Treatment and lifestyle change recommendations by cardiologist for patients attending cardiology outpatient clinics: a TLC study

Abstract

Introduction

Just as it is important to recommend lifestyle changes such as exercise, diet and smoking cessation to patients in the low-medium-risk group for protection from cardiovascular diseases, it is also important to identify patients in the high-risk group and reduce cardiovascular risk with lifestyle changes and, when necessary, pharmacological treatment.

Aim

This study evaluated the treatment and lifestyle change recommendations given by cardiologists to patients.

Material and methods

Our study was shared with cardiologists via e-mail from January 2024 to February 2024, and the surveys were answered online. Our questionnaire, consisting of 30 questions, covers topics related to cardiovascular protection, diet, nutritional habits, lifestyle, and diagnosis and treatment strategies of coronary artery disease, heart failure, arrhythmia, and dyslipidemia.

Results

Of the 104 participants included in the analysis, 37 (35.58%) were female, and 67 (64.42%) were male. The proportion of participants who recommended regular exercise to all of their patients was low at 25 (24.04%). It was determined that 60 (57.69%) participants were recommended to use aspirin in primary prevention in patients with moderate-severe cardiovascular risk. Achieving the target LDL value remains at a very low rate (2.88%).

Conclusions

The rate of recommending lifestyle changes, diet and exercise to patients in cardiology outpatient clinics is very low. SGLT2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitors (ARNI) have become highly regarded drugs in heart failure patients. The rate of achieving the target low-density lipoprotein cholesterol value in patients admitted to the cardiology outpatient clinic remains very low.

Summary

Identifying patients in the high-risk group and reducing cardiovascular risk with lifestyle changes and, when necessary, pharmacological treatment is essential. Therefore, this study evaluated the treatment and lifestyle change recommendations given by cardiologists to patients. In the 104 participants included in the analysis, the rate of recommending lifestyle changes, diet, and exercise to patients in cardiology outpatient clinics is very low. SGLT2i and ARNI have become highly regarded drugs in heart failure patients. The rate of achieving the target low-density lipoprotein cholesterol value in patients admitted to the cardiology outpatient clinic needs to be higher.

Introduction

Cardiovascular (CV) diseases are the most common cause of morbidity and mortality worldwide. The increasing average age of the population, irregular and unhealthy diet, inactive life, and widespread smoking are among the main causes of CV diseases [1]. Myocardial infarction (MI), stroke and peripheral arterial diseases (PAD) can be prevented to a great extent by correcting modifiable risk factors in CV diseases. Therefore, the role of cardiologists in primary and secondary prevention is critical [1, 2].

High blood pressure is a major risk factor for coronary artery disease (CAD), heart failure (HF), cerebrovascular disease and PAD. Therefore, in the presence of comorbid diseases, antihypertensive drug selection and lifestyle changes recommended to patients are important [3]. Smoking cessation should be one of the most important goals in primary prevention of CV disease, especially in young people [4]. With regular physical activity, weight decreases, LDL cholesterol (LDL-C) and triglyceride levels decrease, HDL cholesterol (HDL-C) levels increase, insulin sensitivity increases and blood pressure decreases [5]. There is a protective relationship between weekly moderate exercise and CV mortality [5, 6].

Just as it is important to recommend lifestyle changes such as exercise, diet, and smoking cessation to patients in the low-medium-risk group in terms of protection from CVD, it is also important to identify patients in the high-risk group and reduce CV risk with lifestyle changes and, when necessary, pharmacological treatment. Cardiology physicians have important responsibilities in these matters.

Aim

Therefore, this study evaluated the treatment and lifestyle change recommendations given to cardiac patients by cardiologists.

Material and methods

The study targeted cardiologists working in university hospitals, state hospitals, training and research hospitals, private hospitals, and private practices throughout Turkey. In addition, it is a survey study and was conducted prospectively.

