- Email: [email protected]
Medical education — communicating best practice
Atherosclerosis 143 Suppl. 1 Ž1999. S13]S16
Medical education } communicating best practice N.R. Poulter U Cardio¨ ascular Studies Unit, Department of Clinical Pharmacology, Imperial College School of Medicine, St Mary’s Campus, London W2 1PG, UK
Abstract There is unequivocal evidence that reduction of modifiable risk factors for coronary heart disease ŽCHD., such as elevated serum cholesterol, high blood pressure and smoking, decreases cardiovascular mortality. However, levels of intervention appear to be poor and there is often little evidence of a combined multiple risk factor approach to intervention, which is likely to be the optimal way to lower a patients overall risk of developing CHD. Attention has recently focused on bridging the gap between knowledge in the field of preventive cardiology and its application in everyday clinical practice. This can only be accomplished by the development of uncomplicated, practical guidelines that are evidenced-based and that provide specific targets for risk factors and indications for drug therapy. Q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Modifiable risk factors; Coronary heart disease ŽCHD.; Cardiovascular mortality
Almost half of the deaths which occur in many parts of the modern industrialised or ‘westernised’ world are due to cardiovascular disease w1x. Although the relative contributions that coronary heart disease ŽCHD. and stroke make to these cardiovascular mortality rates varies dramatically worldwide w2x, in most European and North American countries CHD is the major cause of cardiovascular death w1x. Numerous risk factors have been described for CHD and data from several sources suggest that the major risk factors have been identified ŽTable 1. w3]6x. The pivotal risk factor appears to be dyslipidemia w7x, with smoking, hypertension, and diabetes as other major determinants of subsequent CHD. The first strategy to adopt for primary and secondary CHD prevention is to try and reduce the modifiable risk factors. Unfortunately, for reasons which are unclear, the importance of these risk factors is a constant source of controversy w8x and worse still, or perhaps in part as a consequence of this controversy, action to intervene on these major risk factors is limited in most parts of the world. For U
Tel: q44-171-594-3445r3446; fax: q44-171-594-3411.
instance, due to commercial interests, action on smoking by most governments such as those of the UK and USA is either non-existent or damaging w9x. In relation to hypertension, levels of intervention are woefully low. Added to that, the proportion of hypertensive patients whose blood pressure is reasonably controlled } whilst increasing in the last 20 years } remains a minority. Recently, in both the USA and England, surveys showed that only approximately 30% of hypertensive patients have their blood pressures controlled w10,11x. The definitions of control used differ between the two countries with - 140r90 mmHg in the USA and - 160r95 mmHg in England. Differences such as these no doubt contribute significantly to the lower CHD and stroke rates currently prevalent in the USA compared with those in the UK. The situation regarding the investigation and treatment of dyslipidemia is even more worrying than for hypertension. Treatment rates vary widely across Europe, but not in relation to prevailing CHD event rates ŽTable 2. w12x. National survey data from England and Scotland reveal that in the year following publication of the Scandinavian Simvastatin Survival Study Ž4S. w13x, less than 1% of UK adults were receiving lipid-lowering therapy w14,15x. By the fol-
0021-9150r99r$ - see front matter Q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 1 - 9 1 5 0 Ž 9 9 . 0 0 1 0 2 - 1
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
S14 Table 1 Major coronary heart disease risk factors Non-modifiable Age
Sex
Family history
Modifiable Elevated cholesterol Obesity Glucose intolerance
Hypertension Sedentary lifestyle Insulin resistance
Smoking Diabetes mellitus Left ventricular hypertrophy
lowing year Ž1996. this proportion had only risen to approximately 1.2% despite the fact that epidemiological surveys indicate that almost 10% of the UK adult population have some sort of arterial disease w14,15x susceptible to lipid-lowering therapy. It should be emphasized that these low treatment rates prevail in countries which have among the world’s highest rates of coronary mortality w16x. Compounding the situation, a European survey of 150 medical and epidemiological experts about the role of lifestyle and health w17x, showed that those arising from the UK and Irish Republic were much less persuaded of the importance of dietary fat inducing heart disease and dietary salt causing high blood pressure than experts from northern and southern Europe. The publication of the ASPIRE study w18x, reported that less than 10% of patients leaving hospitals across the UK with a diagnosis of either acute myocardial infarction or myocardial ischaemia, were using lipidlowering agents. The recently published EUROASPIRE study w19x has confirmed more contemporary and continuing widespread therapeutic nihilism regarding lipid-lowering treatment. In an assessment of public awareness and attitudes to CHD, and an evaluation of related health behaviours in five European countries, a considerable degree of indifference to the disease was revealed, even among those who had previously suffered a myocardial infarction w20x. Those surveyed reported having been adequately informed with credible health information and yet, for example, among postmyocardial infarction patients, a minority were trying to reduce fat and cholesterol or increase exercise and Table 2 European drug consumption: daily drug dosage per 1000 personsr day
