Cardiovascular disease is the leading cause of death worldwide.1 The cornerstone for the prevention of cardiovascular disease is the promotion of a healthy lifestyle together with the identification and treatment of traditional cardiovascular risk factors (CVRF). Attaining those healthy habits should be a therapeutic goal for the entire population. Unfortunately, it is well known that compliance with lifestyle recommendations is poor among the general population.

Cardiologists should promote healthy lifestyles, adequate CVRF control and good medication adherence in each visit, for primary and secondary prevention, in order to reduce morbidity and mortality of cardiovascular disease. Despite these recommendations are well known by physicians, it is uncertain whether they follow them in their lives.

The aim of this study was to analyze CVRF, lifestyle, and adherence to cardiovascular treatment of cardiologists in Latin America, Portugal, and Spain.

Out of the 12799 potential target physicians, 1470 (11.4%) responses were obtained and analyzed. Eight hundred and seventy-five (61.4%) of them were female (45 responders did not define their gender). Median age was 49 [IQR, 38.0–60.0] years and 1138 (79.8%) lived in couple (44 responders did not define their civil status). All respondents were cardiologist selected by each national society 1378 (95%), although 5% of them did not complete the proper box in the form. Out of them, 715 (55.1%) were clinical cardiologists.

Cardiovascular risk factors, heart disease, and treatment adherence

The prevalence of CVRF was low: hypertension (23.5%), hyperlipidemia (25.1%), DM (6.7%), and active smokers (5.5%) (Fig. 1). Median body mass index (BMI) was 24.7kg/m2 [IQR, 22.5–27.1] and abdominal waist circumference was 89.0cm [IQR, 77.0–97.0] (Fig. 2). Previous heart disease was low (7.3%). With regard to medication adherence, 56.8% of responders reported <50% adherence to treatment.

Fig. 1.

Showed the number of CVRF found in different countries. CVRF, cardiovascular risk factors.

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Fig. 2.

Median of BMI represented in the analyzed countries. BMI, body mass index.

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To the best of our knowledge, this study provided the first approach to assess lifestyle and cardiovascular habits of cardiologists from Spain, Portugal, and Latin-America. In this study, a significant number of valid responses were obtained. This means that our results may show a reliable depiction of CVRF, lifestyle, and cardiovascular treatment adherence of cardiologists from different countries on different continents.

Healthy lifestyles have been found to have a positive impact on quality of life and even life expectancy.6 The strategy of prevention, according to Geoffrey Rose paradigm “a large number of people at small risk may give rise to more cases of disease than the small number who are at a high risk”7 could address cardiovascular health over the entire life course and reduce health disparities. Individual behavior is influenced by different factors such as familiar lifestyle, ethnic and cultural grouping, workplace and policy of the state and global levels. It is important to point out the crucial role of health care physicians in encouraging evidence-based population-level interventions.8 If the physicians are really convinced about the benefit of preventive strategies, especially dietary habits and PA, they could have a more convincing attitude when transmitting healthy messages to their patients. In the same way, physicians who are adherent to their own treatment could be more convincing when transmitting messages to their patients about the benefits of adequate therapeutic adherence.

Diet is a potent determinant of CVRF such as hypertension, obesity, DM, hyperlipidemia and overall cardiovascular health.9 A recent systematic review positioned the Mediterranean diet as the most likely dietary model to provide protection against coronary heart disease.10 The PREDIMED study showed an absolute risk reduction on cardiovascular events in primary prevention when implementing healthy dietary recommendations.11 In another work, the questionnaire of adherence to the Mediterranean diet of 14 items (MEDAS-14) was validated.12 In the present study, the PREDIMED score was used to know the physicians’ adherence to Mediterranean diet, finding a low adherence.3 Despite a statistically significant difference was found when comparing Spain and Portugal with Latin-America, all of them reported a low adherence to Mediterranean diet. No difference between genders was found. Of note, when comparisons between age groups were analyzed, the group with the lowest adherence to the Mediterranean diet was the youngest one. An explanation for this finding may be the perception of having a low cardiovascular risk and a healthy status when belonging to a younger age group.

The European guidelines for cardiovascular risk prevention recommend <5g salt intake per day.6 In our survey, almost 80% of the population followed the recommendation. Recently, the PESA study4 showed that skipping breakfast was associated with an increase of prevalent noncoronary and generalized atherosclerosis. Comparing both studies, the PESA study reported a <5% consumption of total daily energy at breakfast in 3% of their population,4 while in our population, this number reached 33.2%. These results could make us reconsider the importance of regular breakfast and its relation with primary cardiovascular prevention.