In this study, the predetermined questionnaire was shared with cardiologists via e-mail from January 2024 to February 2024 and answered online. One hundred five cardiologists participated in our survey; 104 (99.05%) cardiologists gave consent for the survey results to be used and shared in the analysis.

This questionnaire, consisting of 30 questions about treatment and lifestyle change recommendations given to patients applying to cardiology outpatient clinics, was used to assess the awareness of cardiologists on this issue. Patients included in the study, who were recommended by cardiologists, were patients admitted to cardiology outpatient clinics, older than 18 years, with one or more of the following diagnoses: coronary artery disease, hyperlipidemia, hypertension, diabetes mellitus, arrhythmia, and heart failure. Participants were advised to exclude certain patient groups (unstable patients, active malignancy, disabled patients) from their responses to the survey in order not to influence the study results. Our questionnaire covered topics related to CV prevention, diet, eating habits, lifestyle, diagnosis and treatment strategies for CAD, HF, arrhythmia, and dyslipidemia.

The responses from physicians who voluntarily completed the questionnaire were analyzed through the SurveyMonkey survey research site, which uses an Internet database. The responses of participants who completed the questionnaire but did not approve the use of the data for scientific purposes were excluded from the analysis.

Statistical analysis

The SurveyMonkey statistical analysis program was used to analyze the data. Categorical variables are given as numbers (n) and percentages (%). The program G*Power 3.1.9.7 was used for sample size calculation. The sample size was calculated using Student’s t-test with 80% power, error level α = 0.05, and Cohen (d) effect size = 0.3. Accordingly, completing the study with at least 71 participants was deemed appropriate. Data are presented as mean ± SD for continuous variables and absolute numbers (%) for binary variables. A p-value < 0.05 was considered statistically significant.

Results

The study included 105 physicians working as specialists in the cardiology units; 104 (99.05%) cardiologists gave consent for the survey results to be used in the analysis and shared. Of the 104 participants included in the analysis, 37 (35.58%) were female, and 67 (64.42%) were male. Eighteen (17.31%) participants were < 30 years old, 73 (70.19%) were between 30 and 45 years old, 12 (11.54%) were between 46 and 65 years old, and 1 (0.96%) was > 65 years old. Twenty (19.23%) of the participants had been working as cardiologists for > 15 years, 29 (27.88%) for 11–15 years, 26 (25.0%) for 5–10 years, and 29 (27.88%) for < 5 years. Forty-seven (45.19%) worked in a university hospital, 50 (48.08%) in a state hospital, 5 (4.81%) in a private hospital, 2 (1.92%) in a private practice (Figure 1). Among the participants, 39 (38.46%) saw more than 60 patients daily in the outpatient clinic, and 22 (21.15%) participants saw fewer than 20 patients (Figure 2).

Figure 1.

Demographic characteristics of the participants. A – Gender, B – age, C – professional experience, D – institution

Figure 2.

Number of patients seen daily by the participants in the outpatient clinic

The number of participants who recommended regular exercise to all of their patients was 25 (24.04%), and the number of those who did not recommend it to any of their patients was 3 (2.88%). The majority of the participants did not refer their patients to cardiac rehabilitation programs after acute MI, or they referred very few of them (Table I).

Table 1.

