Principal findings
The A-3-P survey shows that a large majority of high CVD risk patients in England, identified by long-term use of therapies for hypertension, lipid-lowering or diabetes, fail to achieve the lifestyle, risk factor and therapeutic targets set by the Joint British Societies’ (JBS3) on CVD prevention1 and NICE guidelines on hypertension management and cardiovascular risk assessment and reduction, including lipid modification30–32 Lifestyles are unhealthy with correspondingly high prevalences of obesity and central obesity, and inadequate blood pressure, cholesterol and glucose control. A wide treatment gap exists between the evidence-based guidelines and clinical practice.
Overall, 1 in 10 of high CVD risk patients were current smokers, with a significantly higher prevalence in men compared with women. Moreover, over a third of current smokers had no recall of professional advice to stop smoking in the last 3 years and more than two-fifths did not intend to quit smoking within the next 6 months. Stopping smoking is the most cost-effective strategy for CVD prevention.33
Healthy diet and weight loss (≥5% initial weight) is associated with moderate improvement in BP, LDL-C, triglyceride and glucose levels among individuals with overweight/obesity.4 Weight loss reduces or delays the development of T2DM in persons with obesity.4 13 About one-fifth of obese patients have never been told they were overweight by a health professional and two-fifths were not advised to follow dietary guidelines. More than two-thirds of patients reported not receiving any professional advice on physical activity, three-fifths were not achieving the physical activity goal and a quarter were not involved in any planned physical activity.
There is a wealth of scientific evidence that control of blood pressure, lipids and glucose can reduce the risk of CV events in high-risk patients.6–14 High blood pressure is one of the most important treatable causes of premature morbidity and mortality.28 The most recent 2019 NICE NG136 guidelines on the diagnosis and treatment of hypertension in adults recommends that the clinic blood pressure treatment target should be <140/90 mm Hg for everyone aged under 80 years, including people with type 2 diabetes.31 The major change in this new guideline is that it adds people with a moderate risk of developing CVD (QRISK of between 10% and 19% of developing CVD in the next 10 years), rather than just those at high risk of CVD, to the list of indications in which drug treatment can be offered. This brings the risk threshold for treatment in hypertension in line with that for statins.31 It also goes further in recommending treatment be considered in younger patients (under 60 years) with QRISK less than 10% risk, where there might be concerns about their ‘lifetime risk’.30 In this survey, just over a third achieved the recommended target of <140/90 mm Hg. Less than half of patients on blood pressure-lowering medication were aware of their blood pressure level and only two-fifths knew their blood pressure target. Importantly, nearly half of patients at high CVD risk because of treated dyslipidaemia and/or diabetes had blood pressure>140/90 mm Hg but without any antihypertensive medication prescribed.
Lipid management was very poor with two-fifths of patients on lipid-lowering medication having LDL-C≥2.5 mmol/L. More than half of patients in this group had never been told they had high cholesterol. Only two-fifths were aware of their TC level and less than a third reported knowing their cholesterol target. A large majority (nearly 90%) of high risk patients, because of treated hypertension and/or diabetes, had LDL-C≥2.5 mmol/L but without any lipid-lowering therapy being prescribed. The most recent NICE guidelines on CVD risk assessment and reduction, including lipid modification (CG181) together with the updated NICE pathway on lipid modification therapy for preventing CVD, recommend offering atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD, estimated using the QRISK V.2 assessment tool.31 32 NICE pathway on lipid modification therapy for preventing CVD, last updated in 2021, recommends measuring TC, HDL cholesterol and non-HDL cholesterol in all people who have been started on atorvastatin 20 mg for primary prevention at 3 months of treatment and aiming for a greater than 40% reduction in non-HDL cholesterol.30 However, in contrast to the European guidelines, there is no LDL-C target for primary prevention in the JBS3 and NICE lipid modification guidelines.
According to the JBS3 guidelines, people with diabetes mellitus type 2 should be considered and managed as high CVD risk and prescribed cardioprotective medications including ACE inhibitors/ARBs and statins.1 However, in this survey, two-fifths of patients with known diabetes had HbA1c above the guidelines target of <7%, two-fifths were on ACE inhibitors/ARBs and less than three-fifths on statins. The OGTT in those without self reported diabetes demonstrate that nearly two-fifths of patients had some form of dysglycaemia (IFG, IGT or newly diagnosed diabetes).32 As the OGTT is the only test which most reliably identifies all patients with diabetes and also those with IGT34,35,36 screening with an OGTT should be recommended for all patients at high CVD risk without self-reported diabetes.
