Cardiovascular prevention is better than a cure
Paul Tunnah interviews Professor Neil Poulter
With limited early warning signs and increasingly poor diets and lifestyles, cardiovascular disease has become a real public health issue. In addition, the expense of secondary prevention and treatment causes real concern for governments looking for healthcare savings in the current economic climate. But sadly, many patients never even get the option of a second chance, not realising until too late they are burdened with this ‘silent killer’.
So the key to managing cardiovascular disease is to identify the risk factors early and practice effective prevention, but it this an area where pharma can get involved? What are the misconceptions that result in barriers to prevention? How can we turn people’s perceptions around and what are the most important factors to consider in prevention?
pharmaphorum discussed these issues with Professor Neil Poulter, Chair of Preventative Cardiovascular Medicine at Imperial College London, and a leading expert in this area with a wealth of experience in cardiovascular prevention. We explored how public education, pharma, governments and even the food industry all have a part to play a part in tackling the epidemic that is the world’s number one cause of death.
To listen to the full interview, please click on the play button below, with a shortened transcript of some edited highlights shown in print below.
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PT: Thanks for speaking with me today. Could you start by providing an overview of your background please?
NP: I am Chair of Preventive Cardiovascular Medicine at Imperial College, London and also Co-director of the International Centre for Circulatory Health, which is part of NHLI at Imperial College, and Co-director of the newly formed Imperial Clinical Trial Unit. I was involved in clinical medicine up until 1980 then went to Kenya, set up a research programme into the aetiology of hypertension, stayed 5 years and then did an MSc in Epidemiology. Since then I ran the WHO study of cardiovascular disease and oral contraceptives that took about 10 years before coming to Imperial College in 1997.
PT: And it’s currently preventive cardiovascular medicine that you focus on at the moment?
NP: Yes, various aspects of preventive cardiovascular medicine, particularly optimal management of hypertension and dyslipidaemia and prevention of type 2 diabetes.
“Particularly in hypertension, there is almost a taboo in using single pill combinations.”
PT: Over the course of your career what changes have you seen in the management of cardiovascular disease?
NP: Increasingly assertive action on blood pressure with better agents, change in the numbers and types of agents we use for hypertension with lower thresholds, lower targets etc. The field of lipids has really been revolutionised by the arrival of statins and gone from horrendous neglect in the UK to almost being very well done, at least in secondary prevention. Type 2 diabetes lags behind in many ways, because what we’ve shown are effective interventions on lipids and blood pressure, whereas on glucose lowering the evidence is much less compelling and we’re still trying to find good oral or injectable hypoglycaemic agents.
PT: What other drug treatments would you say have had the most impact over this period?
NP: I would just say statins, statins and statins! In secondary prevention aspirin has become de rigor and the antihypertensive agents, ACE inhibitors and ARBs, have become part of routine secondary preventive care. Calcium channel blockers have risen to take their place and my guess is they will really start to become the best agents, except for perhaps in the young where ACEIs and ARBs might be better.
PT: With all these changes in the drug landscape, how has that been manifested in the patients that you are being presented with?
NP: Well, they are taking more drugs. That in itself is a problem from compliance / adherence point of view and should be dealt with by producing more single pill combinations, which are very unpopular in the UK but much more commonly used in other parts of the world. Particularly in hypertension, there is almost a taboo in using single pill combinations. We were taught in clinical pharmacology that it was bad medicine to have single pill combinations, but it’s routine in gynaecology, oncology, infectious disease and diabetes, so why do we not use them in hypertension? The excuses have been that it costs more, but two drugs given as one pill, versus two drugs given as two pills improves compliance by just over 20% and if you do that you know you are going to lower blood pressure more and you are going to save more lives.
PT: When you look at the patients you are being presented with, what could they have done to help prevent the onset of cardiovascular disease?
NP: It’s a chronic degenerative disease, largely explained by diet and lifestyle. It goes right back to square one with exercise and diet from when we are born. Some might take it back to the diets and lifestyles of the mothers leading to small babies, which are more prone to cardiovascular disease, if you believe the cardiovascular marker hypothesis.
“So we know that for a proportion of patients, the first vascular event that they get is death…”
PT: What are the early warning signs that people can monitor for early onset of cardiovascular disease?
NP: In a hypertension clinic you get people who have got nothing wrong with them as far as they are concerned, somebody just checked their blood pressure or cholesterol and found it to be high. Hypertension is called the “silent killer”, because you very often get no symptoms at all. So we know that for a proportion of patients, the first vascular event that they get is death, maybe for one in five patients. The early warnings one can have is looking if they’ve got a family history, look at the body weight, look in the mirror – that’s a good early warning sign. Are you doing exercise? Are you smoking? These are all warning signs.
PT: We talk about prevention of cardiovascular disease, but do you think it is prevention or more a focus on identifying high risk and early detection?
NP: Most people went to medical school to treat sick people, so you start with those who have had a heart attack or who have got angina and then go to people with high blood pressure and high cholesterol. Ultimately the only way we are going to make an impact on the epidemic is to stop these things happening in the first place. Unless you start treating everyone’s blood pressure with drugs, you are only going to be dealing with half the problem from a preventive point of view. We have to go to a more primordial setting and try and stop the elevation of blood pressure with age (similarly with adverse effects on lipids) and that involves diets and lifestyles from the very beginning. That isn’t to say that we shouldn’t be treating people at high risk with established disease, but ultimately we have to try and stop the risk factors emerging and that’s at a population level.
PT: What are the barriers to getting the higher risk patients to take part in screening and prevention?
