European heart health survey 2019

Abstract Background Rising life expectancy in the western population is increasing the prevalence of heart valve diseases (HVD). Hypothesis The level of awareness and initial screening for HVD should be sufficient. The potential impact of HVD on the daily activities of the elderly population in Europe might affect our society. Methods and Results A survey was conducted, including a total of 12 832 people aged ≥ 60 years in 11 European countries. Of all the people surveyed, 5.6% could correctly describe aortic valve stenosis. Most participants (75.0%) claimed they regularly do activities like sports or social activities, 29.2% provide care for a family member, friend or acquaintance. The majority (69.2%) would be prevented from doing these activities by symptoms such as chest pain, fatigue or shortness of breath. Having chest pain (76.5%) and shortness of breath (57.8%) were reasons for most people to arrange an appointment with their GP, whereas only 26.2% would visit a GP for fatigue. 67.6% of respondents claimed to be checked with a stethoscope by their GP occasionally, never, or only when they ask. The preferred treatment option for HVD is a keyhole procedure (45.8%), whereas open heart surgery would only be preferred by 7.0%. Conclusion Knowledge about HVD is still low. Neither appointments with a GP driven by symptoms nor regular use of a stethoscope are a reliable guarantee for early diagnosis. With the over 60s in Europe playing an active role in social life, awareness campaigns and regular heart health checks may guarantee early diagnosis and treatment of HVD.


| INTRODUCTION
Moderate or severe heart valve disease (HVD) occurs in over 13% of the population aged >75 years. 1,2 Due to the relationship between increasing life expectancy and degenerative HVD, the number of patients with severe HVD has been growing steadily over recent years 3 and is likely to continue to grow. In the primary care setting, a significant proportion of patients with suspected heart failure are found to have HVD. 4 The number of hospitalisations due to HVD doubled within the last 20 years and the proportion of people dying from HVD has continued to increase. 5 The impact of HVD on survival holds especially true for severe aortic valve stenosis, which is the most common HVD in the elderly and affects up to 7% of the population older than 65 years. 1 Untreated aortic stenosis is associated with a high mortality-even in patients without symptoms. [6][7][8][9] Nowadays, HVD can be treated successfully either with surgery or catheterbased approaches s. [11][12][13][14] Therefore, to minimize mortality, patients with HVD should be diagnosed early, closely monitored and have access to timely and appropriate treatment. 10 In order to achieve this, effective screening and detection, as well as a well-informed population are the key. Prior Heart Health Surveys showed alarmingly low levels of awareness and knowledge of HVD. 14,15 On the other hand exponentially rising TAVI procedures have caused criticism. This is based on the assumption that patients are too old and too frail to profit from treatment. 16 There has been much debate among clinicians as to whether some older patients would benefit from certain treatments, especially if they are elderly or too frail to receive open heart surgical interventions. Therefore, the 2019 European Heart Health Survey sought to reveal the impact of HVD symptoms on quality of life, daily activities, and societal contribution, to demonstrate why access to treatment is important.
Additionally, the 2019 survey-as the previous surveys from 2017 and 2015-assessed again the awareness and concern about aortic stenosis and symptoms of heart valve disease as well as the frequency of stethoscope checks-a key step to the detection of the condition.

| Conduct of the survey
The survey was conducted in the following 11 European countries: Austria, Belgium, Germany, France, Ireland, Italy, Netherlands, Spain, Sweden, Switzerland and the United Kingdom.
An online survey was utilized for all territories. The online panels were actively managed and recruited for market research purposes.
All participants went through a double opt-in process and agreed to participate to provide honest opinions for market research studies.
For each survey, an invitation was sent to respondents via email on a random basis within the target groups. Each invitation reiterated the terms and conditions for the research, including the potential use by the researchers of the information provided. Participants were reminded that personal identity and other personally identifiable details of the respondents would be protected. The survey was con-

| Statistical analysis
Subgroup analyses were performed taking into consideration age All data not displayed is available on request.