Peptic ulcer Antihypertensives Lipid lowering Antibiotics NSAIDs Psycholeptics
France
Germany
Italy
UK
14 166 32 26 30 129
9 139 13 11 23 36
16 104 8 14 31 57
17 119 2 13 33 33
only one-half reported changing their diets or reducingrstopping smoking. Predictably the UK respondents reported less of these interventions than the group as a whole. Although it has not been possible to carry out randomized trials to evaluate the benefits of smoking cessation, extensive trial data have demonstrated the major benefits associated with the lowering of blood pressure and lipid levels w21,22x. This extensive database forms the basis for the many sets of national and international guidelines for the prevention of CHD or cardiovascular disease w23]26x. Despite these multiple sets of guidelines, it is clear that there is a gap between theory and practice w18]20x. The possible reasons for this gap, the size of which varies around the world, are many, and some of the likely contenders are listed in Table 3. It seems likely that all of these possibilities contribute to some degree to the problem. Whatever the reasons, there is clearly an urgent need to get currently available evidence on the prevention of cardiovascular diseases into practice. There appears, in the context of cardiovascular disease, to be little wrong with the quality of evidence generated in large intervention trials, the reviews of that evidence and of the guidelines which have been generated largely on the basis of these reviews. The problems are presumably in the means of communication of these guidelines. Sadly, it appears that eyecatching headlines or ‘sound-bites’ in the media are more likely to influence health-orientated activities than the results of a systematic review of several well-conducted randomized trials. The dissemination of the key messages incorporated in the guidelines on disease management does not appear to be effective, in that they are not being put into practice. In a recent systematic review designed to assess the evidence for the effectiveness of clinical practice guidelines in improving patient outcomes in primary care, the authors concluded that there was little evidence that guidelines were effective w27x. Similarly, in his review of the use and impact of guidelines and consensus statements w28x, Chalmers concluded, on the basis of several reported studies in several areas of medicine, ‘that the main value of Table 3 Managing cardiovascular risk factors: why the gap between theory and practice? v v v v v v
Patients Physicians Disease Drugs Concepts Guidelines
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
guidelines and consensus statements is not to produce rapid or substantial change in clinical practice’. On a more positive note, however, he added that the impact of guidelines can certainly be enhanced by various manoeuvres including obtaining at a local practice level the support of respected medical colleagues, by publishing the recommendations in reputable journals, avoiding economic disincentives and other barriers and critically, by being brief. More recently Jackson and Feder w29x outlined three key components of successful guidelines. These components are firstly the clear identification of the key decisions to be made and their possible consequences; ideally these should be expressed as a flow diagram or algorithm. Secondly, they recommend a compilation of the relevant valid evidence which clinicians need in order to make decisions on each of the key decision points. Thirdly, the presentation of the evidence and recommendations in a concise and accessible format. The apparently limited impact of guidelines to date is not always reflected in cardiovascular disease rates, which are not universally bad or even sub-optimal. Many countries such as Finland, Australia and the USA have made huge strides in terms of reducing rates of cardiovascular diseases w16x, and even in the UK CHD rates have fallen effectively over the last 20]25 years w1x. Furthermore, these changes appear to correlate well with changes in standard risk factors w30x. One outstanding example from the field of hypertension is the massive reduction in stroke rates observed in Japan during recent years which parallels equivalently large increases in the rates of hypertension treatment w31x and reductions in sodium intake by the Japanese population. Paradoxically, the community-based intervention