Article

PDF
Access to the PDF text
Advertising


Free Article !

Archives of cardiovascular diseases
Volume 106, n° 5
pages 274-286 (mai 2013)
Doi : 10.1016/j.acvd.2013.02.005
Received : 5 December 2012 ;  accepted : 28 February 2013
Antihypertensive, antidiabetic and lipid-lowering treatment frequencies in France in 2010
Fréquences des traitements médicamenteux anti-hypertenseurs, antidiabétiques et hypolipémiants en France en 2010
 

Philippe Tuppin a, , Pauline Ricci-Renaud a, Christine de Peretti b, Anne Fagot-Campagna a, Christelle Gastaldi-Menager a, Nicolas Danchin c, François Alla a, Hubert Allemand a
a Caisse nationale d’assurance maladie des travailleurs salariés (CNAMTS), direction de la stratégie des études et des statistiques, 26-50, avenue du Professeur-André-Lemierre, 75986 Paris cedex 20, France 
b Institut de Veille Sanitaire, Saint-Maurice, France 
c Département de cardiologie, hôpital européen Georges-Pompidou, université Paris Descartes, Paris, France 

Corresponding author. Fax: +33 1 72 60 17 26.
Summary
Background

The frequencies of treatment for cardiovascular risk factors are poorly documented in large populations, particularly according to the presence or absence of cardiovascular disease (CVD).

Aims

To assess frequencies of reimbursements for antihypertensive, lipid-lowering and antidiabetic medications in France among national health insurance beneficiaries in 2010 and their associations according to age, sex, French regions, level deprivation and the presence of certain CVD.

Methods

Treatment frequencies were calculated among the beneficiaries (58 million people) on the basis of reimbursements for three specific categories of medicinal products in 2010. The presence of CVD was defined by a diagnosis associated with chronic disease status and hospital stays in 2010.

Results

Among people aged greater or equal to 20years, treatment frequencies were 22% (men 20% vs. women 23%) for antihypertensives, 15% (14% vs. 16%) for lipid-lowering agents and 6% (6% vs. 5%) for antidiabetic medications. These frequencies were, respectively, 33%, 23% and 8% in patients aged greater or equal to 40years and 55%, 38% and 14% in patients aged greater or equal to 60 years. The frequency of at least one treatment for at least one of the three risk factors was 41% in patients aged greater or equal to 40 years and 66% in patients aged greater or equal to 60 years. Among patients aged greater or equal to 20 years, 22% were treated for at least one risk factor in the absence of CVD and 3% were treated for at least one risk factor in the presence of CVD. Regional differences were observed, with higher frequencies of antihypertensive and antidiabetic use in the North, North-East and Overseas regions. Treatment frequencies increased with level of deprivation, especially for antidiabetics.

Conclusion

This national study more clearly defines treatment frequencies and the populations and regions with the highest treatment frequencies.

The full text of this article is available in PDF format.
Résumé
Contexte

Les fréquences de traitements des facteurs de risque cardiovasculaire sont peu connues dans de larges populations, particulièrement selon la présence ou non d’une maladie cardiovasculaire (MCV).

Objectifs

Décrire les fréquences nationales et régionales des traitements anti-hypertenseurs, antidiabétiques et hypolipémiants et de leurs associations en France parmi les assurés du régime général de l’assurance maladie selon l’âge, le sexe, la région, le niveau de défavorisation et la présence de certaines MCV.

Méthodes

Ces fréquences ont été calculées parmi ces assurés (58 millions), sur la base de trois remboursements de médicaments spécifiques en 2010. L’existence d’une MCV a été définie par les diagnostics des affections de longue durée et des séjours hospitaliers en 2010.

Résultats

Chez les personnes de 20ans et plus, la fréquence d’un traitement anti-hypertenseur était de 22 % (hommes 20 %, femmes 23 %), d’un hypolipémiant de 15 % (14 % vs 16 %) et d’un antidiabétique de 6 % (6 % vs 5 %). Après 40ans, elles étaient de 33 %, 23 % et 8 % et après 60ans de 55 %, 38 % et 14 %. La fréquence d’au moins un traitement pour au moins un des trois facteurs était de 41 % pour ceux de 40ans et plus et de 66 % pour ceux de 60ans et plus. Parmi les personnes de 20ans et plus, 22 % avaient au moins un facteur de risque traité et pas de MCV, et 3 % au moins un facteur traité et une MCV. Des fréquences plus élevées de l’utilisation d’anti-hypertenseurs et d’antidiabétiques étaient constatées dans les régions Nord, Nord-Est et Outremer. Les fréquences des traitements augmentaient avec le niveau de défavorisation, surtout pour les antidiabétiques.

