set by prevention guidelines. Despite better outcomes for those attending CR, there is marked variability in CR attendance and evidence of inverse care, with lowest attendance in highest risk regions. These results provide a baseline to inform the challenges for future implementation of the first European Society of Cardiology guideline on CR.

Background and Aims: The 2021 ESC guidelines on cardiovascular (CV) disease prevention recommend the SMART-REACH lifetime risk model to guide treatment decisions in patients with established atherosclerotic CV disease. The aim was to develop the SMART-REACH2 model for estimating lifetime risk of recurrent CV events and treatment benefits in patients with established atherosclerotic CV disease, with systematic recalibration to the four European and other global risk regions. Methods: SMART-REACH2 was derived in 8708 individuals aged 40–90 years with coronary, cerebrovascular, peripheral artery disease and/or abdominal aortic aneurysm from the UCC-SMART cohort. Sex-stratified, cause-specific Cox models for recurrent CV events and non-CV death were fitted using age as timescale and routinely available predictors. Recurrent CV events were defined as a composite of myocardial infarction, stroke, or CV death. Recalibration was based on representative cohorts per risk region. External validation was performed in 2 085 780 patients from 54 countries; model performance was assessed by calibration plots and Harrell's C-statistic. Results: In the derivation cohort, 2057 recurrent CV events occurred over a median follow-up of 8.5 years (25th–75th: 4.3–13.0). In external validation, 307 706 events occurred. The pooled C-statistic was 0.68 (95% confidence interval 0.66–0.69) and ranged from 0.66 (0.64–0.69) for European low-risk region up to 0.72 (0.66–0.78) for Latin America, with adequate calibration across risk regions. Performance was consistent across sexes and CV disease subtypes. Using SMART-REACH2, estimated potential gains in CV disease-free life expectancy for a 50-year-old example patient receiving intensified preventive treatment (15 mmHg systolic blood pressure and 1.0 mmol/L low-density lipoprotein cholesterol reduction) ranged from 2 years in the low-risk region to 4.4 years in the very-high-risk region. Conclusions: The updated SMART-REACH2 model accounts for geographical and sex-specific variations and allows estimation of short-term and lifetime risk of recurrent CV events and treatment benefits, facilitating shared decision-making as recommended by guidelines.

Background Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. Methods Between 2020 and 2023, adults hospitalised in the previous 6–24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120–129/70-79 mm Hg) or below target (Results Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76–1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120–129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate Conclusions More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

Purpose Current research on potentially clinically significant drug-drug interactions (DDIs) in individuals with atrial fibrillation (AF) has predominantly focused on DDIs involving direct oral anticoagulants (DOACs), with limited evidence regarding other medications. Our study aimed to: (i) assess the overall prevalence of DDIs; (ii) investigate potential demographic correlates of DDIs; and (iii) examine the association of DDIs with adverse clinical outcomes in a nationwide cohort of older adults with AF and multimorbidity. Methodology Data from the Swedish national registers were linked to establish a cohort with a 2-year follow-up of adults ≥ 65 years who, on 1 January 2017, had a diagnosis of AF, ≥ 1 comorbidity and were prescribed ≥ 2 medications (n = 192,716). This study describes the prevalence of 72 potentially clinically significant DDIs from an adapted explicit international consensus list and a review focused specifically on DDIs involving DOACs. Correlates of DDIs were assessed through logistic regressions. Cox regression analyses were conducted to examine the association between DDIs and adverse clinical outcomes: overall and cardiovascular (CV) mortality, overall and CV hospitalisation, stroke, bleeding, and falls. Results In the overall population, 37.5% presented with ≥ 1 potential DDI, with CV (33.8%) and central nervous system (CNS) drugs (12.4%) most frequently involved. Sex, age, and civil status were most consistently associated with DDIs. Individuals with ≥ 1 DDI had a higher hazard of CV death (hazard ratio 1.28 95% confidence interval (CI) [1.24–1.32]), CV hospitalisation (1.12 [1.10–1.15]) and falls (1.06 [1.02–1.09]). DDIs with DOACs were associated with gastrointestinal bleeding (2.80 [1.35–5.81]). DDIs with CNS drugs were associated with stroke (1.19 [1.09–1.29]) and falls (1.32 [1.27–1.39]). Conclusion Potentially clinically significant DDIs were prevalent in older adults with AF and multimorbidity, with adverse clinical implications. Identifying these high-risk groups is essential for preventive strategies and effective clinical management.