There may be several explanations for the poor control of blood pressure, lipid and glucose, such as unhealthy lifestyles, monotherapy, low-dose prescriptions, not up-titrating of medications to achieve risk factors targets, the absence of such targets, physician inertia to treat patients according to the recent guidelines and poor patient adherence with medications. The most recent guidelines recommend in most patients initiating antihypertensive treatment with a two-drug, preferably as a single-pill combination. One of the explanations for the poor lipid management in patients may be the absence of LDL-C target for primary prevention in the JBS3 and NICE lipid modification guidelines both recommending initiation of Atorvastatin 20 mg in all people at high risk of developing of CVD. In addition to the poor glycaemic control in patients with self-reported diabetes, there were many patients without known diabetes who had some form of dysglycaemia including undetected diabetes.
Importantly, a large majority of patients in this survey identified as being at high CVD risk on the basis of being prescribed blood pressure and/or lipid-lowering medications and/or having diabetes, had more than one of these risk factors. Overall, 41.8% had one, 39.4% had two, 5.6% had three and 0.2% had four uncontrolled cardiovascular risk factors (current smoking, elevated blood pressure, elevated LDL-C or uncontrolled diabetes). Only 13.0% had all four risk factors controlled. As total cardiovascular risk is a function of the interaction of many risk factors, the multifactorial risk factor management is important because modest increases of several risk factors can result in a higher absolute risk than a high level of a single risk factor. Screening and managing all CVD risk factors is more effective than treating single risk factors in isolation. This is acknowledged in the JBS3 and NICE lipid modification and hypertension guidelines recommending the assessment and managing of blood pressure, lipids and diabetes according to total cardiovascular risk using the QRISK V.2 risk assessment tool.
Comparison with other surveys
A comparison between A-3-P (2017–2019) and ASPIRE-2-PREVENT (2008–2010) is provided to illustrate possible trends in lifestyle and attainment of risk factor targets but without formal statistical tests as these two surveys were conducted in different general practices which may not be comparable, the patients are older in the third survey and there was a difference in the identification of the study populations with a lower proportion of patients identified at high cardiovascular risk because of treatment for diabetes mellitus in the third survey. However, despite the potential for bias the overall trends are interesting with some improvement in lifestyle management in A-3-P with fewer people smoking, being overweight, obese or centrally obese and an increase in the proportion of people achieving the physical activity target. When it comes to the medical risk factor control, there appears to be no improvement in the blood pressure, LDL-cholesterol and glucose control (online supplemental table 4).
The results of A-3-P are in accordance with other earlier surveys of primary prevention in Europe.20 37–39 By comparison with the EUROASPIRE V survey on 2759 patients from 16 European countries, using the same design and methodology as A-3-P, our survey found 47.0% of patients in EUROASPIRE V reached the target of<140/90 mm Hg (<140/85 mm Hg in people with diabetes), compared with 37.8% in A-3-P. Among patients with treated dyslipidaemia, 46.9% of EUROASPIRE V patients achieved LDL-cholesterol target of<2.6 mmol/L, compared with 59.5% in A-3-P. Among patients on diabetes treatments, the HbA1c<7.0% was achieved by 65.2% and 62%, respectively. Compared with EURIKA study on 7641 patients from 12 European countries without clinical CVD, and with at least one major CVD risk factor, blood pressure was controlled in 37.1 in A-3-P and 39% of patients in EURIKA. The lipid control in A-3-P was better than in EURIKA. Among treated patients with dyslipidaemia, 81.5% of A-3-P patients attained an LDL-C of <3 mmol/L, compared with 41% of patients in EURIKA.37 In another study of 8928 patients in 10 European countries, 32% of high CVD risk patients were smokers, 36% obese, 49% had blood pressure>140/90 mm Hg, 64% TC≥5 mmol/L and 14% fasting glucose levels>6.1 mmol/L.38 The International ChoLesterol management Practice Study investigated achievement of LDL-C targets in patients at high or very high CVD risk receiving lipid-modifying therapy in countries outside Western Europe and the proportion of patients achieving guideline-specified treatment targets was 44% for LDL-C, 55% for blood pressure and 39% for diabetes.39