Conclusions

Cette étude nationale permet de mieux connaître les fréquences des traitements des facteurs de risque cardiovasculaire et d’appréhender les populations et régions où elles sont plus élevées.

The full text of this article is available in PDF format.

Keywords : Risk factors, Diabetes, Hypertension, Hyperlipidaemia, France

Mots clés : Facteurs de risque, Diabète, Hypertension artérielle, Hyperlipidémie, Maladies cardiovasculaires, France

Abbreviations : ALD, ATC, CVD, ENNS, PMSI, SNIIRAM


Background

Cardiovascular diseases (CVD) are a leading cause of healthcare consumption, disability and mortality in industrialized countries. Although the number of people affected by CVD is increasing, standardized morbidity and mortality are declining as a result, among other factors, of improved early management of recognized diseases by aggressive treatment, but also improved treatment of cardiovascular risk factors [1, 2, 3, 4, 5, 6, 7, 8].

Compared with other European countries, in 2008, France had the lowest standardized mortality rate for ischaemic heart disease and the second lowest standardized mortality rate for stroke among patients aged 45–74years, for both men and women [9]. These data are confirmed by morbidity data, as the three French MONICA registries reported a significant mean 19% decrease in rates of myocardial infarction and coronary mortality between 2000–2003 and 2004–2007 for both sexes, and the Dijon registry reported a stable incidence of stroke between 1985 and 2004 with a more advanced age of onset [10, 11]. The standardized national hospitalization rate for myocardial infarction decreased by 17% between 2002 and 2008. This reduction was more marked among those aged greater or equal to 65 years (–22%). Before the age of 65 years, hospitalization rate decreased for men (–10%), but increased for women (+7%) [12]. The annual hospitalization rate for stroke decreased by 3% overall, but increased by 11% before the age of 65 years [13]. Surveillance of the levels of primary prevention of CVD and their impact in these populations therefore remains a priority, including in the youngest.

The prevalence rates, treatment and control of cardiovascular risk factors are usually measured by repeated cross-sectional studies in samples from the general population, generally based on self-reported medication consumption or measurement with (or without) clinical examination and laboratory tests [14, 15]. However, subgroup analyses are usually difficult due to the small sample sizes. Hypertension, diabetes and hyperlipidaemia are cardiovascular risk factors accessible to drug treatments, the use of which has been poorly studied in national administrative databases.

The present study was designed to assess national and regional frequencies of reimbursements for antihypertensive, lipid-lowering and antidiabetic medications in France among national health insurance beneficiaries in 2010 and their associations according to age, sex, French regions, level deprivation and the presence of certain CVD.

Methods

In 2010, the Régime Général de l’Assurance Maladie (French national health insurance general scheme) covered about 58 million people living in France, i.e. almost 90% of the French population and almost 75% of the population after the exclusion of local mutualist sections. The Système National d’Information Inter-Régimes de l’Assurance Maladie (SNIIRAM; French national interscheme health insurance information system) comprises an individual and anonymous database, which comprehensively records all healthcare consumption, ambulatory care or outpatient visits, reimbursed by national health insurance, with historical data limited to a period of 3years plus the current year [16]. Other information is also available, such as the town of residence, 100% reimbursement of care for certain chronic diseases (Affections de Longue Durée [ALD]), based on the opinion of the national health insurance general scheme consultant physician. All this information can be linked to data collected in healthcare institutions by the Programme de Médicalisation des Systèmes d’Information (PMSI; medicalized information systems programme) using the unique anonymous patient identifier generated from the Numéro d’Inscription au Répertoire des personnes physiques (social security number). Diagnoses are coded in PMSI according to the International Classification of Diseases, 10th edition (ICD-10), which is also used to code diseases corresponding to ALD.

The study population comprised national health insurance general scheme beneficiaries for whom at least one healthcare reimbursement in 2010 was recorded in SNIIRAM. This criterion was justified by the fact that survival and date of death are only available for general scheme beneficiaries (about 75% of the population) and not for the beneficiaries of other schemes managed by local mutualist sections in SNIIRAM. As the survival status was not available for all patients, the selection of beneficiaries in whom at least one healthcare reimbursement in 2010 was recorded therefore ensures that all beneficiaries of the general scheme, including local mutualist sections, were alive in 2010. Some beneficiaries could not be included due to the absence of reimbursement in the SNIIRAM database, because their treatments were financed directly by the institution (for example medical and social welfare institutions) and were therefore not reimbursed individually, or because they had no reimbursement whatsoever during the index year.

The presence of CVD was estimated by the presence of an ALD with a specific ICD-10 CVD code before or during 2010 and/or the presence of a short-stay hospitalization in 2010 with CVD ICD-10 codes in any position (main, associated or related diagnosis). Selected CVD were coronary heart disease and myocardial infarction (I20 to I25), stroke (I61 to I66, I69, G45) and peripheral artery disease (I70.2), grouped under the term CVD. National health insurance beneficiaries with other CVD codes not included above were excluded to eliminate people with CVD not known to be highly associated with the cardiovascular risk factors studied.

