Primary prevention is aimed at lifestyle interventions and health-promoting environments

Primary prevention of IHD focuses on lifestyle issues, notably smoking, nutrition and physical activity.

Concerning smoking, there are three issues: stimulating smokers to stop, preventing young people to start, and protecting non-smokers against exposure to tobacco smoke. Raising taxes, media campaigns and individual support have been shown effective as interventions to reduce smoking. For the latter, the primary care setting as well as the school setting is important. In the Tobacco control scale, countries are rated according to their accomplishment on the following five elements of tobacco control policies:

• Warnings on tobacco packages
• Price increases by increasing taxes
• Smoke-free working areas, public places and restaurants
• Information and public campaigns
• Advertising bans

See also the EUphacts Smoking and Smoking policies.

In the area of nutrition, effective interventions are of an integrative approach, and may include information and education, measures related to the availability of certain food items in schools, legislative measures (e.g. food labeling, restrictions on marketing to children of foods/drinks that are high in fats, salt and sugar and low in essential nutrients) and challenges towards industry to develop healthier food products. The core issue is making the healthy choice the easy choice.

Also for physical activity, interventions combine campaigns to enhance physical activity with measures that create an environment which stimulates people to be more physically active. See also the EUphact on Physical activity.

Successful campaigns aimed at neighborhoods (e.g. of low average educational level), schools or in primary care, often combine the focus on the various lifestyle issues.

Secondary prevention targets cholesterol, hypertension, and overweight

For high cholesterol and hypertension (high blood pressure), secondary prevention includes the detection of cases, either in the general population or in high-risk groups. The latter would include those with a familial history of CVD, persons having diabetes or overweight, or smokers above a certain age. Treatment of the condition should consider the entire spectrum of CVD risk factors. Medication can lower (total) cholesterol by 20-50%, resulting in a decrease in IHD incidence up to 30%. See also the EUphact Blood pressure.

The ‘European Guidelines on cardiovascular disease prevention in clinical practice’ emphasizes the importance of healthy lifestyles in people with an enhanced risk of developing CVD. It indicates cholesterol-lowering medication when lifestyle changes are not sufficiently effective (De Backer et al., 2003). It also advises medication when a risk assessment based on the risk factor profile calculation in SCORE indicates a more than 5% increased risk of developing CVD during the coming 10 years.

Interventions in overweight and obese people focus on improving dietary habits and physical activity. Since short-term effects are often not consolidated, long-term strategies are advocated, as well as an integrated approach. See also EUphact Overweight.

Many diagnostic possibilities exist

A doctor can make use of the following tools when diagnosing coronary heart disease:

• Anamnesis (case history, or history of previous disease)
• Signs of myocardial ischemia on the (physical exertion-)electrocardiogram (ECG)
• Echocardiography or other picture-forming examination
• Visualisation of the coronary arteries with high-speed Computer Tomography (coronary angiogram)
• Coronary angiography: to determine the location of the blockage
• Blood test when a heart attack is suspected: the release of myocardial-specific enzymes into the blood is indicative of an acute heart attack. Currently testing for the presence of the protein troponin in serum is the standard method to identify death (necrosis) of heart tissue.

Surgical treatment is either declining or stabilising in most of Europe

For both heart attack and angina pectoris the most common treatments are:

• PCI (percutaneous coronary intervention), to dilate the arterial constriction
• Medication, by thrombolytics (to dissolve the blood clots), beta-blocking agents, ACE (angiotensin-converting enzyme)-inhibitors, aspirin and cholesterol-lowering medication especially statins.
• Surgery: bypass surgery or coronary artery bypass grafting (CABG).

PCI and bypass surgery (CABG) are the most common types of invasive operations carried out (Boersma et al., 2002). Both types of coronary intervention are very effective in relieving angina pectoris. It is estimated that almost 80% of patients with an acute heart attack require an invasive intervention. Of those patients (figures for Western Europe in 2002), 57% received a PCI treatment, 21% a CABG, and 21% exclusively a medicinal treatment. Trends in the volume of surgical and percutaneous procedures show that the growth of coronary surgery in 12 European countries subsided in the mid 1990s, whereas percutaneous (non-surgical) intervention rates are rising in all countries (Simoons, 2003).

Treatment of IHD has contributed to improved survival

The prognosis for coronary heart disease has improved in the past decades. The two-year death rates for Swedish patients with unstable angina pectoris, for example, dropped from 30% in 1988 to 19% in 1995 (Abrahamsson et al., 2000). Research in the United States has shown that a positive outcome is now more common for heart attack patients (Hellermann et al., 2002).

There are remarkable differences between countries in the numbers and proportions of medical procedures carried out in relation to coronary heart disease (Boersma et al., 2002). There is, on the other hand, no clear relationship between the number of medical procedures performed and the death rate for coronary heart disease. On the whole, however, the recent decline in the death rate in Western Europe and the United States appears to be substantially (around 40%) attributable to improvements in the treatment of coronary heart disease (Kesteloot et al., 2006).

A similar observation comes from the MONICA project: around two-thirds of the decline in CHD mortality during the MONICA period was ascribed to a decline in CHD incidence rates and the remaining one-third of the decline was ascribed to improvements in survival because of better treatments (Tunstall-Pedoe et al., 1999; Kuulasmaa et al., 2000; Tunstall-Pedoe et al., 2000).

Other studies found comparable results. In England and Wales approximately half the falls in IHD deaths between 1981 and 2000 could be attributed to primary prevention: reductions in the three major risk factors in people without recognized IHD. Primary prevention had a bigger impact on mortality than did secondary prevention (Unal et al., 2005). In Scotland about half of the fall in coronary mortality between 1975 and 1994 could be explained by reductions in major risk factors (Capewell et al., 1999).

New developments in diagnostics and treatment

In recent years there have been many developments in the diagnostics and treatments for coronary heart disease, including faster diagnosis and treatment without hospitalisation:

• Extension of equipment of ambulances with e.g. an ECG monitor.
• Increasing availability of defibrillators in public places (shopping centres, airports, football stadiums).
• Improved treatment in acute state of the disease: increasing numbers of patients receive percutaneous treatment in the acute stage of an infarction