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The EUROACTION preventive cardiology program

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  1. 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.

  2. 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.

  3. 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.

  4. 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)

  5. 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.

  6. 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)

  7. 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.

  8. 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.

  9. 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.