Controversies in cardiovascular medicine Why are we failing to implement effective therapies in cardiovascular disease ?

Worldwide, there are ~18 million deaths each year from cardiovascular disease and at least 2-3 times as many experience non-fatal cardiovascular events. Numerous evidence-based prevention and management guideline recommendations for cardiovascular disease are available. However, significant gaps between the evidence and its implementation persist ('evidence-practice gap'). There exist 'under-use' gaps with lack of implementation of proven effective strategies and 'over-use' gaps with inappropriate use of strategies with strong evidence against, or insufficient evidence for their effectiveness and safety. To better tackle the global burden of cardiovascular disease (CVD), more effective strategies are needed. We discuss three selected areas where advances in implementation research for CVD could provide improvements. First, a better assessment and understanding of the most important modifiable context-specific barriers to evidence-based care will allow optimal tailoring of interventions to overcome them. Second, novel community intervention strategies from outside current CVD research should be considered, especially for CVD areas where major barriers exist and little progress has been made. Examples of such interventions include cell phone text messaging, non-physician health workers for the delivery community CVD care in areas of need, and low-cost single-pill combination CVD therapy. Third, increasing our understanding of successful implementation and sustainability of improvements is essential for CVD as a widespread chronic disease. Learning how to better implement effective therapies for CVD will have a larger effect on patient outcomes than most single new drugs and is a priority for tackling the global burden of CVD.