The presence of a treatment for one of the defined risk factors was estimated by the presence of three or more reimbursements recorded in the database in 2010 (or two prescriptions in the case of large packaging) for at least one indicated medicinal product. Medicinal products were identified in the SNIIRAM by ATC class (Anatomical Therapeutic Chemical Classification System) and the corresponding Code Identifiant de Présentation (CIP; presentation identification code). Medicinal products indicated for diabetes corresponded to ATC class A10 (drugs used in diabetes). Indicated antihypertensive medications were those for which the Marketing Authorization specified an indication in the treatment of hypertension (i.e. class C02, antihypertensive; C03, diuretics; C07, beta blocking agents; C08, calcium channel blockers; and C09, agents acting on the renin-angiotensin system). Class C10 was used to identify treatments for hyperlipidaemia.

For each of the three risk factors considered, treatment frequencies of one or several risk factors and their associations by age, sex and region and according to the presence or absence of CVD were calculated on the basis of the populations of beneficiaries with any healthcare consumption reported during 2010. Some age groups were combined (≥20 years; ≥40 years; ≥60 years; 18–74years) to allow national or international comparisons. Regional frequencies were standardized according to sex and age of the population of the general scheme beneficiaries of the Répertoire National Inter-régimes des bénéficiaires de l’Assurance Maladie (RNIAM; national interscheme directory of national health insurance beneficiaries) on 1st January 2011. The cost analysis was based on the amount of annual reimbursement for each treatment according to the refunded amount of each drug studied. Spearman's test was used to identify regional correlations between standardized treatment frequencies and standardized regional hospitalization rates for stroke, ischaemic heart disease and heart failure in 2008 for the overall population. Treatment frequencies were studied according to a geographic deprivation score expressed in quintiles, established on a scale based on the place of residence according to four factors: mean household income; percentage of high school graduates among the inhabitants aged greater or equal to 15 years; percentage of manual workers in the working population; and unemployment rate [17]. Treatment frequencies were also studied according to the degree of urbanicity of the French county defined by counties in which no residence is separated from the next by more than 200m. For these two analyses, people living in French Overseas departments were excluded due to a lack of place of residence codification. Statistical analyses were performed with SAS Enterprise Guide 4.1 software (SAS Institute, Inc., Cary, NC, USA).

Results

Treatment frequencies for all general scheme beneficiaries included in 2010 were 16% (men, 15%; women, 17%) for antihypertensive drugs, 11% (men, 12%; women, 11%) for lipid-lowering agents and 4% (men, 5%; women, 4%) for antidiabetic drugs (Table 1). Treatment frequencies were 33%, 23% and 8%, respectively, for patients aged greater or equal to 40 years and 55%, 38% and 14%, respectively, for those aged greater or equal to 60 years. Peak frequencies were observed in those aged 75–79 years for lipid-lowering agent treatments (47%) and antidiabetics (17%) and in the group aged 85–89 years for antihypertensives (75%), in both men and women.

Regardless of the age groups, women received antidiabetic treatments and lipid-lowering agents less often than men (4% vs. 5% and 11% vs. 12%, respectively), these differences being more marked over the age of 40 years. In contrast, women overall received antihypertensive treatments more often than men (17% vs. 15%), but this difference was only observed between the ages of 20 and 44 years.

The frequency of treatment for at least one of the three risk factors considered was 41% in subjects aged greater or equal to 40 years and 66% for those aged greater or equal to 60 years (Table 2). The peak frequency was observed in those aged 85–89 years (81%). Treatment frequencies for combinations of the various risk factors in individuals aged greater or equal to 40 years ranged between 4% for triple combinations and 15% for double combinations, most frequently an antihypertensive and a lipid-lowering agent. Treatment frequencies with the various combinations were higher in men than in women for almost all age groups.

At the regional level (Figure 1), the frequency of antihypertensive treatment standardized for age and sex ranged from 14% to 19%. Regional differences were observed, with higher treatment frequencies in the North and North-East regions and in the French West Indies, followed by the Centre (apart from Île-de-France) and Reunion regions. Lower treatment frequencies were observed in Île-de-France, Brittany and in the South and South-East regions. Antidiabetic treatment frequencies ranged from 3% to 8%, and a marked geographical gradient was also observed, with high treatment frequencies in Overseas regions, followed by the North and North-East regions, and lower frequencies in the Western regions of France. Regional differences were also observed for lipid-lowering agents, with treatment frequencies ranging between 7% and 13%, but with no clearly defined geographical gradient. The highest treatment frequencies were observed in the North, North-East, North-West, Centre-West and Corsica regions, with lower frequencies in Overseas regions. Combination treatments for all three risk factors accentuated these configurations, with high frequencies in the North, North-East and Overseas regions.