NP: You could take the view that you don’t have to make them take part at all. For example, if you had a pricing system whereby products that are high in fat, sugar, salt etc. become more expensive and healthier products become cheaper. Such policies, which would involve government and the food industry, could drive change in the right direction. If you make smoking extremely difficult to do and expensive, then people will stop. There is a perception that a healthy diet is expensive, but it’s not necessarily true. There’s also the perception that all the nice things are bad for you and that’s just a question of turning people’s perceptions around.
PT: How much focus do you see the pharma industry having on screening and preventative measures, as opposed to just treatment?
NP: Their interest in screening and prevention is that it would increase the use of their treatments, but I can’t imagine pharma being involved to a level where interventions would prevent those risk factors evolving. I’m not suggesting that pharma wants everyone to get high blood pressure and high cholesterol and high glucose, but from a financial point of view it wouldn’t be in their best interests to eliminate all these risk factors before they ever became a problem! Not that I think there is any danger of that in the next 20 or 30 years.
“Diabetes is one of our major concerns and there are lots of antidiabetic hypoglycaemic agents under investigation that are potentially very exciting.”
PT: Are you seeing pharma companies involved in producing screening technologies?
NP: Some of the companies support screening programmes of various sorts around the world and there has been a move in some settings to try and persuade people to treat, for example, pre-hypertension, because that opens a huge market. At the moment I think that’s not appropriate, we should be doing that with diets and lifestyle.
PT: Are there particular drugs or technologies in the pipeline that you think will have a big impact in this space?
NP: Diabetes is one of our major concerns and there are lots of antidiabetic hypoglycaemic agents under investigation that are potentially very exciting. Then within hypertension there are various new drugs coming though, but like all of these one can never be certain whether they will be a winner or not.
PT: What areas within cardiovascular disease and its prevention to you think are the best areas for pharma to get involved in?
NP: Because of the impending danger of diabetes that’s where the screening story needs to be looked at and evaluated in terms of its benefits – cost effective and otherwise. Treating glucose has not been particularly successful, but pharma has experience in lipid and blood pressure screening, which are now in theory part of our national recommendations for everyone over the age of 40. Doing that within the confines of the NHS is a big cost, so industry could step in here is to provide the support and the means to pick these people up. The cynics would say “oh yes, that’s so they can get more people taking their drugs”. Well so be it – if you are going to pick up people who are otherwise undetected and pharma is prepared to do that, it would be a very good thing.
PT: On a more global basis, are you seeing particular programmes that you regard as being significantly successful in preventing cardiovascular disease?
NP: No. Interestingly the QOF targets that our GPs have been working to since 2004 are causing a lot of interest. There is no doubt that our management of blood pressure and lipids has improved since then, but they were improving before as well. Pay for performance has captured lots of interest around the world and it does provide quite a good model. You could take the purist view that it’s a terrible thing that we need to be bribed to do things that we should have done in the first place, but a more pragmatic view is if that is going to improve health around the nation then let’s do it.
“With greater drug use, within a couple of years you would see an improvement in morbidity and mortality rates…”
PT: Wider use of prevention should lead to cost savings, but what kind of timescale do you think we would see that benefit over?
NP: First of all, it is cost effective to prevent. One of the safest, cheapest ways of saving cardiovascular lives is to lower blood pressure or lipids effectively, almost irrespective of what drugs you use. We know that within a couple of years in both strokes and heart attacks you see the benefits of blood pressure and lipid lowering. In primary prevention, we are only treating about half of the patients, maybe two thirds of those that should be treated, so there is huge potential there for improving blood pressure control. With greater drug use, within a couple of years you would see an improvement in morbidity and mortality rates around those risk factors. The main tools that we know save cardiovascular events are going to be generic by next year so we should be using them much more, there will be savings because of the cardiovascular events. Strokes and heart attacks are very expensive things.
PT: How do we get the government and industry to invest more in cardiovascular disease prevention?
NP: One of the striking things about the cuts that have just been announced is that the government has protected the National Institute for Health Research and MRC funding, so the research side of things has been protected and that’s a long sighted and brave view. As I said, it’s in industry’s interests to support screening, even if only for commercial reasons.
PT: Finally, if there were two or three key fundamentals for people to observe in order to help prevent the onset of heart disease, what would you say those are?
NP: Increased intake of fresh fruit and vegetables, cut down salt, cut down saturated fats, take more exercise (and with it lose calories) and stop smoking.
About the interviewee:
Professor Neil Poulter is Chair of Preventive Cardiovascular Medicine at Imperial College London, where he is also co-Director of the International Centre for Circulatory Health. He was President of the British Hypertension Society from 2003-2005 and was elected as a Fellow of the Academy of Medical Sciences in 2009.
Prior to his current position, Professor Poulter worked in a number of positions focussed on cardiovascular disease, including acting as Co-Principal Investigator and Study Co-ordinator of the WHO international collaborative case control study of cardiovascular disease and steroid hormone contraception. He has achieved an MSc in Epidemiology with distinction and is accredited as a general physician by the Royal College of Physicians.
Professor Poulter has contributed chapters to several major textbooks and published over 300 papers in medical journals, including co-authoring the 1998 and 2005 Joint British Recommendations on Prevention of CHD, the 2003 World Health Organisation/International Society of Hypertension Statement on Management of Hypertension, the 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension, and the 2004 British Hypertension Society guidelines for management of hypertension. He has also played a senior role in the design management and conduct of several major trials including ASCOT and ADVANCE.
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