In this article, Janis Morrissey, Director of Health Promotion, Information and Training at the Irish Heart Foundation, examines the recommendations outlined in the paper commissioned by the Irish Heart Foundation, titled Primary Prevention of CVD: Best Practices and Lessons for Ireland.
While mortality rates from cardiovascular disease (CVD) have seen a decline in recent years, the slowdown of this decline raises concerns about decreased life expectancy. The Department of Health’s Cardiovascular Health Policy is out-of-date, and there are significant gaps between the vision set out by Healthy Ireland and Sláintecare, and their implementation. It is not sustainable for the health services to continue to focus on those already ill. If the political will existed, there is an enormous opportunity to prevent cardiovascular disease.
Cardiovascular disease imposes a substantial economic burden on the Irish State, with an estimated cost of €1.7 billion annually, nearly half of which comprises direct healthcare costs. The economic, health, and societal impacts of recent crises, coupled with a need for a sustainable approach, underscore the crucial role of population health in Ireland’s future. The discourse on health is dominated by intervention strategies in high-risk individuals and the rhetoric on prevention inevitably falls short of the reality in terms of national policy priorities and resource allocation. There is a need to shift away from individual-centric approaches to policy-based strategies, advocating for a comprehensive response to address the intertwined challenges of cardiovascular health, economic well-being, and broader social issues.
The term primary prevention encompasses measures to:
The paper Primary Prevention of CVD: Best Practices and Lessons for Ireland, which was commissioned by the Irish Heart Foundation and led by Prof Ivan Perry and UCC colleagues, aims to provide an evidence synthesis to inform policy and practice.
While CVD mortality rates have decreased in Ireland, the overall burden and associated costs persist. The broader context of noncommunicable diseases (NCDs) further underscores the need for a holistic approach that addresses shared risk factors. Lifestyle risk factors, such as smoking and poor diet, need to be reframed at a systemic level, shifting away from individual blame and the ‘lazy language of lifestyle’ to systemic support for healthier choices.
The absolute number of cases of CVD has increased in Ireland due to population aging, improved survival, and population growth. The average annual decline in age-standardized CVD mortality between 2000 and 2010 was approximately 7 per cent in men and women aged 35 – 74 years, falling to 4 per cent in both sexes from 2010 to 2015. This slowdown in the CVD mortality decline is linked to high and increasing obesity levels, diminishing returns from tobacco control policies, and persistent social inequalities in exposure to CVD risk factors and access to care.
Moreover, the burden of cardiovascular disease should also be set within the broader context of noncommunicable diseases. Tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets all increase the risk of dying from a non-communicable disease, including CVD. It is difficult to overstate the role of these core risk factors, both individually and in combination, on a wide range of adverse health outcomes, including the incidence of CVD and diabetes, death from CVD, death from cancer, risk of cognitive decline and dementia, overall life expectancy, healthy life expectancy, and death from all causes. It is estimated that around 40 per cent of all deaths in Ireland are attributable to preventable risk factors.
Population-based strategies, as opposed to individual-focused interventions, are essential for addressing the scale and threat of CVD. The paper advocates for reducing the incidence of heart disease and stroke through legislative measures and public policies targeting entire populations. Comparative research highlights the superior impact of population-wide risk reduction compared to high-risk individual strategies.
Focusing on a broader range of risk factors across the life course, including tobacco use, unhealthy diet, physical inactivity, and harmful alcohol use, provides an integrated approach that also benefits other NCDs. Priority should be given to reducing exposure to CVD risk factors of the whole population across the life course, regardless of the CVD risk, with a focus on behavioural risk factors.
However, it is not suggested that screening for CVD risk be abandoned, but that the ‘high risk’ approach should not be the prime focus of public health policy for the primary prevention of cardiovascular disease. Screening should be used as an adjunct to population-wide strategies with a particular focus on detecting undiagnosed hypertension and other established risk factors for which effective interventions are available.
Data from Ireland on hypertension is relatively sparse and over ten years old. The Irish Longitudinal Study on Ageing (TILDA) found that the prevalence of hypertension (systolic blood pressure (BP) ≥ 40 mmHg or diastolic BP ≥ 90 mmHg and/or currently taking antihypertensive medications) was approximately 64 per cent in those aged 50 years and older. Approximately 45 per cent of those with high blood pressure were unaware of their condition.
Evidence from well-designed intervention studies and a meta-analysis of randomised controlled trials builds a strong case for CVD risk factor screening and management in the pharmacy setting. Further work is needed to assess the feasibility for involving pharmacists in Ireland in the management of confirmed hypertension and the overall cost effectiveness of both screening and potential management interventions in the pharmacy setting.
Existing policies like the Department of Health’s Cardiovascular Health Policy and Healthy Ireland framework lay the groundwork for prevention, yet formal reviews of their impact are lacking. The discourse on health often prioritises intervention strategies for high-risk individuals, hindering primary prevention efforts. The Sláintecare Report emphasises upfront investments and a robust prevention strategy to prevent chronic diseases from overwhelming the healthcare system.
The challenges of preventing cardiovascular and the promotion of health and wellbeing are ultimately political, revolving around how we organise ourselves as a society. There is a need for greater investment in Ireland’s public health infrastructure to support the implementation and evaluation of public health programs and initiatives.
Given the contribution of major CVD risk factors to the burden of disease, including both behavioural risks and the wider societal and environmental determinants, actors at all levels of the policy spectrum must be involved in formulating, implementing, and resourcing effective policies for primary prevention, from Government to clinicians, and from NGOs to statutory agencies.
The fundamental social, economic, commercial, and political determinants of health and wellbeing, with a focus on social justice, should be addressed. There is a need for greater policy alignment on climate action and public health. The promotion of health and wellbeing through food taxes and subsidies, along with greater investment in Ireland’s public health infrastructure, are imperative.
Specific recommendations include:
The launch of the Prevention Paper also saw the establishment of the Health Promotion Alliance Ireland, an all-island coalition of over twenty organisations with a shared interest in advocating for major policy change to promote the primary prevention of chronic disease.
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In conclusion, the transformation of cardiovascular health in Ireland necessitates a comprehensive, population-focused strategy that addresses the root causes of CVD. The recommendations presented provide a roadmap for policymakers, healthcare professionals, and wider society to collaboratively work towards a healthier future. As we face the evolving landscape of public health challenges, a proactive and integrated approach is essential to safeguard the well-being of the Irish population.
Further information is available at irishheart.ie.
Janis Morrissey
Director of Health Promotion, Information and Training, Irish Heart Foundation
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