Figure 1


Figure 1. 

Regional treatment frequencies for cardiovascular risk factors* and combinations of risk factors among general scheme beneficiaries in 2010, adjusted for age and sex. *A patient treated for hypertension and diabetes was counted in hypertension, diabetes and hypertension–diabetes.

Zoom

In the population of subjects aged greater or equal to 20 years without CVD, 18% received an antihypertensive, 12% received a lipid-lowering agent and 5% received an antidiabetic agent (Table 3); 7% received a combination of an antihypertensive and a lipid-lowering agent and 2.1% received a triple combination. Among subjects aged greater or equal to 40 years without CVD, 28% received an antihypertensive, 19% received a lipid-lowering agent and 7.3% received an antidiabetic. Eighty percent of patients with CVD received an antihypertensive, 71% received a lipid-lowering agent and 21% received an antidiabetic. Among patients aged greater or equal to 60 years, these proportions were 83%, 70% and 22%, respectively.

Figure 2 and Table 3 show the proportion of patients treated for a given risk factor, according to the presence or absence of CVD. In the overall population aged greater or equal to 20 years, 25% were treated for at least one risk factor: 22% had no CVD and 3.4% had documentation of CVD. Among patients without CVD receiving an antihypertensive treatment, 53% were not treated for the other two risk factors, 7% also received an antidiabetic, 29% received a lipid-lowering agent and 11% received treatments for all three risk factors. These treatment frequencies among patients with at least one CVD were 17%, 4%, 59% and 20%, respectively.



Figure 2


Figure 2. 

Proportion of general scheme beneficiaries treated for a given risk factor and also receiving treatment for other risk factors in 2010, according to the presence or absence of cardiovascular disease, according to age. *Coronary heart disease and myocardial infarction, stroke and peripheral artery disease. HL: hyperlipidaemia; HT: hypertension.

Zoom

The frequency of each treatment increased with the level of deprivation, especially for diabetes (Table 4). This trend was more marked in women for each of the three risk factors studied, but women were generally older than men for each quintile. Antihypertensive and lipid-lowering treatment frequencies according to eight deciles of urbanization decreased for urban units with more than 50,000 inhabitants, while the frequency of antidiabetic treatments was relatively stable (data not shown).

Age-adjusted hospitalization rates in France have been previously published. In 2008, these rates were 105.1/100,000 for stroke, 377.4/100,000 for ischaemic heart disease and 177.5/100,000 for heart failure. Using these estimates, we found a positive correlation between regional stroke hospitalization rate and the frequency of antidiabetic treatment (r =0.62, P =0.007), the treatment frequency of all three risk factors (r =0.57, P =0.002) and the frequency of antihypertensive treatment (r =0.40, P =0.04), but not of lipid-lowering agents. On the contrary, only the regional frequency of lipid-lowering agents was correlated with the ischaemic heart disease hospitalization rate (r =0.45, P =0.02). Only moderate and borderline significant correlations were observed between the heart failure hospitalization rate and treatment frequencies (r between 0.40 and 0.45, P <0.05).

Among patients without CVD, the annual costs of reimbursement of treatments were €749 million (€360 per person treated) for antidiabetics, €761 million (€144 per person treated) for lipid-lowering agents and €1,417 million (€173 per person treated) for antihypertensives, i.e. a global cost of almost €3 billion a year for the French national health insurance general scheme.

Discussion

This study, based on a population of almost 58 million national health insurance general scheme beneficiaries (90% of the population) living in France, a country with low cardiovascular mortality and universal health insurance coverage, reports a high frequency of treatment for cardiovascular risk factors (antihypertensives, 16%; lipid-lowering agents, 11%; antidiabetics, 4%; and at least one treatment, 20%) in 2010, particularly in patients aged greater or equal to 40 years (antihypertensives, 33%; lipid-lowering agents, 23%; antidiabetics, 8%; at least one treatment, 41%). It also reports marked variations of treatment frequencies according to age groups and between regions, as well as several sex-related differences.