One of the mainstays in cardiovascular prevention is PA. Regular physical exercise decreases all-cause and cardiovascular mortality.13 Physicians must warn against inactivity and help patients to introduce PA to daily life. The European Guidelines on cardiovascular disease prevention, recommend moderate or vigorous aerobic exercise.6 When PA practicing by the physicians was analyzed using the international PA questionnaire,5 our results showed a moderate activity when the whole population was analyzed. Although there was a statistically significant difference related to greater PA in Spain and Portugal compared with Latin-America, it did not reach the level of vigorous PA in any case, no difference was found between gender neither by age.

Even physicians know smoking is one of the main CVRF associated with coronary disease, 5.5% of the responders were active smokers, this data is probably under-reported, smoking is more prevalent, this could suggest a selection bias. When the differences between Spain and Portugal, and Latin-America were analyzed, active smoking was more frequent in Spain and Portugal. Surprisingly, active smoking was more frequent in women. This finding could be explained because of a lower rate of active smoking male responders or because of a progressive increase of active smoking in women. It is interesting to analyze the different age groups because it was observed an increase in active smoking prevalence in the oldest group, possibly because younger physicians are more aware of the importance of quitting smoking, which can be translated into better recommendations for the patients.

Focusing on the most important differences found between Spain, Portugal, and Latin-America, it should be noted that the youngest physicians were more common from European countries and women from Latin-America which can be related to the interest in cardiovascular prevention. Population in Latin-America had a higher BMI as can be seen in Fig. 2, reflecting the highest rate of overweight in those countries compared to the European countries analyzed. Despite the higher prevalence of hypertension and hyperlipidemia in Latin-America, more physicians in Latin-America reported to achieved CVRF goals. Another interesting fact is that treatment adherence was higher in Latin-America.

Regarding the most important differences between genders, women were older than men. This fact would explain the higher prevalence of CVRF. Nevertheless, they had a lower BMI and greater adherence to the treatment compared to men. This could move us to think that female cardiologists could provide to their patients with better advice to improve their cardiovascular health than male cardiologists.

There were few differences between clinical cardiologists and the other subspecialties, suggesting that awareness about CVRF and healthy lifestyle habits was independent of the specialty.

Only 2 surveys with similar characteristics have been published, but both are limited to only one country. Thus, Faggiano et al.,14 analyzed a sample of Italian cardiologists. From the enrolled patients, women represented 26.5%, mean age was 52.7 years and 74% of the responders were clinical cardiologists. Active smokers were 12.4%. The prevalence of hypertension was 23.3%, DM 3.2%, and hyperlipidemia 35%. Only 5.2% had a previous cardiovascular event, 45% of the population practiced moderate PA and 83% followed Mediterranean diet. With these results, authors concluded that cardiovascular profile of Italian cardiologists may not be considered as ideal or even favorable according to guidelines recommendations. On the other hand, Abuissa et al.,15 analyzed a sample of United States cardiologists. Women represented 7.1% of the whole sample, the mean age was 48 years and 1.3% were active smokers. Prevalence of hypertension was 14%, DM 0.6%, hyperlipidemia 28%, and 4% had a previous coronary event. Authors concluded that cardiologists appear to follow healthier lifestyles than the general adult United States population. Compared with our results, we found a greater representation of women, although the median age was similar. Similar to Faggiano et al.14 our study showed a greater participation of clinical cardiologists (55%). Hypertension prevalence was similar to the Italian population, DM prevalence was higher than the other surveys, hyperlipidemia prevalence was lower, and previous heart disease was more common (7.3%). Surprisingly, Abuissa et al.15 population had a lower percentage of CVRF.

An interesting concept is the “Cardiovascular health” defined by the presence of ideal health behaviors (non-smoking, BMI<25kg/m2, PA at goal levels, and pursuit of a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol<200mg/dL, untreated blood pressure<120/<80mmHg, and fasting blood glucose<100mg/dL).16 When we translate this concept to the survey, only 62 (4.22%) participants meet the 7 optimal values of CVRF. Although the results have the limitations of any voluntary survey, they should make us to think about the role that we, as cardiologists, have in conveying the concept of prevention, healthy habits and CVRF, how we apply it to us and the conviction that we are going to apply to our patients.

Despite the heterogeneity of the sample, this work provided the first data regarding CVRF, lifestyle and cardiovascular treatment adherence of cardiologists in Latin-America, Portugal, and Spain. Cardiologists were relatively aware of the importance of controlling CVRF although there is more room for improvement. Some differences were found between participants from both sides of the Atlantic. Adopting a healthy lifestyle should be the first step for cardiologists to ensure a greater success on their patients and, consequently, in the whole population.

Sección de Cardiología Clínica de la Sociedad Española de Cardiología.

None declared.