Our results reflect a wide dissemination of the CEIPC guidelines: more than three quarters of Spanish doctors had heard of the Spanish adaptation of the European guidelines on CVD prevention in clinical practice (CEIPC guidelines) and almost 60% totally or partially knew the contents of the guideline. However, only 36% were using the CEIPC guidelines in clinical practice, with family doctors being more likely to use them than general physicians, as the latter are still working as PCPs without any specialist accreditation. An unexpected result was that PCPs working in academic teaching centres were not doing better in terms of using CEIPC guidelines that those not affiliated to this kind of centres. This result could be explained because CEIPC guidelines were widely disseminated to all kind of centers, regardless their academic characteristics.
A survey of 1,382 physicians from Croatia  showed that 56.9% were using the European CVD prevention guidelines in clinical practice; PCPs were found to be more likely to use their own experience, while internists and cardiologists were more likely to use the European guidelines. Another study of 500 physicians from the United States  found that, despite 90-100% of awareness of CVD guidelines among physicians, only 50-60% incorporated them into clinical practice. A survey conducted in six European countries among 220 cardiologists and PCPs reported that physicians’ use of CVD prevention guidelines in different European countries varied between 60% and 97% .
A discouraging observation stemming from this study is that less than half the physicians (40%) calculated overall cardiovascular risk in more than 80% of their patients with at least one risk factor. Similarly, the Reassessing European Attitudes about Cardiovascular Treatment (REACT) study , which examined attitudes to and implementation of coronary heart disease and lipid treatment among 754 European PCPs, showed that 43% of physicians rarely or never used risk calculator charts, 43% sometimes referred to them, but only 13% reported that this was always the case. A further survey showed that 62% of physicians used a subjective assessment of risk factors rather than a specific risk calculator, with cardiologists being more likely than PCPs to use a subjective assessment . A recent study done in Canada showed that 74% primary care physicians performed CV risk assessment in eligible patients annually . Interestingly, we found that young, urban and family doctors more often assessed the risk than old, rural and general physicians.
Regarding the barriers to cardiovascular risk assessment, the European survey of physicians’ practices in the control of cardiovascular risks factors (EURIKA study)  found that 60% of physicians reported that they did not calculate total cardiovascular risk owing to time constraints, a finding similar to that of our study. A further significant barrier reported in the EURIKA study was that risk assessment is of little use and, moreover the participants did not know how to use it. In contrast, in addition to time constraints, we found the most important barriers to be the lack of computer-based risk charts, charts not being based on Spanish data, major risk factors not being included in risk charts (also reported in the EURIKA study) and each risk factor being addressed separately. Doctors probably do not understand how integrated cardiovascular risk management guidelines still promote the management of raised blood pressure and blood cholesterol. It has been mentioned that it is time for terms such as hypertension and hypercholesterolaemia to be removed from our vocabulary, and the next generation of clinicians should treat risk and not risk factors .
Although many physicians in our survey suggested that the patient himself was a significant impediment to achieving CVD targets, this may reflect the perceived difficulty in adherence to lifestyle factors and pharmacological treatments. Other studies [5, 8] have also shown patient compliance to be the most common barrier to the implementation of cardiovascular risk reduction. A study designed to assess understanding of CV risk by patients recently diagnosed with diabetes mellitus and/or metabolic syndrome treated at primary care centres showed that participants had poor awareness of their CV risk and almost half thought they had good or excellent health .
The most important reason reported by physicians for being sceptical about recommendations was the existence of too many guidelines, a result similar to that found by researchers of the EURIKA study . PCPs may be overwhelmed by the amount of literature they receive and the existence of multiple guidelines for the same topic, which renders it difficult for them to determine which one is/are the best to use in clinical practice. Another important reason reported was that targets for individual risk factors are not realistic in many patients, a fact also mentioned by physicians of the EURIKA study . In clinical practice sometimes it is not easy to implement recommendations of guidelines and achieve specific targets because patients may have multiple comorbidities, being a real challenge to appropriately manage all the conditions.
Almost half the PCPs in our study felt they had insufficient personal training and probably needed further experience and skills to improve the implementation of lifestyle and behavioural change recommendations in their patients. In addition, 41% felt sceptical about the effectiveness of lifestyle advice. This finding is similar to that of a survey of 2,082 PCPs carried out in eleven European countries  which reported that 58.2% and 52.8% of physicians had the perception that they were minimally effective in helping patients achieve or maintain normal weight or in helping patients practise regular physical exercise, respectively. Another major barrier to the implementation of lifestyle and behavioural change recommendations reported in our study was the limited dedication time of nursing staff. In another study  46% of physicians recommended increasing the number of nurses trained in prevention as a practical means of improving guideline implementation. It has previously been suggested that clinical practice may be improved by allowing nurses to discuss more thoroughly with patients the importance of lifestyle changes in reducing the risk of CVD [16, 17].
One limitation of this study regards low participation rate and sample representativeness. PCPs who responded to the survey presumably were more interested in CVD prevention and aware of the CEIPC guidelines, although the potential biases are unpredictable. There is the potential that nonresponding physicians have a different knowledge base, awareness, practice patterns, and perceptions than our responding physicians. However, the large sample size and the similar regional distribution of nonresponders help mitigate some of this concern. In addition, this study was largely based on self-reporting by PCPs, which might not accurately reflect the way they actually practise.
Another limitation of this study is that we lack information on reliability and validity of the questionnaire used. Whether this has any impact on the results remains to be evaluated. However, we did perform a pilot study in order to test for comprehension and usefulness.
Mean age of respondents (50 years) and mean time in practice (22 years) reflect a population relatively old, which reflects a population of doctors with high experience in clinical practice, and this might have influenced the results of the study. Despite such limitations, we are reasonably confident of the generalizability of our results, as the sample of doctors was large, randomly selected, and represented all the regions of Spain.