trials carried out to date have almost uniformly been disappointing in terms of observed reductions in cardiovascular disease. Unfortunately these trial results have been incorrectly interpreted to suggest that the interventions are themselves ineffective. However, these results are more likely to reflect the difficulties of carrying out such studies and the failure to persuade apparently healthy people to change aspects of diet and lifestyle, rather than the potential benefits of so doing. Clearly if populations do not make the recommended changes } benefits will not accrue. Perhaps if those whose job it is to manipulate the population } those in advertising } were given the task of changing diets in such trials, the results may have been very different. If we are to communicate best practice to the general population Žideally having already persuaded the medical profession } hitherto a significant hurdle. our messages must be simple, effective, cost-effective, and achievable, but perhaps most importantly
S15
should be given by those trained and effective at communicating. For the moment that usually precludes the medical and other allied professions. References w1x British Heart Foundation Health Promotion Research Group. Coronary Heart Disease Statistics. 1997 ed. London, UK: British Heart Foundation. w2x Poulter NR, Sever PS, McG Thom. CVD: Practical issues for prevention. St Albans: Caroline Black, 1996. w3x Kannel WB, Wilson PW. An update on coronary risk factors. Med Clin N Am 1995;79:951]971. w4x Stamler J, Wentworth D, Neaton JD. for the MRFIT Research Group. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? J Am Med Assoc 1986;256:2823]2828. w5x Assmann G, Cullen P, Schulte H. The Munster Heart Study ŽPROCAM.. Results of follow-up at 8 years. Eur Heart J 1998;19:A2]11. w6x Shaper AG, Pocock SJ. Risk factors for ischaemic heart disease in British men. Br Heart J 1987;57:11]16. w7x Poulter NR. Is one risk factor more important than another? Risk 1993;1:4]9. w8x Ravnskov U. Cholesterol lowering trials in coronary heart disease: frequency of citation and outcome. Br Med J 1992;305:15]19. w9x Chapman S. The role of doctors in promoting smoking cessation. Br Med J 1993;307:518]519. w10x Colhoun HM, Poulter NR. Blood pressure screening, management and control in England; results from the Health Survey for England 1994. J Hypertens 1998;16:747]753. w11x Burt VL, Cutler JA, Higginas M et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the Health Examination Surveys, 1960 to 1991. Hypertension 1995;26:60]69. w12x Gozlan M. European drug consumption. Lancet 1994; 344:1695]1696. w13x Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study Ž4S. Lancet 1994:344;1383]1389. w14x Prescott-Clarke T, Primatesta P, editors. Health Survey of England 1995. London: HMSO, 1997. w15x Dong W, Erens B, editors. Scottish Health Survey 1995. Edinburgh: The Stationery Office, 1997. w16x World Health Statistics Annual 1994. Geneva: WHO, 1995. w17x Steptoe A, Wardle J. What the experts think: a European survey of expert opinion about the influence of lifestyle on health. Eur J Epidemiol 1994;10:195]203. w18x Bowker TJ, Clayton TC, lngham JE et al. A British Cardiac Society Survey of the Potential for Secondary Prevention of Coronary Diseases } ‘ASPIRE’. Heart 1996;75:334]342. w19x EUROASPIRE Study Group. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results. Eur Heart J 1997:18;1569]1582. w20x Shepherd J, Alcalde V, Befort P-A, Boucher B, Erdmann E, Gutzqiller F et al. ŽHELP Study Group. International comparison of awareness and attitudes towards coronary risk factor reduction: the HELP study. J Cardiovasc Risk 1997;4: 373]384. w21x Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA et al. Blood pressure, stroke and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990;335:827]828.
S16
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
w22x Gould AL, Rossouw JE, Santanello NC, Heyse JF, Furberg CD. Cholesterol reduction yields clinical benefit: impact of statin trials. Circulation 1998;97:946]952. w23x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. Eur Heart J 1998;19:1434]1503. w24x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. Atherosclerosis 1998;140:199]270. w25x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. J Hypertens 1998;16:1407]1414. w26x Wood D, Durrington P, Poulter N, McInnes G, Reece A,
w27x
w28x w29x w30x
w31x
Wray W. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80: S1]S29. Worral G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc J 1997;156:1705]1712. Chalmers J. Guidelines and consensus statements: their use and impact. J Human Hypertens 1995;9:37]40. Jackson R, Feder G. Guidelines for clinical guidelines. Lancet 1998;317:427]428. Hunink MAM, Goldman L, Tosteson ANA, Mittleman MA, Goldman PA, Williams LW. The recent decline in mortality from coronary heart disease, 1980]1990. J Am Med Assoc 1997;277:535]542. Ueshima H, Tatara K, Asakura S, Okamoto M. Declining trends in blood pressure level and the prevalence of hypertension, and changes in related factors in Japan, 1956]1980. J Chron Dis 40:137]147.