Aims: Anxiety and depression are associated with poor outcomes in patients with coronary heart disease (CHD), however their association with achieving recommended cardiovascular prevention standards is unclear. We examined this association across all World Health Organization (WHO) regions. Methods and results: Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding 6–24 months with incident or recurrent CHD who underwent a standardized interview and examination (2020–2023) across 14 countries. The main outcome was the INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. A total of 4546 patients (21.1% women) with a mean (SD) age of 60.0 (10.3) were interviewed. Prevalence’s of anxiety and/or depression were greater in women than men, and prevalence of CHD lifestyle and behavioral risk factors increased alongside severity of anxiety and depression symptoms. Compared to those without symptoms, adjusted odds ratios for achieving a suboptimal INTERASPIRE-GTS were: 1.52 (95% CI 1.13–2.04, P = 0.006) for symptoms of depression; 1.57 (95% CI 1.09–2.26, P = 0.015) for “possible” comorbid anxiety and depression; and 2.09 (95% CI 1.22–3.57, P = 0.007) for those with “probable” comorbid anxiety and depression. Conclusion: Increasing severity of depression and anxiety symptoms are associated with reduced potential for achieving guideline standards for CHD secondary prevention. Secondary prevention programs should integrate risk-stratified management of individuals with symptoms of anxiety and/or depression to improve CHD guideline targets. Lay summary: We examined if patients with symptoms of anxiety and/or depression were more or less likely to achieve guideline standards for secondary prevention of coronary heart disease (CHD).Increasing severity of symptoms of anxiety and depression was associated with reduced potential for achieving guideline standards for secondary prevention of CHD.A higher proportion of women with CHD experience more severe levels of anxiety and depression on their own, and combined as a comorbidity.Patients with CHD should be treated holistically, acknowledging the heart and mind connection.

Background: INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods: Patients 18–80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results: Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76–1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions: INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.

Aims: Lipoprotein(a) [Lp(a)], an inherited lipoprotein, was measured in patients with coronary disease participating in the INTERASPIRE study. The aim of this study was to survey patients’ knowledge and perceptions of cardiovascular risk and their views on Lp(a) testing, consequences, and treatment. Methods and results: In seven participating countries, recruited patients were divided into those with elevated Lp(a) [≥ 50 mg/dL (≥115 mmol/L)] and those with normal levels. In the elevated group, patients were given an educational leaflet about Lp(a), advised to see their physician and subsequently attended a telephone interview that included study-specific questionnaires assessing knowledge, risk perception, and interest in and acceptability of Lp(a) testing. A random sample of patients with normal Lp(a) were interviewed in the same way. Eight hundred fifty-six patients were interviewed, 523 (22.6% female) with normal Lp(a) and 333 (29.1% female) with elevated Lp(a). Knowledge of cardiovascular disease (CVD) was similar in both groups with a score of 62.1% in normal Lp(a) and 59.6 in elevated Lp(a) P = 0.073. Knowledge of Lp(a) and its management in both groups was poor. Patients with elevated Lp(a) were worried by their result but found testing acceptable and appreciated the benefits. They were motivated to reduce their risk of CVD despite the absence of medical therapies and were eager to receive advice. Conclusion: Health professionals working in CVD care should be aware of the need to investigate patients with coronary disease for Lp(a) and be equipped to give advice on how to reduce overall cardiovascular risk especially given the absence of licenced therapies to treat Lp(a).