Cardiovascular risk factors

Comparisons of the prevalence rates of risk factors between surveys are sometimes limited by differences in the methods of measurement, criteria, age structures and heterogeneous populations. In France, the Étude Nationale Nutrition Santé (ENNS; national health nutrition study) was based on a sample of 2413 participants aged between 18 and 74years in 2006–2007 [18]. The prevalence of known or unknown hypertension (systolic blood pressure140mmHg, diastolic blood pressure90mmHg or antihypertensive treatment) was 31% (34% in men; 28% in women), while the prevalence of treated hypertension was only 15%, similar to the 16% rate reported in the present study. Only one half of the hypertensive patients treated in ENNS presented satisfactory blood pressure control according to current guidelines [19]. In 2006–2007, a regional French survey (the MONA LISA study) conducted in a sample of 4825 participants aged between 35 and 74years with an identical definition of hypertension to that of the ENNS study, reported an adjusted prevalence of hypertension of 47% in men and 35% in women and, as in the present study, a higher prevalence in the North and East of France (Lille and Strasbourg) than in the South of France (Toulouse) [20]. Almost 80% of patients with known hypertension were treated. The ENNS study also noted that, compared with 1996, the prevalence of hypertension had decreased by 7% in men and 18% in women and blood pressure control had improved. International comparisons based on the same definitions show that the prevalence of hypertension in the United States in 2007–2008 in patients aged greater or equal to 18 years was 29% and the prevalence of treated hypertension was 19%, with an improvement of the proportion of patients treated with adequate control [14]. In England in 2006 in patients aged greater or equal to 16 years the prevalence of hypertension was 30% and the prevalence of treated hypertension was about 16% [15]. These prevalence rates of treated hypertension were therefore slightly lower than that observed in the present study, i.e. 22% in patients aged greater or equal to 20 years. All these data concerning hypertension suggest that, despite an increasingly frequent use of antihypertensive drugs (in one third of patients aged40 years), the treated population represents only one half of all hypertensive patients and, even when hypertension is treated, optimal blood pressure control is not always achieved.

The 2006–2007 ENNS study reported a prevalence of hypercholesterolemia of 30% (treatment or LDL-cholesterolemia>1.6g/L) in participants aged between 18 and 74years (33% in men and 27% in women) and specific treatment for 13% of patients (about a third of dyslipidaemic patients), close to the 12% rate reported in the present study [18]. The MONA LISA study reported a reduction of the prevalence of high low-density lipoprotein cholesterol concentrations in patients aged 35–64 years (42% in 1996–1997 and 36% in 2006–2007) [21]. In the USA, in 1999–2006, the prevalence of hypercholesterolaemia (cholesterol>240mg/dL or treatment) was 26%, while the prevalence of undiagnosed hypercholesterolaemia was 8% [22]. Even more than with antihypertensive treatments, these other data source indicate that the proportion of the population treated for dyslipidaemia represents only a small share of the real prevalence of dyslipidaemia, indicating the need for continuing improvement in the mean lipid concentrations of the population.

The ENNS study reported a prevalence of diabetes of 4.6% for participants aged between 18 and 74years on the basis of abnormal fasting blood glucose and/or specific treatment, with 20% of patients with untreated diabetes [23]. The prevalence of treated diabetes was estimated to be 3.7% (2.9–4.8%), consistent with that estimated in our population (4.5% in those aged 18–74years), in view of the large confidence interval in ENNS. In the USA, the global age-adjusted prevalence of diabetes for patients aged greater or equal to 20 years is much higher, with an estimated prevalence of 9.9% in 1999–2006, and a prevalence of undiagnosed diabetes of 2.7% [24, 25]. The ENNS study also reported antihypertensive treatment in 76% of diabetic patients and statin treatment in 52% of these patients, similar to the concomitant treatment rates of 74% for antihypertensives and 59% for lipid-lowering agents (including statins) among the diabetic patients of our study in 2010. This emphasizes the high cardiovascular risk of diabetic patients, as already reported by other authors [26].

The other major cardiovascular risk factors cannot be assessed from the data available in SNIIRAM, but the results of specific studies conducted on these risk factors contribute to those of the present study. The OBEPI study conducted in 2009 reported that 32% of French adults aged greater or equal to 18 years were overweight and 14% were obese (men, 14%; women, 15%). Obesity was more frequent in the North and North-East regions (17% to 20%) [27, 28]. In national surveys, the self-reported prevalence of smoking in those aged 12–75 years was 30% in 2005 versus 33% in 2000, with rates of 33% for men and 26% for women [29]. The prevalence of smoking among men has almost halved over the last 30 years, while the trend towards a decrease in smoking among women started later, after 1991.