Medical education } communicating best practice N.R. Poulter U Cardio¨ ascular Studies Unit, Department of Clinical Pharmacology, Imperial College School of Medicine, St Mary’s Campus, London W2 1PG, UK
Abstract There is unequivocal evidence that reduction of modifiable risk factors for coronary heart disease ŽCHD., such as elevated serum cholesterol, high blood pressure and smoking, decreases cardiovascular mortality. However, levels of intervention appear to be poor and there is often little evidence of a combined multiple risk factor approach to intervention, which is likely to be the optimal way to lower a patients overall risk of developing CHD. Attention has recently focused on bridging the gap between knowledge in the field of preventive cardiology and its application in everyday clinical practice. This can only be accomplished by the development of uncomplicated, practical guidelines that are evidenced-based and that provide specific targets for risk factors and indications for drug therapy. Q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Modifiable risk factors; Coronary heart disease ŽCHD.; Cardiovascular mortality
Almost half of the deaths which occur in many parts of the modern industrialised or ‘westernised’ world are due to cardiovascular disease w1x. Although the relative contributions that coronary heart disease ŽCHD. and stroke make to these cardiovascular mortality rates varies dramatically worldwide w2x, in most European and North American countries CHD is the major cause of cardiovascular death w1x. Numerous risk factors have been described for CHD and data from several sources suggest that the major risk factors have been identified ŽTable 1. w3]6x. The pivotal risk factor appears to be dyslipidemia w7x, with smoking, hypertension, and diabetes as other major determinants of subsequent CHD. The first strategy to adopt for primary and secondary CHD prevention is to try and reduce the modifiable risk factors. Unfortunately, for reasons which are unclear, the importance of these risk factors is a constant source of controversy w8x and worse still, or perhaps in part as a consequence of this controversy, action to intervene on these major risk factors is limited in most parts of the world. For U
Tel: q44-171-594-3445r3446; fax: q44-171-594-3411.
instance, due to commercial interests, action on smoking by most governments such as those of the UK and USA is either non-existent or damaging w9x. In relation to hypertension, levels of intervention are woefully low. Added to that, the proportion of hypertensive patients whose blood pressure is reasonably controlled } whilst increasing in the last 20 years } remains a minority. Recently, in both the USA and England, surveys showed that only approximately 30% of hypertensive patients have their blood pressures controlled w10,11x. The definitions of control used differ between the two countries with - 140r90 mmHg in the USA and - 160r95 mmHg in England. Differences such as these no doubt contribute significantly to the lower CHD and stroke rates currently prevalent in the USA compared with those in the UK. The situation regarding the investigation and treatment of dyslipidemia is even more worrying than for hypertension. Treatment rates vary widely across Europe, but not in relation to prevailing CHD event rates ŽTable 2. w12x. National survey data from England and Scotland reveal that in the year following publication of the Scandinavian Simvastatin Survival Study Ž4S. w13x, less than 1% of UK adults were receiving lipid-lowering therapy w14,15x. By the fol-
0021-9150r99r$ - see front matter Q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 1 - 9 1 5 0 Ž 9 9 . 0 0 1 0 2 - 1
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
S14 Table 1 Major coronary heart disease risk factors Non-modifiable Age
Sex
Family history
Modifiable Elevated cholesterol Obesity Glucose intolerance
Hypertension Sedentary lifestyle Insulin resistance
Smoking Diabetes mellitus Left ventricular hypertrophy
lowing year Ž1996. this proportion had only risen to approximately 1.2% despite the fact that epidemiological surveys indicate that almost 10% of the UK adult population have some sort of arterial disease w14,15x susceptible to lipid-lowering therapy. It should be emphasized that these low treatment rates prevail in countries which have among the world’s highest rates of coronary mortality w16x. Compounding the situation, a European survey of 150 medical and epidemiological experts about the role of lifestyle and health w17x, showed that those arising from the UK and Irish Republic were much less persuaded of the importance of dietary fat inducing heart disease and dietary salt causing high blood pressure than experts from northern and southern Europe. The publication of the ASPIRE study w18x, reported that less than 10% of patients leaving hospitals across the UK with a diagnosis of either acute myocardial infarction or myocardial ischaemia, were using lipidlowering agents. The recently published EUROASPIRE study w19x has confirmed more contemporary and continuing widespread therapeutic nihilism regarding lipid-lowering treatment. In an assessment of public awareness and attitudes to CHD, and an evaluation of related health behaviours in five European countries, a considerable degree of indifference to the disease was revealed, even among those who had previously suffered a myocardial infarction w20x. Those surveyed reported having been adequately informed with credible health information and yet, for example, among postmyocardial infarction patients, a minority were trying to reduce fat and cholesterol or increase exercise and Table 2 European drug consumption: daily drug dosage per 1000 personsr day