Recommendations for lifestyle changes

Questions	Answers	N (%)
Do you tell patients that they should exercise regularly?	All of them 75–99% 50–74% 25–49% < 25% None of them	25 (24.04) 31 (29.81) 21 (20.19) 14 (13.46) 10 (9.62) 3 (2.88)
In your daily cardiology practice, what percentage of patients do you recommend a Mediterranean-type diet?	All of them 75–99% 50–74% 25–49% < 25% None of them	22 (21.15) 27 (25.96) 22 (21.15) 19 (18.27) 12 (11.54) 2 (1.92)
Do you recommend dietary salt restriction for patients with heart failure/hypertension?	All of them 75–99% 50–74% 25–49% < 25% None of them	67 (64.42) 18 (17.31) 10 (9.62) 3 (2.88) 5 (4.81) 1 (0.96)
Do you advise your patients who smoke to quit smoking/get support to quit smoking?	All of them 75–99% 50–74% 25–49% < 25% None of them	73 (70.19) 21 (20.19) 7 (6.73) 3 (2.88) 0 (0) 0 (0)
Do you advise your patients who drink alcohol to restrict/get support to quit drinking alcohol?	All of them 75–99% 50–74% 25–49% < 25% None of them	34 (32.69) 21 (20.19) 20 (19.23) 12 (11.54) 12 (11.54) 5 (4.81)
Do you refer your patients for admission to a cardiac rehabilitation program after acute myocardial infarction?	All of them 75–99% 50–74% 25–49% < 25% None of them	5 (4.81) 0 (0) 13 (12.5) 12 (11.54) 44 (42.31) 30 (28.85)

In this study, 86 (82.69%) of the participants recommended SGLT2 inhibitors to reduce HF-related hospitalization or CV death in patients with HFpEF (HF with preserved EF) and/or HFmrEF (HF with mildly reduced EF). In comparison, 11 (10.58%) did not recommend them and 7 (6.73%) were undecided (Table II). Participants recommended aspirin for primary prophylaxis in patients with moderate to severe CV risk at the rate of 57.69%. The percentage of those who directly recommend coronary angiography to this patient population is 24.04%.

Table II.

Treatment recommendations

Questions	Answers	N (%)
Which antihypertensive drug group do you prefer the most in your hypertensive patients? (If you prefer combined drugs, you can select more than one option.)	ACE inhibitors ARB Calcium channel blockers B-blockers Diuretics Mineralocorticoid receptor antagonists A-blockers	75 (72.12) 50 (48.08) 68 (65.38) 18 (17.31) 38 (36.54) 5 (4.81) 3 (2.88)
Do you recommend electrical/medical cardioversion for rhythm control in patients with chronic atrial fibrillation?	All of them 75–99% 50–74% 25–49% < 25% None of them	9 (8.65) 12 (11.54) 26 (25.0) 14 (13.46) 33 (31.73) 10 (9.62)
Which drug/method do you prefer the most for rate control in patients with chronic atrial fibrillation?	B-blockers Non-dihydropyridine calcium channel blockers Digoxin Amiodarone Sotalol Propafenone Atrioventricular node ablation/modification	97 (93.27) 4 (3.85) 3 (2.88) 0 (0) 0 (0) 0 (0) 0 (0)
Do you prefer SGLT-2 inhibitors as first-line treatment in your patients with low ejection heart failure, regardless of diabetes mellitus?	Yes No Undecided No opinion	94 (90.38) 5 (5.77) 4 (3.85) 0 (0)
Do you prefer SGLT-2 inhibitors to reduce heart failure-related hospitalization or CV death in patients with symptomatic HFpEF (HF with preserved EF) and/or HFmrEF (HF with mildly reduced EF)?	Yes No Undecided No opinion	86 (82.69) 11 (10.58) 7 (6.73) 0 (0)
Do you prefer angiotensin receptor inhibitors (ARNI) as first-line treatment in your patients with low ejection heart failure?	Yes No Undecided No opinion	60 (57.69) 37 (35.58) 7 (6.73) 0 (0)
Do you recommend medication supplements in addition to medical/interventional treatment for patients with heart failure? (You can select more than one option.)	No Vitamin Herbal products Omega 3 Probiotic	72 (69.23) 22 (21.15) 3 (2.88) 13 (12.5) 10 (9.62)
Do you prefer PCSK9 inhibitors for your patients using statin + ezetimibe to reach the target LDL value?	Yes No Undecided No opinion	23 (22.12) 59 (56.73) 18 (17.31) 4 (3.85)
Do you recommend aspirin for primary prophylaxis in patients with moderate to severe cardiovascular risk?	Yes No Undecided No opinion	60 (57.69) 34 (32.69) 9 (8.65) 1 (0.96)
Do you routinely recommend influenza vaccination to your patients whom you follow up after acute coronary syndrome?	Never Rarely Frequently All of them No opinion	15 (14.42) 39 (37.5) 37 (35.6) 10 (9.62) 3 (2.88)
Would you recommend low dose colchicine (0.5 mg 1 × 1) in ACS patients with uncontrolled or recurrent cardiovascular events under optimal medical therapy?	Never Rarely Frequently All of them No opinion	35 (33.65) 43 (41.35) 14 (13.46) 2 (1.92) 10 (9.62)
Would you prefer finerenone to reduce the risk of hospitalization due to heart failure in patients with type 2 DM and chronic renal failure?	Never Rarely Frequently All of them No opinion	47 (45.19) 26 (25.0) 6 (5.77) 0 (0) 25 (24.04)
Would you prefer intravenous iron carboxymaltose/iron derisomaltose treatment in patients with symptomatic HFrEF or HFmrEF with iron deficiency to reduce heart failure-related hospitalization and improve quality of life?	Never Rarely Frequently All of them No opinion	7 (6.73) 29 (27.88) 54 (51.92) 1 (0.96)
Which agent do you frequently use for long-term single antiplatelet treatment in patients with acute coronary syndrome who do not need oral anticoagulants?	Acetyl salicylic acid Clopidogrel Ticagrelor Prasugrel	69 (66.35) 33 (31.73) 2 (1.92) 0 (0)