| RESULTS
In total, 12 832 people aged 60 years or older in 11 European countries participated in the 2019 European Heart Valve Survey. The participants characteristics are listed in suppl Table 1.
Q2. Which one of these diseases are you most concerned by?
The disease with the highest level of concern among the respondents is cancer (34.0%), followed by Alzheimer´s Disease ( • If you were to be treated for a heart condition, which one of these treatment options would you prefer?
• Keyhole procedure that would cure you • Lifelong daily drug treatment that would relive or better free you from symptoms • Lifelong weekly drug treatment that would relive or better free you from symptoms • Open heart surgery that would cure you • None of the above F I G U R E 1 Q1. Do you know what "aortic stenosis" is? concerned about Alzheimer´s (29.8% vs 20.8%; p < 0.001). While concern about cancer decreased with age (60-64 years: 36.4% vs >80 years: 22.5% p < 0.001), concern about HVD increased with age (60-64 years: 4.9% vs >80 years: 9.3%; p < 0.001; Figure 2 F I G U R E 3 Q3: Which of the following activities do you regularly do (on a weekly or monthly basis)? (by age) p < 0.001). The most common form of caregiving is to care for a partner (13.9%), followed by caring for someone else (8.9%) and for grandchildren (7.8%). Rarely, people care for a friend or acquaintance (3.8%). There is only a small age difference among carers when comparing the different age groups. One third of people aged 80 and above regularly care for other people (suppl Figure 1). Q5: Would chest pain, fatigue or shortness of breath prevent you from doing any of the listed activities? (Tick all that apply).
In total, 69.2% of over 60s claim that the symptoms of HVD Q6: Which of the following symptoms would prompt you to seek an appointment with your general practitioner (GP)?
In total, 93.7% of all respondents claim that having at least one of the symptoms of HVD would make them seek an appointment with their GP. Of the respondents, 76.5% would go to a GP if they experienced chest tightness/pain, 64.1% for abnormal heart beats, 57.8% for shortness of breath and 45.9% when feeling faint. Fewer people would visit a GP if they experienced symptoms not thought to be directly related to the heart, such as fatigue (26.2%), reduced physical activity (19.9%) and feeling older than their age (12.5%). Compared with younger people, elderly people stated more often that none of the symptoms would prompt them to see their GP (80+ years: 10.0%; 60-64 years: 6.9%).
Q7. When you visit a GP how often do they check your heart with a stethoscope?
Most respondents claim they occasionally (35.4%) receive a stethoscope check, while only a third (28.2%) say that their GP checks their heart at every visit. 67.8% of the respondents get checked occasionally or more over this period.
Males (31.3%) are more likely to be checked at every visit compared to females (24.2%, p < 0.001)-a trend consistent throughout the 3 years (2017: males 30.2%, females 24.6%) the survey was conducted.
There was no significant difference in stethoscope use based on age. To check for differences in healthcare systems, stethoscope checks were analyzed in each participating country. Stethoscope checks for over 60s in Europe are highest in France at "every GP visit" (76.1%) and in checks received occasionally or more (92.8%). Belgium was second (56.9%, 82.2%) and lowest in the Netherlands (4.9%, 30%) and the UK (6.4%, 46.6%). In the UK, 36.6% of respondents claim to be never checked with the stethoscope, as did 35.1% of respondents in the Netherlands. However, only 3.9% of over 60s in France say they are never checked with a stethoscope (Figure 4).
Q8: If you were to be treated for a heart condition, which one of these treatment options would you prefer?
Europeans claim they would prefer a keyhole procedure (45.8%) compared to lifelong daily drug treatment (19.7%) or lifelong weekly drug treatment (19.2%). Open heart surgery is the least popular treatment option (7.0%) among over 60s in Europe (suppl Figure 2). The results of this survey of over 12 000 people showed the following: 1. HVD is still not well known and has low levels of concern compared to other diseases such as cancer and Alzheimer's disease. , and a small increase in concern about HVD. 14,15 The percentage of people correctly describing aortic stenosis is close to the estimated prevalence of aortic stenosis in the population participating in the survey. The small increase might be due to higher prevalence of HVD in an aging population, and therefore respondents' friends, family, or even themselves may have been affected, or through the awareness campaigns started within the last years. Interestingly, the percentage of describing aortic stenosis correctly differed widely between the different countries in Europe. Whereas participants from the Netherlands gave the correct description in 12.0%, only 1.6% of the participants from Belgium gave the correct answer.
Maybe the different healthcare systems or might have an influence on the level of knowledge.
The concern about morbidities differs between the age groups.
Whereas young patients are more concerned about cancer, elderly patients are more concerned about heart valve disease, Alzheimer or other morbidities, which were not specified in more detail and could contain neurological as well as all other diseases including myocardial infarction. We show in our results, that the attitude towards morbidity and death certainly changes with age, especially regarding cancer.
Elderly people might be more concerned about diseases baring the risk of neurological impairment or worse prognosis.
The survey results also show that elderly people nowadays are likely to be highly involved in social activities and play an important role in caring for others. If these people develop symptoms of HVD, the results suggest they will be prevented from fulfilling their normal everyday activities. This would have an impact on social networks and communities. Thus, detecting people with HVD and treating them early is very important.
Even if patients suffer from symptoms preventing them from doing their regular activities, they will not automatically seek an appointment with their GP. With typical symptoms like chest pain, three out of four would seek an appointment, but with atypical symptoms like reduced physical activity or fatigue only a minority would see their GP. Therefore, a significant proportion of patients with HVD do not a seek medical consultation and are consequently diagnosed late or never. The EU Heart Health Survey has demonstrated that around 50% of the patients undergoing surgery for HVD were in NYHA class III or IV, which unnecessarily increases postoperative complications and mortality. 18 Early detection and treatment is associated with improved long-term outcome in symptomatic patients. 10 Additionally, patients with asymptomatic HVD might profit from early treatment as well. 9 To overcome this, regular checks with a stethoscope could be an adequate detection method and should be performed. However, as of today only 28.2% of people over the age of 60 throughout Europe claim to be checked with a stethoscope at every visit. The lower number of women who are regularly checked compared to men is also alarming. There are substantial differences in rates of stethoscope check throughout the European countries surveyed. Whereas France continues to have a high percentage of people regularly getting checked with stethoscopes, the Netherlands and the UK show extremely low rates of stethoscope checks.
In recent years, treatment of HVD (in particular, the treatment of aortic valve stenosis) has been revolutionized. Randomized trials and big registries have shown positive outcome results of transcatheter aortic valve implantation (TAVI) compared to medical and surgical treatment-independent of the individual surgical risk. [11][12][13]19,20 Additionally, TAVI offers advantages to the patient including shorter recovery time allowing patients to leave the hospital earlier and get back to normal life, which can lead to cost savings to healthcare systems. 21 Discussions about long-term durability of keyhole devices are still ongoing, but show promising results with no inferiority to surgical devices until now. [22][23][24] As available data suggests TAVI as the gold standard for most of the patients with aortic valve stenosis, the numbers of TAVI procedures already exceeded the number of surgical aortic valve repair in many European countries. In Germany TAVI is performed already twice as often as isolated surgical aortic valve repair. 11,12 In case of other HVD than aortic valve stenosis, the results of keyhole procedures are promising and new techniques and devices may offer valuable treatment options. [25][26][27][28] This survey proves that people would definitely prefer keyhole procedures over surgery for the treatment of HVD, but also over medical daily or even weekly treatment. Despite this preference, the HVD survey 2017 showed that only a minority (19%) of respondents are aware of the possibility of receiving a keyhole procedure to treat HVD, whereas the majority are more likely to know about open heart valve replacement. 15 People should be encouraged to seek for an appointment with their GP in case of HVD symptoms. People might be willing to undergo a curative therapy earlier and would seek a medical appointment earlier if it was better known that there a less invasive keyhole therapy was more widely available. Awareness campaigns, patient organizations and education on the different treatment options could help with this.