Peptic ulcer Antihypertensives Lipid lowering Antibiotics NSAIDs Psycholeptics
France
Germany
Italy
UK
14 166 32 26 30 129
9 139 13 11 23 36
16 104 8 14 31 57
17 119 2 13 33 33
only one-half reported changing their diets or reducingrstopping smoking. Predictably the UK respondents reported less of these interventions than the group as a whole. Although it has not been possible to carry out randomized trials to evaluate the benefits of smoking cessation, extensive trial data have demonstrated the major benefits associated with the lowering of blood pressure and lipid levels w21,22x. This extensive database forms the basis for the many sets of national and international guidelines for the prevention of CHD or cardiovascular disease w23]26x. Despite these multiple sets of guidelines, it is clear that there is a gap between theory and practice w18]20x. The possible reasons for this gap, the size of which varies around the world, are many, and some of the likely contenders are listed in Table 3. It seems likely that all of these possibilities contribute to some degree to the problem. Whatever the reasons, there is clearly an urgent need to get currently available evidence on the prevention of cardiovascular diseases into practice. There appears, in the context of cardiovascular disease, to be little wrong with the quality of evidence generated in large intervention trials, the reviews of that evidence and of the guidelines which have been generated largely on the basis of these reviews. The problems are presumably in the means of communication of these guidelines. Sadly, it appears that eyecatching headlines or ‘sound-bites’ in the media are more likely to influence health-orientated activities than the results of a systematic review of several well-conducted randomized trials. The dissemination of the key messages incorporated in the guidelines on disease management does not appear to be effective, in that they are not being put into practice. In a recent systematic review designed to assess the evidence for the effectiveness of clinical practice guidelines in improving patient outcomes in primary care, the authors concluded that there was little evidence that guidelines were effective w27x. Similarly, in his review of the use and impact of guidelines and consensus statements w28x, Chalmers concluded, on the basis of several reported studies in several areas of medicine, ‘that the main value of Table 3 Managing cardiovascular risk factors: why the gap between theory and practice? v v v v v v
Patients Physicians Disease Drugs Concepts Guidelines
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
guidelines and consensus statements is not to produce rapid or substantial change in clinical practice’. On a more positive note, however, he added that the impact of guidelines can certainly be enhanced by various manoeuvres including obtaining at a local practice level the support of respected medical colleagues, by publishing the recommendations in reputable journals, avoiding economic disincentives and other barriers and critically, by being brief. More recently Jackson and Feder w29x outlined three key components of successful guidelines. These components are firstly the clear identification of the key decisions to be made and their possible consequences; ideally these should be expressed as a flow diagram or algorithm. Secondly, they recommend a compilation of the relevant valid evidence which clinicians need in order to make decisions on each of the key decision points. Thirdly, the presentation of the evidence and recommendations in a concise and accessible format. The apparently limited impact of guidelines to date is not always reflected in cardiovascular disease rates, which are not universally bad or even sub-optimal. Many countries such as Finland, Australia and the USA have made huge strides in terms of reducing rates of cardiovascular diseases w16x, and even in the UK CHD rates have fallen effectively over the last 20]25 years w1x. Furthermore, these changes appear to correlate well with changes in standard risk factors w30x. One outstanding example from the field of hypertension is the massive reduction in stroke rates observed in Japan during recent years which parallels equivalently large increases in the rates of hypertension treatment w31x and reductions in sodium intake by the Japanese population. Paradoxically, the community-based intervention trials carried out to date have almost uniformly been disappointing in terms of observed reductions in cardiovascular disease. Unfortunately these trial results have been incorrectly interpreted to