Back to school: How reattending a discipline can increase survival

Cardiovascular disease (CVD) and acute myocardial infarction (AMI) are the main causes of mortality in the world, their major risk factors and treatment strategies (both non-pharmacologic and pharmacologic) having been widely studied throughout the planet. However, a blank space in the study of this pathology is how a set of multidisciplinary interventions may influence the survival of patients post AMI, mainly in large populations. That was the purpose of the study of Wallert and collaborators, who studied this correlation during the time of attendance at Heart School, a program of the Swedish Health Service for patients who presented with AMI to re-educate at a secondary prevention level. The program focused on the new therapeutic scheme that those patients would need and would strengthen interdisciplinary measures for reducing cardiovascular risk. I congratulate the authors on their effort of analyzing the records of over 47,000 patients to obtain the data and verify the statistical significance between attending Heart School and the reduction in mortality from cardiovascular and overall mortality, indicating that the service performed in the Heart Schools reduces to almost half these rates of mortality. The study of a multidisciplinary approach for rehabilitation in patients with high cardiovascular risk has been widely studied in various centers for several years, some of them using the same database as used by the current authors. However, we found few records of secondary prevention studies involving not only pharmacological treatment, but the entire set of approach of risk factors in patients post-AMI. The study by Wallert and colleagues proved that even a population with high cardiovascular risk who have suffered AMI can be aided, by several factors, to increase the survival rate, not only in pharmacological ways. The current paradigm of the importance of primary prevention takes us to the false dogma that secondary prevention cannot be appreciated in the population with CVD and public policies should make primary prevention the main priority. We are not depreciating the importance of primary prevention; in recent years large population studies, such as those of Wallert et al. and Szummer et al., have shown us that, since we are dealing with the largest cause of mortality in the world, both sides of the issue must be faced. The factors that influence the development of AMI and the clinical state of the patients post AMI should be dealt with equally, or at least with similar importance, and any factor that can increase the survival rate of these patients will have a significant impact in any population, regardless of the level of prevention. The main scientific limitations in the recent literature regarding this theme lie in the assessment of populations, with little time given to follow up, and in large heterogeneous populations that, even with the impeccable statistical treatment of meta-analysis, compromised the final outcomes and contributed to more questions than answers regarding the theme. Perhaps the main problem faced by the authors, and generally faced by everyone who works in secondary prevention in CVD patients, would be the reproduction of their results in other centers and the homogenization of their interventions even in programs with well consolidated guidelines. I believe that such a problem could be circumvented if, following the main study, each one of the specific interventions (e.g. focus on physical activity or smoking cessation) addressed in the program were studied. This approach would not only permit a better analysis of this problem but also to help the development of new multidisciplinary methodologies to be applied in the Heart Schools and to customize the approach to different populations even at the level of national policy making. Another point that the reader can question regarding the study would be how the authors separated the effect of prescribed medication after AMI from the effect generated by the Heart School. I understand