Risk factors and prevention

These data suggest the possibility of preventative actions directed towards specific populations, in particular some departments, patients with lower socioeconomic status, and specific age and sex groups. The North-East and Overseas departments present a high cardiovascular risk, particularly for antihypertensives and antidiabetics. While geographical variations in screening, diagnosis and treatment practices are possible, these variations are similar to those of regional standardized hospitalization rates for myocardial infarction and coronary heart disease, stroke and, especially, heart failure [30]. Hospitalization rates for CVD are known to be higher among lower socioeconomic categories [31], but the association between cardiovascular risk factors and diseases with socioeconomic status has rarely been reported in France. While the level of adequacy of treatment and control of risk factors could not be assessed in our study, the higher risk factor treatment frequencies that we observed in the most deprived populations may justify more aggressive screening and management of these factors in these populations, assuming that they were not more adequately treated than the general population. We also observed the expected sex differences, with overall higher treatment frequencies in the elderly and in men. However, we reported a higher treatment use of antihypertensive agents in women aged 20–44 years, as observed by other French (ENNS), British and North American studies [14, 15]. This could be explained by early detection and treatment facilitated by more frequent medical consultations (contraception, pregnancy, etc.). However, despite a lower prevalence of hypertension and a slightly higher treatment frequency in young women than in men, the adjusted hospitalization rates for stroke and coronary heart disease in women aged less than 65years were reported to have increased between 2002 and 2008 in France. This could be partially explained by cardiovascular risk factors other than those investigated in this study, particularly smoking, obesity and, possibly, oral contraception. Moreover, women aged les than 60 years with complementary universal medical coverage, attributed in France to people with an income below the poverty threshold, have about a twofold higher hospitalization rate for hypertension, stroke and myocardial infarction compared with women without complementary universal medical coverage [31]. Specific prevention actions could therefore also be directed towards relatively young women from low socioeconomic categories.

Patients with several risk factors may be another major target for prevention

A recent meta-analysis demonstrated the high-risk of experiencing myocardial infarction or stroke during lifetime in the presence of several risk factors [32]. For men aged 45 years, the presence of at least two risk factors among hypertension, hyperlipidaemia, diabetes and smoking is associated with an excess risk of 49%. Also, treatments of the various cardiovascular risk factors may not all have the same impact on cardiovascular morbidity and mortality. For example, an American study attributed a 24% reduction in mortality for reduction of total cholesterol, a 20% reduction for reduction of systolic blood pressure and a 12% reduction for reduction of smoking prevalence [33].

This study also illustrates the predominant role of primary prevention compared with secondary prevention of CVD. Over the age of 20 years, 22% of the population is treated for at least one risk factor in the absence of CVD, versus only 3% for at least one risk factor in the presence of CVD. While a population-based approach therefore appears to be necessary, its impact may look small in view of the low proportion of events concerned. Various studies have investigated the impact of primary or secondary prevention measures on the reduction of coronary mortality [33, 34, 35, 36]. According to one of these studies, primary prevention measures appeared to be responsible for about 40% of the reduction of mortality, while the rest was due to initial management and secondary prevention [33]. In another English study, primary prevention had a fourfold higher impact on reduction of mortality compared with secondary prevention [35].

Eventually, while the efficacy of the two strategies is improved by statins and the arrival of less expensive generics, the positive effect of drug management of major cardiovascular risk factors on cardiovascular mortality is likely to be decreased by the obesity and diabetes epidemic and probably by the high rate of persistent smoking [34].

Study limitations

This study was based on a large population covered by the French national health insurance general scheme (90% of the French population). However, some population groups insured by other schemes due to their occupation or their sector of activity may differ in terms of their sociodemographic characteristics and habitat, but also according to the frequency of risk factors and their management. However, the impact of this bias on our results is probably low. The prevalence of CVD may also have been underestimated, as the data analyzed in this study were derived from administrative databases with their classical limitations concerning their primary objective, i.e. data collection and coding. It is therefore possible that some patients may have been incorrectly classified in the various groups of CVD. Finally, the frequency of antihypertensive treatment may overestimate the prevalence of treated hypertension, as some medicinal products are also indicated in the treatment of angina, cardiac disorders and heart failure, which are more frequent diseases in the elderly. Finally, treatment use, as commented in the discussion section, partially reflects the prevalence of risk factors and does not provide information on the control of risk factors.

Conclusion

In a historical context of reduction of global morbidity and mortality rates related to CVD, this study highlights the predominant role of treatments for primary prevention of CVD and emphasizes the considerable proportion of intermediate- and high-risk patients already treated. Despite this large proportion, the results of other studies show that progress still needs to be made to delay or limit the frequency of CVD and to more effectively detect, treat and control cardiovascular risk factors. In this setting, the present study identifies populations with high levels of treatment, but in age and sex groups and regions that also have high levels of cardiovascular morbidity or other cardiovascular risk factors. It is necessary to ensure that treatment and control are adequate for the level of risk in these groups: the departments of the North-East region of France, Overseas departments and metropolitan zones; and the elderly, men, but also young women, in whom hospitalization rates for CVD appear to be increasing. The Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (French salaried workers’ national health insurance fund) has set up several programmes concerning the management of these risk factors. One of the main programmes is SOPHIA, a support programme for diabetic patients that is currently being extended nationwide. Since 2010, the cardiovascular risk prevention programme is designed to more accurately evaluate the global cardiovascular risk, optimizing identification of patients at high cardiovascular risk by increasing the awareness of a large population to the value of non-pharmaceutical measures (smoking cessation, diet, physical activity). An active health programme is also being developed for 2013 with a diet component for the so-called low-risk population and a cardiac health component for the so-called high-risk population. More action to prevent the second leading cause of death in France is still required.