The number of participants who frequently recommended the use of low-dose colchicine (0.5 mg 1 × 1) in patients with ACS who had recurrent CV events while under optimal medical treatment was deficient, at 14 (13.46%). Influenza vaccination was rarely recommended by 39 (37.50%), frequently recommended by 37 (35.58%), and never recommended by 15 (14.42%) of the participants (Table II). One of the study’s striking findings was that the rate of achieving the target LDL-C value was very low, at 3 (2.88%), in patients admitted to the cardiology outpatient clinic. PCSK9 inhibitors were recommended at a low number of 23 (22.12%) in patients using statin + ezetimibe to reach the target LDL-C value (Table III).

Table III.

Risk management

Questions	Answers	N (%)
Are you able to reach the target LDL value in your patients?	All of them 75–99% 50–74% 25–49% < 25% None of them	3 (2.88) 40 (38.46) 45 (43.27) 14 (13.46) 2 (1.92) 0 (0)
How soon after discharge do you check lipid profiles in patients with acute coronary syndrome?	1 month 3 months 6 months 1 year	53 (50.96) 40 (38.46) 8 (7.69) 3 (2.88)
Do you use SCORE2/SCORE2-OP risk algorithms to estimate your patients’ total cardiovascular disease risk in your daily cardiology practice?	Never Rarely Frequently All of them No opinion	29 (27.88) 51 (49.09) 19 (18.27) 1 (0.96) 4 (3.85)
Which treatment method would you recommend to your patients whose stable ischemic coronary artery disease is detected by non-invasive tests?	Medical treatment CAG if angina persists after medical treatment Coronary angiography	19 (18.27) 60 (57.69) 25 (24.04)

Discussion

Cardiovascular diseases have predispositions and risk factors at behavioral, biological, and social levels. The etiology and pathogenesis of these diseases largely depend on lifestyle. Major risk factors include smoking, lack of physical activity, and unhealthy diet [1–3]. Behavioral risk factors can lead to HT, increased blood sugar and lipid levels, and obesity [4, 5]. Such mediating factors can be controlled within primary prevention. Determining factors also exist at social, economic, and cultural levels, such as urbanization and population aging. Additional risk factors include male gender, poverty, stress, and genetic predisposition [1, 3]. Evidence shows that a large proportion of the burden of CV disease is associated with behavioral factors and that heart disease, stroke and type 2 diabetes can be prevented mainly by mitigating or eliminating these health risk behaviors [7, 8]. Therefore, lifestyle change and treatment recommendations given by cardiologists in the CV center are essential. As a result of our study, it was determined that cardiologists do not currently give enough lifestyle change recommendations to patients. Still the recommendations of the European Cardiology Guidelines are highly followed in terms of medical treatment.

