Young patients with heart disease are smoking more and twice as many suffer from diabetes compared to 12 years ago. Heart disease prevention in routine clinical practice is inadequate, with only a third of patients being referred to and joining prevention and rehabilitation programmes, whilst doctors are prescribing more and more drugs. Yet lifestyle programmes should be the backbone of preventive care. Saving people's lives from acute heart attacks is not sufficient, and an urgent investment in prevention is needed to address the lifestyle causes of heart disease. These are the conclusions of an Article published in this week's edition of The Lancet. The Article is one of four cardiology papers published in this edition, ahead of the American College of Cardiology meeting at the end of March.

Heart disease is preventable, yet it is the biggest killer in Europe causing 2 million deaths every year. The first (1995-96) and second (1999-2000) EUROASPIRE (European Action on Secondary and primary Prevention by Intervention to Reduce Events) surveys showed that in coronary patients cardiovascular risk factors such as smoking, high blood pressure, and high cholesterol were poorly managed in people with heart disease in Europe. Indeed, despite clear national and international guidelines on the best ways to prevent heart disease, they reported a widening gap between what is recommended and the results achieved in clinical practice.

In this study, Professor David Wood from Imperial College London, UK, and colleagues report the third (2006-7) EUROASPIRE survey outcomes*, examining more than a decade of heart disease prevention practices in 22 countries in Europe.

Findings showed a continuing and widening gap between the guidelines and patients' lifestyles in terms of stopping smoking, and reducing obesity and diabetes, and at the same time substantial increases in doctors prescribing of all of the major classes of cardioprotective drugs.

The authors report that over 12 years there has been no reduction in the proportion of patients with heart disease who smoke (20.3% in EUROASPIRE I, 21.2% in II, and 18.2% in III), but there has been a large increase in the proportion of younger female smokers. In addition, there has been a substantial increase in obesity and diabetes. In 1995-96, 25% of patients were obese and 17.4% had diabetes, this rose to 38% and 28% in 2006-7.

Further, despite large increases in the use of all classes of blood pressure lowering drugs, blood pressure management showed no improvement. Three out of five patients in all three surveys had raised blood pressure, and almost half of all patients remained above the recommended lipid targets. However, the number of patients with raised cholesterol has more than halved.

According to the authors, the results show how even when faced with a life-threatening disease it is difficult for people to change their behaviour. It is even harder when they don't have the professional support from a multidisciplinary team of nurses, dieticians, physiotherapists and doctors providing comprehensive prevention and rehabilitation programmes. They also point out that simply prescribing more cardioprotective drugs is clearly not enough and drug treatments need to be combined with professional lifestyle intervention.

They conclude by calling for comprehensive lifestyle programmes to be an integral part of health-care provision and health insurance plans for all patients with heart disease.

In an accompanying Comment, Mette Brekke and Bjørn Gjelsvik from The University of Oslo in Norway, say that the results give three messages: "First, to help patients with coronary heart disease achieve a healthy lifestyle should be mandatory and have high priority for doctors and health authorities. Second, therapeutic targets…[such as blood pressure and lipid targets] are too ambitious and might take focus away from important lifestyle issues. Finally…political action is needed to reverse the negative trends of obesity and sedentary habits, ranging from fighting against the fast food and sugar industries to safe bicycle paths and healthy school meals."