Disclosure of interest

N. Danchin: research grants from AstraZeneca, Daiichi-Sankyo, Eli Lilly, GSK, Merck, Novartis, Pfizer, sanofi-aventis, Servier and The Medicines Company; speaker or consulting fees from AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer-Ingelheim, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, MSD-Schering, Novartis, Novo Nordisk, Pfizer, Roche, sanofi-aventis, Servier and The Medicines Company. None for other authors.

References

Arveiler D., Wagner A., Ducimetiere P., and al. Trends in coronary heart disease in France during the second half of the 1990s Eur J Cardiovasc Prev Rehabil 2005 ;  12 : 209-215 [cross-ref]
Birkhead J.S., Walker L., Pearson M., and al. Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP) Heart 2004 ;  90 : 1004-1009 [cross-ref]
Fang J., Alderman M.H., Keenan N.L., , and al. Declining US stroke hospitalization since 1997: National Hospital Discharge Survey, 1988–2004 Neuroepidemiology 2007 ;  29 : 243-249 [cross-ref]
Harmsen P., Wilhelmsen L., Jacobsson A. Stroke incidence and mortality rates 1987 to 2006 related to secular trends of cardiovascular risk factors in Gothenburg, Sweden Stroke 2009 ;  40 : 2691-2697 [cross-ref]
Islam M.S., Anderson C.S., Hankey G.J., and al. Trends in incidence and outcome of stroke in Perth, Western Australia during 1989 to 2001: the Perth Community Stroke Study Stroke 2008 ;  39 : 776-782 [cross-ref]
Rothwell P.M., Coull A.J., Giles M.F., and al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study) Lancet 2004 ;  363 : 1925-1933 [cross-ref]
Setoguchi S., Glynn R.J., Avorn J., and al. Improvements in long-term mortality after myocardial infarction and increased use of cardiovascular drugs after discharge: a 10-year trend analysis J Am Coll Cardiol 2008 ;  51 : 1247-1254 [cross-ref]
Yan A.T., Yan R.T., Tan M., and al. Optimal medical therapy at discharge in patients with acute coronary syndromes: temporal changes, characteristics, and 1-year outcome Am Heart J 2007 ;  154 : 1108-1115 [inter-ref]
Muller-Nordhorn J., Binting S., Roll S., and al. An update on regional variation in cardiovascular mortality within Europe Eur Heart J 2008 ;  29 : 1316-1326
Bejot Y., Rouaud O., Benatru I., and al. [Contribution of the Dijon Stroke Registry after 20 years of data collection] Rev Neurol (Paris) 2008 ;  164 : 138-147 [cross-ref]
Wagner A., Ruidavets J.B., Montaye M., and al. Évolution de la maladie coronaire en France de 2000 à 2007 Bull Epidemiol Hebd 2008 ;  40–1 : 415-419
de Peretti C., Chin F., Tuppin P., and al. Personnes hospitalisées pour infarctus du myocarde en France : tendances 2002–2008 Bull Epidemiol Hebd 2012 ;  41 : 459-465
de Peretti C., Chin F., Tuppin P., and al. Personnes hospitalisées pour accident vasculaire cérébral en France : tendances 2002–2008 Bull Epidemiol Hebd 2012 ;  10–1 : 125-130
Egan B.M., Zhao Y., Axon R.N. US trends in prevalence, awareness, treatment, and control of hypertension, 1988–2008 JAMA 2010 ;  303 : 2043-2050 [cross-ref]
Falaschetti E., Chaudhury M., Mindell J., and al. Continued improvement in hypertension management in England: results from the Health Survey for England 2006 Hypertension 2009 ;  53 : 480-486 [cross-ref]
Tuppin P., de Roquefeuil L., Weill A., and al. French national health insurance information system and the permanent beneficiaries sample Rev Epidemiol Sante Publique 2010 ;  58 : 286-290 [inter-ref]
Rey G., Jougla E., Fouillet A., and al. Ecological association between a deprivation index and mortality in France over the period 1997–2001: variations with spatial scale, degree of urbanicity, age, gender and cause of death BMC Public Health 2009 ;  9 : 33
Unité de surveillance et d’épidémiologie nutritionnelle (Usen). Étude nationale nutrition santé (ENNS 2006) – Situation nutritionnelle en France en 2006 selon les indicateurs d’objectif et les repères du Programme national nutrition santé (PNNS), Institut de veille sanitaire, Université de Paris 13, Conservatoire national des arts et métiers, 2007. 74 p. Available at: RAPP_INST_ENNS_Web.pdf.