Despite evidence showing that lifestyle change improves health outcomes and reduces health care costs, lifestyle counseling is not routinely implemented in doctors’ clinical practices [9, 10]. Similar to the literature, as a result of our study, a low percentage (24.04%) of the participants recommend exercising to all of their patients.

In the 2023 ESC update for the treatment of ACS, the addition of ezetimibe is recommended with a Class 1 recommendation level if LDL-C targets (LDL-C < 1.4 mmol/l or 55 mg/dl) are not achieved with maximally tolerated statin alone after 4–6 weeks following ACS [9–11]. Initiation of PCSK9 inhibitor treatment is recommended with a Class 1 recommendation level in patients who cannot achieve the LDL-C target (LDL-C < 1.4 mmol/l or 55 mg/dl) despite maximum tolerated statin and ezetimibe treatment [2, 6, 12]. In our study, the majority of the participants, 56.73% (n = 59), did not prefer to give PCSK9 inhibitors to patients using statin + ezetimibe to reach the target LDL-C value. In the ESC 2023 update on the diagnosis and treatment of acute and chronic HF, SGLT-2 inhibitors are recommended with Class 1 (Level of evidence A) to reduce HF-related hospitalization or CV death in patients with symptomatic HFpEF and/or HFmrEF [11]. In our study, most of the participants (82.69%) stated that they would recommended SGLT-2 inhibitors to reduce heart failure-related hospitalization or CV death in patients with HFpEF and/or HFmrEF.

In the ESC 2023 update for the diagnosis and treatment of acute and chronic HF, iron replacement with ferric carboxy maltose or ferric derisomaltose is recommended with Class 2a (Level of evidence A) to reduce HF-related hospitalization in patients with symptomatic HF with reduced EF (HFrEF) or HFmrEF with iron deficiency, while intravenous iron replacement is recommended with Class 1 (Level of evidence A) to improve HF symptoms and improve quality of life in patients with symptomatic HFrEF or HFmrEF [11]. In our study, 51.92% (54) of the participants frequently used intravenous iron carboxymaltose/iron derisomaltose treatment to reduce HF-related hospitalization and improve quality of life in patients with iron deficiency and symptomatic HFrEF or HFmrEF. In the 2023 ESC update on the treatment of ACS, influenza vaccination is recommended in all patients with ACS with Class 1 (Level of evidence A) [2, 13]. In our study, influenza vaccination was routinely recommended by only 9.62% of the participants in patients followed up after ACS.

The main limitations of our study are that it consists of a predominantly young-middle age group (30–45) with professional experience of 11–15 years and a relatively limited number of participants (104 participants). Since the number of participants included in the study was relatively limited, the study’s results cannot be generalized to the whole country. However, this study will provide a foundation for more comprehensive studies on this subject.

Conclusions

The rate of recommending lifestyle changes, diet and exercise to patients in cardiology outpatient clinics is very low. As for medical treatment recommendations, the rate of compliance with the current ESC Guidelines appears to be high. SGLT2i and ARNI have become highly regarded drugs in heart failure patients. One of the study’s most striking findings was that the rate of achieving the target LDL-C value in patients admitted to the cardiology outpatient clinic remains very low.

Funding Statement

Funding No external funding.

Ethical approval

Ethics committee approval of our study was obtained from Ufuk University Faculty of Medicine Non-Interventional Clinical Research Committee with date and issue number 20200521/2.

Conflict of interest

The authors declared no conflict of interest.