| Limitation of the survey
The 2019 European Heart Health Survey was only fielded in countries in Western Europe. Respondents were pre-selected based on their agreement and ability to participate in an online survey. Among other factors this might have influenced the age distribution with fewest participants in the age group >80 years. Nonetheless, the large number of respondents may overcome the latter limitations.

| CONCLUSION
Concern and knowledge of HVD have increased over the years but remain low. Typical symptoms of HVD lead to a GP appointment for the majority of patients. However, for some patients with typical or atypical symptoms, a HVD diagnosis may still be missed due to low rates of regular stethoscope checks. The aging population in Europe means that people aged 60 years and above are likely to continue playing an active role in society and caring for others. The survey results show that the symptoms of HVD can prevent these people from taking part in these positive activities, suggesting that there may be a secondary negative consequence of HVD to society if it is not properly treated in time. Awareness campaigns should be advanced to draw attention to the wider impact on society, while continuing to raise awareness of the symptoms and treatment options of HVD to achieve a fully informed population. In addition, advocating for regular heart health checks for over 60s may help to guarantee early diagnosis of HVD in all patients.

ACKNOWLEDGMENT
The 2019 Heart Health Survey was conducted by Censuswide and funded by Edwards Lifesciences.

DATA AVAILABILITY STATEMENT
Data available on request due to privacy/ethical restrictions.