Godet-Mardirossian H., Girerd X., Vernay M., and al. Patterns of hypertension management in France (ENNS 2006–2007) Eur J Prev Cardiol 2012 ;  19 : 213-220 [cross-ref]
Wagner A., Sadoun A., Dallongeville J., and al. High blood pressure prevalence and control in a middle-aged French population and their associated factors: the MONA LISA study J Hypertens 2011 ;  29 : 43-50 [cross-ref]
Ferrieres J., Bongard V., Dallongeville J., and al. Trends in plasma lipids, lipoproteins and dyslipidaemias in French adults, 1996–2007 Arch Cardiovasc Dis 2009 ;  102 : 293-301 [cross-ref]
Ford E.S., Li C., Pearson W.S., and al. Trends in hypercholesterolemia, treatment and control among United States adults Int J Cardiol 2010 ;  140 : 226-235 [cross-ref]
Bonaldi C., Vernay M., Roudier C., and al. A first national prevalence estimate of diagnosed and undiagnosed diabetes in France in 18- to 74-year-old individuals: the French Nutrition and Health Survey 2006/2007 Diabet Med 2011 ;  28 : 583-589 [cross-ref]
Beckles G.L., Zhu J., Moonesinghe R. Diabetes – United States, 2004 and 2008 MMWR Surveill Summ 2011 ;  60 : 90-93
Fryar C.D., Hirsch R., Eberhardt M.S., and al. Hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in US adults, 1999–2006 NCHS Data Brief 2010 ;  103 : 1-8
Fagot-Campagna A., Fosse S., Roudier C., and al. Caractéristiques, risque vasculaire et complications chez les personnes diabétiques en France métropolitaine : d’importantes évolutions entre Entred 2001 et Entred 2007 Bull Epidemiol Hebd 2009 ;  42–3 : 450-455
Charles M.A., Eschwege E., Basdevant A. Monitoring the obesity epidemic in France: the Obepi surveys 1997–2006 Obesity (Silver Spring) 2008 ;  16 : 2182-2186 [cross-ref]
INSERM/TNS HEALTHCARE(KANTARHEALTH)/ROCHE. ObEpi : enquête épidémiologique nationale sur le surpoids et l’obésité 2009. Available at: cms2_cahiers_obesite/.
Peretti-Watel P, Beck F, Wilquin JL. Les Français et la cigarette en 2005 : un divorce pas encore consommé. In: Beck F, Guilbert P, Gautier A. (dir.) Baromètre santé 2005. Attitudes et comportements de santé, INPES, Saint-Denis, 76–110. Available at: BS2005_Sommeil.pdf.
L’état de santé de la population en France. Suivi des objectifs annexés à la loi de santé publique. Rapport 2011. DREES. Available at: Etat_sante-population_2011.pdf.
Tuppin P., Drouin J., Mazza M., and al. Hospitalization admission rates for low-income subjects with full health insurance coverage in France Eur J Public Health 2011 ;  21 : 560-566 [cross-ref]
Berry J.D., Dyer A., Cai X., and al. Lifetime risks of cardiovascular disease N Engl J Med 2012 ;  366 : 321-329 [cross-ref]
Ford E.S., Ajani U.A., Croft J.B., and al. Explaining the decrease in US deaths from coronary disease, 1980–2000 N Engl J Med 2007 ;  356 : 2388-2398 [cross-ref]
Capewell S., Hayes D.K., Ford E.S., and al. Life-years gained among US adults from modern treatments and changes in the prevalence of 6 coronary heart disease risk factors between 1980 and 2000 Am J Epidemiol 2009 ;  170 : 229-236 [cross-ref]
Unal B., Critchley J.A., Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981–2000: comparing contributions from primary prevention and secondary prevention BMJ 2005 ;  331 : 614
Wijeysundera H.C., Machado M., Farahati F., and al. Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994–2005 JAMA 2010 ;  303 : 1841-1847 [cross-ref]



© 2013  Elsevier Masson SAS. All Rights Reserved.
EM-CONSULTE.COM is registrered at the CNIL, déclaration n° 1286925.
As per the Law relating to information storage and personal integrity, you have the right to oppose (art 26 of that law), access (art 34 of that law) and rectify (art 36 of that law) your personal data. You may thus request that your data, should it be inaccurate, incomplete, unclear, outdated, not be used or stored, be corrected, clarified, updated or deleted.
Personal information regarding our website's visitors, including their identity, is confidential.
The owners of this website hereby guarantee to respect the legal confidentiality conditions, applicable in France, and not to disclose this data to third parties.
Close
Article Outline