A nurse-coordinated multidisciplinary, family-based cardiology programme in hospitals and general practices can improve standards of preventive care in routine clinical practice. Such a programme would reduce cardiovascular disease (CVD) risk factors for patients with coronary heart disease (CHD) and those without symptoms but at high risk of developing CHD1. These are the conclusions of authors of an Article in this week's edition of The Lancet.
Scientific evidence for CVD prevention is compelling -- showing that lifestyle intervention, risk factor management, and cardioprotective drugs can reduce death and disease rates in these patients. However, the EUROASPIRE survey showed that CVD prevention in routine clinical practice is inadequate. Most patients are not referred to a cardiac rehabilitation programme with the result that almost two thirds do not attend. The EUROACTION model was developed by the European Society of Cardiology to help patients with coronary heart disease, high multifactorial risk, and diabetes outside specialist cardiac rehabilitation centres to achieve the lifestyle, risk factor, and therapeutic targets defined in the prevention guidelines in routine clinical practice.* Professor David Wood, National Heart and Lung Institute, Imperial College London, UK and colleagues did a randomised trial, comprising six pairs of hospitals and six pairs of general practices in eight European countries**, to test whether the EUROACTION model was effective. Coordinated by nurses working with dieticians, physiotherapists, and physicians, it focussed on the whole family. As well as lifestyle it also addressed other risk factors such as blood pressure, cholesterol and use of cardioprotective drugs
A total of 1589 and 1499 patients with CHD in hospitals and 1189 and 1128 at high risk in general practice were assigned to the intervention programme (INT) or usual care (UC). In patients with CHD who smoked in the month before the event, 58% in the INT group and 47% in the UC group did not smoke 1 year afterwards -- an increase in non-smokers of 10.4% for the INT group.
Diet was also improved by the EUROACTION programme. Reduced consumption of saturated fat was achieved by 55% of coronary patients in the INT group but only 40% in the UC group. Increased consumption of fruit of vegetables was managed by 72% in INT and 35% in UC, and increased oily fish consumption was achieved by 17% in INT and 8% in UC. High-risk individuals and partners of both groups showed dietary changes in the same direction but only statistically significant for fruit and vegetable consumption.
Physical activity levels were greatly increased in both hospital and general practice INT groups and their partners. For the hospital groups, 54% of INT patients achieved the target (~30 mins activity ~4 times per week) at 1 year follow-up versus 20% UC, and their partners 41% vs 27%. For the high-risk patients, the corresponding values were 50% INT and 22% UC, and their partners 44% INT and 25% UC.
Blood pressure improvements were seen in both CHD and high-risk patients in the INT groups compared with UC. 65% of CHD patients achieved the target of 140/90 mm Hg compared with 55% UC; in the high-risk patients, these figures were 58% and 41% respectively. For CHD patients better blood pressure control was achieved without the use of additional anti-hypertensive drug therapies. Achievement of target total cholesterol of less than 5 mmol/L did not differ between groups, but in high-risk patients the difference in change from baseline to 1 year was 12.7% in favour of INT -- largely due to statin prescription. Drug prescription differed between the groups. In the hospital group, prescriptions for statins were higher in INT than UC (86% vs 80%). And in general practice in the INT group, ACE inhibitors*** (29% vs 20%) and statins (37% vs 22%) were more frequently prescribed than in UC.
The authors say: "EUROACTION was intentionally set up in busy general hospitals and general practices, outside specialist cardiac rehabilitation centres, to provide a service for all coronary and high risk patients in routine clinical practice.It was a family-centred programme and actively involved patients' partners and other family members. A family intervention is appropriate because married couples show concordance for lifestyle, and concordance for change. Those patients making the greatest changes had partners making similar changes."
They conclude: "EUROACTION has shown that standards of preventive care in general hospitals and general practices across Europe can be improved. EUROACTION is a model of preventive cardiology, which has been successfully implemented and assessed, and can be used in routine clinical practice. To achieve the effects of EUROACTION we need to go beyond specialised cardiac rehabilitation services and provide local preventive cardiology programmes, appropriately adapted to the medical, cultural, and economic setting of a country."
In an accompanying Comment, Dr Dariush Mozaffarian, Brigham and Women's Hospital and Harvard Medical School, and Harvard School of Public Health, Boston, MA, USA, says: "EUROACTION shows that both metabolic and lifestyle risk factors can be improved in clinical practice, and that the room for improvement -- and consequent potential for gain -- is particularly promising for lifestyle change."
Professor David Wood, National Heart and Lung Institute, Imperial College London, UK T) +44 (0) 20 8846 7352 E) d.wood@imperial.ac.uk
For Dr Dariush Mozaffarian, Brigham and Women's Hospital and Harvard Medical School, and Harvard School of Public Health Boston, MA, USA please call Todd Datz T) +1 617.432.3952 E) dmozaffa@hsph.harvard.edu / TDATZ@hsph.harvard.edu
1 Although the programme was directed at coronary heart disease patients in hospital, and high risk patients in general practice, the object was to reduce their total cardiovascular risk; that is coronary heart disease and stroke. So the CHD patients were a target of the programme but the objective was to reduce CVD.
*See p2000 table of full Article for full target list for EUROACTION
**The eight countries involved in the study were UK, Sweden, Denmark, France, Italy, Netherlands, Spain, Poland
***ACE inhibitors -- or inhibitors of Angiotensin-Converting Enzyme, are a group of drugs that are used primarily in treatment of hypertension and congestive heart failure
http://www.eurekalert.org/jrnls/lance/pdfs/EUROACTION p1999-2012 + Com 1973-4 June 14.pdf
Journal
The Lancet