Ask anyone what, in their opinion, the main cause of death is in their country, and they would probably answer cancer, or infections or even violent death. However, the reality is that in almost every country, especially those in the first world, people die most frequently from cardiovascular diseases, especially heart attack and stroke. In Spain, for example, a third of deaths in 2013were down to these causes, ahead of cancer and respiratory diseases. In the rest of Europe things are no better: cardiovascular diseases are the leading cause of mortality, accounting for more than 4.3 million deaths a year, 48% of the total. In particular, coronary heart disease is the cause of 1.9 million deaths and stroke 500,000 deaths every year.
It is true that in recent years things have improved significantly. In fact, the greatest increase in human life expectancy has occurred since the second half of the twentieth century, mainly due to new diagnostic techniques, new surgical procedures, such as angioplasty and by-pass among others, and through the development of new drugs. However, while evidence supporting the benefit of these interventions has accumulated, their application in practice is far from perfect. And this happens both in primary prevention - before a cardiovascular event – and in secondary prevention, when treatment is aimed at preventing a repeat event after a first cardiovascular episode has already occurred.
The good news is that many of the factors that lead to an increased risk of cardiovascular disease are modifiable. This means that they can be corrected by lifestyle changes, such as exercise and diet, and pharmacological treatment. But reducing mortality from cardiovascular causes is a task that involves not only the doctor and the health authorities, but also the patients themselves. If the patients are not clear about the severity of their illness, about their co-responsibility in decision making and, above all, about the need to make lifestyle changes and take the prescribed medication, then the doctor must swim against the stream and the public administration runs up extra costs.
An example: it is stating the obvious, but if you don’t take a drug, then it has no effect. So there is no point in prescribing it and buying it from the pharmacy. It is just a waste of time and money. Serious attempts have been made over many years to ensure that patients take their medication. These initiatives, led by the health authorities, must try and change the authorities themselves, the attitude of health professionals and patients, and the drugs being prescribed, so that the treatment of cardiovascular disease fulfills the objective of reducing deaths and preventable disabilities.
Adherence: unfinished business
In 2003, the World Health Organization defined the term adherence as "the extent to which a person’s behaviour - taking medication, following a diet, and/or executing lifestyle changes - corresponds with agreed recommendations from a health care provider”. It comes as something of a surprise to find out that 24% of patients are not taking the treatment prescribed by the doctor within just seven days of discharge after a myocardial infarction. Furthermore, 34% of patients discontinue the treatment of at least one of the drugs in the first month after discharge. This leads to an avoidable progression of the disease, and therefore a greater risk of complication, reduced functional capacity, poor quality of life and even death.
This is also an important problem because it generates very high costs for the health system, since patients require more visits to the emergency services, more hospital admissions and more treatment.
The solution: everyone’s responsibility
Strategies are needed to improve adherence, but this means improving communication between doctor and patient, and getting the patients involved in their own treatment. The complexity of the treatment is also a fundamental aspect, since the number of medications taken by a patient every day is one of the factors that most affects adherence. A patient with a cardiovascular disease takes on average more than four drugs a day. And they often have other diseases that also require medication. So it is likely that six, seven or eight medications need to be taken every day.
In recent years, great efforts have been made to simplify the therapeutic regimen. This has led to the development of a new concept known as a polypill: a capsule containing a combination of the drugs most used for cardiovascular diseases. The use of a polypill allows the patient to receive the same treatment but with fewer daily drugs. This results in better adherence and, consequently, better health and quality of life.
In summary, then, there are various strategies that can help reduce the impact of cardiovascular disease in society. And we should use them, especially when we have drugs that prevent the consequences of these diseases, that are accessible and that do not have to be a burden on our daily lives. The polypill is an example of this: it leads to greater adhesion and reduces costs for the health system.
Taking advantage of these resources is everyone's responsibility. We should never accept a single avoidable death.