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The EUROACTION preventive cardiology program

Purpose

To investigate whether a Europe-wide preventive cardiology program would improve standards of preventive care in routine clinical practice for patients with coronary heart disease and for asymptomatic individuals at high risk of cardiovascular disease

Reference

Wood DA, Kotseva K, Connolly S, et al. on behalf of EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomized controlled trial. Lancet 2008;371:1999–2012.


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The EUROACTION preventive cardiology program - TRIAL DESIGN -

Design

Multicenter, matched, cluster-randomized, controlled trial in six pairs of hospitals and six pairs of general practices in eight European countries.

Patients

3088 patients with coronary heart disease (recruited from hospitals) and 2317 asymptomatic individuals at high risk of cardiovascular disease (recruited from general practices).

Follow-up and primary endpoints

Primary endpoints were family-based lifestyle change (smoking, diet, anthropmetry, physical activity), management of blood pressure, lipids and blood glucose to target concentrations, and prescription of cardioprotective drugs. All endpoints were measured at 1 year.

Treatment

The EUROACTION intervention program (a nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention program) or usual care.


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The EUROACTION preventive cardiology program - TRIAL DESIGN continued -

Participant demographics

Coronary patients

High-risk patients

Usual care

Intervention

Intervention

Usual care

1694

1128

1718

1257

Identified

1589

n/a

1499

1189

Eligible

1061

332*

306*

1118

Initial assessment

946

1005

994

1-year assessment

1019

62.8

63.0

Age – mean (yrs)

62.0

62.5

Age group (yrs)

22%

15%

22%

22%

<55

35%

48%

34%

44%

55–64

42%

37%

44%

34%

≥ 64

Men

70%

57%

70%

50%

Diagnosis

47%

AMI/Heart score ≥5%

54%

42%

51%

16%

Unstable angina/BP-lipids

23%

21%

27%

36%

26%

Stable angina/diabetes

25%

31%

Abbreviations: AMI, acute myocardial infarction; BP-lipids, patients on antihypertensiveor lipid-lowering treatments; * random sub-sample only.

Wood et al. Lancet2008;371:1999–2012.


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The EUROACTION preventive cardiology program - RESULTS -

Compared with usual care, the EUROACTION program was associated with the following:

  • A trend towards a greater likelihood of smoking cessation (in coronary patients)

  • Reduced consumption of saturated fat (in coronary patients), and increased consumption of fruit and vegetables, fish (in high-risk patients) and oily fish (in coronary patients)

  • A greater proportion achieving physical activity targets (all patients)

  • A greater proportion achieving blood-pressure targets (all patients)

  • A greater proportion achieving low-density lipoprotein (LDL)-cholesterol targets (in coronary patients)

  • More frequent prescription of statins (all patients) and angiotensin-converting enzyme inhibitors (high-risk patients)


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The EUROACTION preventive cardiology program - RESULTS continued -

Percentage of participants achieving the primary endpoints at initial assessment

Coronary patients

High-risk patients

UC (n=306)

Int (n=1118)

Int (n=1061)

UC (n=252)

Not smoking

69%

85%

69%

88%

36%

43%

Saturated fat (<10% of total energy)

3%

5%

5%

3%

Oily fish (≥3 times per week)

66%

59%

62%

56%

Fish (≥20 g per day)

35%

28%

50%

45%

Fruit and vegetables (≥400 g per day)

Physical activity (≥30 min, ≥4 times per week)

32%

24%

29%

26%

18%

23%

Body mass index (<25 kg/m2)

19%

22%

17%

Ideal waist circumference (men <94 cm; women <80 cm)

28%

20%

26%

Blood pressure (<140/90 mm Hg or<130/85 mm Hg in individuals with diabetes)

38%

66%

37%

64%

31%

69%

Total cholesterol (<5 mmol/L)

23%

74%

37%

LDL-cholesterol (<3 mmol/L)

70%

28%

75%

HbA1c (<7% in individuals with diabetes)

72%

42%

72%

47%

Antiplatelet drugs

9%

95%

8%

94%

β blockers

12%

85%

13%

78%

16%

Angiotensin-converting enzyme inhibitors

47%

19%

55%

Statins

79%

15%

79%

18%

Wood et al. Lancet2008;371:1999–2012.


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The EUROACTION preventive cardiology program - RESULTS continued -

Percentage of participants achieving the primary endpoints at 1 year

Coronary patients

High-risk patients

UC (n=306)

Int (n=1118)

Int (n=1061)

UC (n=252)

Not smoking

72%

47%

73%

58%

40%

55%

Saturated fat (<10% of total energy)

6%

8%

11%

17%

Oily fish (≥3 times per week)

66%

67%

83%

79%

Fish (≥20 g per day)

39%

35%

78%

72%

Fruit and vegetables (≥400 g per day)

Physical activity (≥30 min, ≥4 times per week)

22%

20%

50%

54%

22%

21%

Body mass index (<25 kg/m2)

23%

27%

15%

Ideal waist circumference (men <94 cm; women <80 cm)

21%

23%

31%

Blood pressure (<140/90 mm Hg or<130/85 mm Hg in individuals with diabetes)

41%

55%

58%

65%

31%

71%

Total cholesterol (<5 mmol/L)

36%

77%

35%

LDL-cholesterol (<3 mmol/L)

74%

45%

81%

HbA1c (<7% in individuals with diabetes)

65%

53%

80%

56%

Antiplatelet drugs

10%

92%

13%

93%

β blockers

16%

80%

17%

76%

20%

Angiotensin-converting enzyme inhibitors

56%

29%

52%

Statins

38%

86%

23%

80%

Data in red indicate a statistically significant difference between the intervention and treatment groups (p<0.05)


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80

Intervention

Percentage(95% CI) ofnon-smokingpatients

60

Usual care (all)

40

Usual care (sub-sample)

20

0

Initial assessment

1-year assessment

The EUROACTION preventive cardiology program - RESULTS continued -

Proportion of non-smoking patients at the initial and 1-year assessmentsamong those reported as smoking in the month before the index event

100

Wood et al. Lancet2008;371:1999–2012.


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Total cholesterol

LDL-cholesterol

Initial assessment

50

+18%

1-year assessment

45

+14%

0%

44%

40

–0.5%

35

36%

36%

36%

30

32%

32%

Percentage

25

26%

20

22%

15

10

5

0

EUROACTION

Usual care

EUROACTION

Usual care

The EUROACTION preventive cardiology program - RESULTS continued -

Changes in proportions of high-risk patients achieving the Europeantarget for concentrations of lipids between initial and 1-year assessments

Wood et al. Lancet2008;371:1999–2012.


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The EUROACTION preventive cardiology program - SUMMARY -

EUROACTION demonstrates that standards of preventive care in general hospitals and general practices across Europe can be improved.

This nurse-led, multidisciplinary, family-based program achieved healthier lifestyle changes and improvements in other risk factors for patients with coronary heart disease and for those at high risk of cardiovascular disease than for those in usual care.

EUROACTION is a model of preventive cardiology. It has been successfully implemented and assessed, and can be used in routine clinical practice.

To fulfil the potential for cardiovascular disease prevention, we need local preventive cardiology programs that are adapted to the medical, cultural and economic setting of a country, and which are accessible through all hospitals and general practices.


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