Efforts to reduce cardiovascular morbidity and mortality and improve quality of life among chronic heart disease patients require appropriate coordination between cardiology and primary care services. For example, ensuring suitable continuity between these services has been shown to reduce hospitalization in chronic heart failure patients by allowing optimization of medical treatment and early identification of decompensations.1
Patients with ischemic heart disease are at high risk of new ischemic events. Cardiac rehabilitation units provide exemplary care to patients recovering from an acute event; however, the very nature of primary care make it the optimal setting for further improvement in long-term secondary prevention, through the promotion of life style changes and measures to ensure that patients adhere to treatment during follow-up.
A recent study conservatively estimated the global direct health-care cost of physical inactivity in 2013 at $54 billion, with $31 billion of this total paid by the public sector; moreover, evaluation of indirect costs indicated that deaths related to physical inactivity cost an estimated $14 billion in lost productivity, with physical inactivity causing 13 million disability-adjusted life-years.2 Most costs were incurred in high-income countries (81% of health-care costs and 60% of indirect costs). Physical inactivity is thus linked not only to high cardiovascular morbidity and mortality, but also to a substantial economic burden.2 It is therefore incumbent on cardiology and primary care services to coordinate efforts to encourage patients to adopt appropriate life style changes.
Poor treatment adherence is a major barrier to secondary prevention in ischemic heart disease patients. The many causes of treatment nonadherence include the chronic nature of the disease, the high frequency of asymptomatic or weakly symptomatic disease, medication copayments, and lack of awareness among physicians and patients; however, the most important cause is without doubt treatment complexity. Poor treatment adherence increases cardiovascular morbidity and mortality and health care costs. For some patients, the use of a polypill is a valid approach to tackling this problem. This approach can be advantageous for patients with a history or high risk of treatment nonadherence, those who are poorly controlled with equipotent doses and have adherence problems, those who are well controlled with the individual polypill components, and those with a high medication burden to treat comorbidities. In contrast, polypill medication is contraindicated in patients predicted not to achieve or at least come close to achieving the therapeutic goals recommended in clinical practice guidelines, as well as in those with intolerance or allergy to one of the polypill components. In Spain, a polypill is currently available composed of aspirin (100 mg), atorvastatin (20 mg), and ramipril (2.5-10 mg).3
Prevention of thromboembolic complications is essential in patients with atrial fibrillation. The risk is effectively reduced with vitamin K antagonists, and recent research shows that the risk of complications is low in patients with a well-controlled INR.4 However, in Spain and other European countries, anticoagulation is inadequate in approximately 40% of nonvalvular atrial fibrillation patients managed with vitamin K antagonists through their primary care center.5 In patients with nonvalvular atrial fibrillation, direct-acting oral anticoagulants are at least as effective as warfarin in preventing stroke and systemic embolism but have a better safety profile, especially regarding the risk of intracranial hemorrhage. These drugs, moreover, provide stable and predictable anticoagulation, rendering periodic anticoagulation tests unnecessary. Unfortunately, the use of these drugs in Spain is heavily restricted, both in primary care and in cardiology services; moreover, these restrictions differ between the various Spanish autonomous communities and impede appropriate access to these anticoagulants. To improve access to these drugs, the Spanish Society of Cardiology and other scientific societies, including those related to primary care, recently proposed a series of amendments to the Health Ministry's policy in this area.6