suggest that the interventions are themselves ineffective. However, these results are more likely to reflect the difficulties of carrying out such studies and the failure to persuade apparently healthy people to change aspects of diet and lifestyle, rather than the potential benefits of so doing. Clearly if populations do not make the recommended changes } benefits will not accrue. Perhaps if those whose job it is to manipulate the population } those in advertising } were given the task of changing diets in such trials, the results may have been very different. If we are to communicate best practice to the general population Žideally having already persuaded the medical profession } hitherto a significant hurdle. our messages must be simple, effective, cost-effective, and achievable, but perhaps most importantly
S15
should be given by those trained and effective at communicating. For the moment that usually precludes the medical and other allied professions. References w1x British Heart Foundation Health Promotion Research Group. Coronary Heart Disease Statistics. 1997 ed. London, UK: British Heart Foundation. w2x Poulter NR, Sever PS, McG Thom. CVD: Practical issues for prevention. St Albans: Caroline Black, 1996. w3x Kannel WB, Wilson PW. An update on coronary risk factors. Med Clin N Am 1995;79:951]971. w4x Stamler J, Wentworth D, Neaton JD. for the MRFIT Research Group. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? J Am Med Assoc 1986;256:2823]2828. w5x Assmann G, Cullen P, Schulte H. The Munster Heart Study ŽPROCAM.. Results of follow-up at 8 years. Eur Heart J 1998;19:A2]11. w6x Shaper AG, Pocock SJ. Risk factors for ischaemic heart disease in British men. Br Heart J 1987;57:11]16. w7x Poulter NR. Is one risk factor more important than another? Risk 1993;1:4]9. w8x Ravnskov U. Cholesterol lowering trials in coronary heart disease: frequency of citation and outcome. Br Med J 1992;305:15]19. w9x Chapman S. The role of doctors in promoting smoking cessation. Br Med J 1993;307:518]519. w10x Colhoun HM, Poulter NR. Blood pressure screening, management and control in England; results from the Health Survey for England 1994. J Hypertens 1998;16:747]753. w11x Burt VL, Cutler JA, Higginas M et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the Health Examination Surveys, 1960 to 1991. Hypertension 1995;26:60]69. w12x Gozlan M. European drug consumption. Lancet 1994; 344:1695]1696. w13x Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study Ž4S. Lancet 1994:344;1383]1389. w14x Prescott-Clarke T, Primatesta P, editors. Health Survey of England 1995. London: HMSO, 1997. w15x Dong W, Erens B, editors. Scottish Health Survey 1995. Edinburgh: The Stationery Office, 1997. w16x World Health Statistics Annual 1994. Geneva: WHO, 1995. w17x Steptoe A, Wardle J. What the experts think: a European survey of expert opinion about the influence of lifestyle on health. Eur J Epidemiol 1994;10:195]203. w18x Bowker TJ, Clayton TC, lngham JE et al. A British Cardiac Society Survey of the Potential for Secondary Prevention of Coronary Diseases } ‘ASPIRE’. Heart 1996;75:334]342. w19x EUROASPIRE Study Group. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results. Eur Heart J 1997:18;1569]1582. w20x Shepherd J, Alcalde V, Befort P-A, Boucher B, Erdmann E, Gutzqiller F et al. ŽHELP Study Group. International comparison of awareness and attitudes towards coronary risk factor reduction: the HELP study. J Cardiovasc Risk 1997;4: 373]384. w21x Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA et al. Blood pressure, stroke and coronary heart disease. Part 2, short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990;335:827]828.
S16
N.R. Poulter r Atherosclerosis 143 Suppl. 1 (1999) S13]S16
w22x Gould AL, Rossouw JE, Santanello NC, Heyse JF, Furberg CD. Cholesterol reduction yields clinical benefit: impact of statin trials. Circulation 1998;97:946]952. w23x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. Eur Heart J 1998;19:1434]1503. w24x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. Atherosclerosis 1998;140:199]270. w25x Wood D, de Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. on behalf of the Task Force. Prevention of coronary heart disease in clinical practice. Recommendations of the second joint task force of European and other societies on coronary prevention. J Hypertens 1998;16:1407]1414. w26x Wood D, Durrington P, Poulter N, McInnes G, Reece A,
w27x
w28x w29x w30x
w31x
Wray W. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80: S1]S29. Worral G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc J 1997;156:1705]1712. Chalmers J. Guidelines and consensus statements: their use and impact. J Human Hypertens 1995;9:37]40. Jackson R, Feder G. Guidelines for clinical guidelines. Lancet 1998;317:427]428. Hunink MAM, Goldman L, Tosteson ANA, Mittleman MA, Goldman PA, Williams LW. The recent decline in mortality from coronary heart disease, 1980]1990. J Am Med Assoc 1997;277:535]542. Ueshima H, Tatara K, Asakura S, Okamoto M. Declining trends in blood pressure level and the prevalence of hypertension, and changes in related factors in Japan, 1956]1980. J Chron Dis 40:137]147.