Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION

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1 Secondary prevention and systems approaches: Lessons from EUROASPIRE and EUROACTION Dr Kornelia Kotseva National Heart & Lung Insitute Imperial College London, UK on behalf of all investigators participating in the Euro Heart Survey on Preventive Cardiology

JES Guidelines on CVD Prevention in Clinical Practice 2007 Priorities for CVD Prevention Patients with established atherosclerotic cardiovascular disease Asymptomatic individuals who are at high risk

2 JES Guidelines on CVD Prevention in Clinical Practice 2007 Priorities for CVD Prevention Patients with established atherosclerotic cardiovascular disease Asymptomatic individuals who are at high risk of developing atherosclerotic cardiovascular disease because of: - Multiple risk factors resulting in raised total CVD risk ( 5% 10 year risk of CVD death - Diabetes type 2 & type 1 with microalbuminuria - Markedly increased single risk factors especially if associated with end organ damage Close relatives (first degree relatives) of patients with premature atherosclerotic CVD

3 Developments of CVD prevention in Europe 1994 First Joint Task Force Recommendations 1994 Joint European Societies Implementation Group on Coronary Prevention EUROASPIRE I 1998 Second Joint Task Force Recommendations EUROASPIRE II 2000 Joint European Societies CVD Prevention Committee 2003 Third Joint Task Force Guidelines 2006/2007 EUROASPIRE III 2007 Fourth Joint Task Force Guidelines

4 EUROASPIRE European Action on Secondary and Primary Prevention of Cardiovascular Disease In Order to Reduce Events European Society of Cardiology Euro Heart Survey Programme

5 EUROASPIRE I Finland Netherlands Germany France Czech Republic Italy Slovenia Spain Hungary

6 EUROASPIRE II Sweden Finland UK Ireland Germany Netherlands Poland Belgium France Italy Spain Czech Republic Hungary Slovenia Greece

7 EUROASPIRE III Netherlands Finland Ireland Russia UK Latvia Germany Czech Republic France Belgium Poland Romania Lithuania Hungary Croatia Slovenia Greece Bulgaria Spain Italy Cyprus Turkey

8 Objectives To determine in patients with CHD whether the European guidelines on cardiovascular disease prevention are being followed. To determine whether the practice of preventive cardiology in patients with CHD in EUROASPIRE III has improved by comparison with EUROASPIRE I and II.

9 EUROASPIRE I, II and III 8547 coronary patients Netherlands Finland Slovenia Germany France Czech Republic Italy Hungary

10 Prevalence of smoking, obesity* and central obesity** 100% *Body mass index 30 kg/m² **Waist circumference 88 cm for women and 102 cm for men 90% 80% 70% p< % 50% p= % 30% p= % 10% 0% Smoking Obesity Central obesity EUROASPIRE I 20.3% 25.0% 42.2% EUROASPIRE II 21.2% 32.6% 53.0% EUROASPIRE III 18.2% 38.0% 54.9%

11 Prevalence of elevated blood pressure*, TC** and LDL-C***, and diabetes mellitus *SBP/DBP 140/90 mmhg for non-diabetics or 130/80 mmhg diabetics ** TC 4.5 mmol/l; *** LDL-C 2.5 mmol/l; *** Fasting plasma glucose 7 mmol/l in patient without history of diabetes 100% 90% p< p< % 70% p= % 50% 40% 30% 20% 10% 0% p=0.004 Raised BP Elevated TC Elevated LDL-C Self-reported diabetes p=0.005 Undiagnosed diabetes*** EUROASPIRE I 58.1% 94.5% 96.4% 17.4% 3.8% EUROASPIREII 58.3% 76.7% 78.1% 20.1% 15.3% EUROASPIREIII 60.9% 46.2% 47.5% 28.0% 14.8%

12 Therapeutic control of blood pressure*, total cholesterol** and diabetes*** 100% *In patients on BP lowering medication; **In patients on lipidlowering medication; *** In patients with known diabetes 90% 80% 70% 60% p=0.57 p< p= % 40% 30% 20% 10% 0% BP <140/90 mmhg (<130/80mmHg in diabetics)* TC < 4.5 mmol/l** Plasma glucose < 7.0 mmol/l*** EUROASPIRE I 41.0% 8.4% 39.1% EUROASPIRE II 41.2% 28.7% 42.1% EUROASPIRE III 38.7% 57.3% 21.5%

13 Cardiovascular protective drug therapies 100% 90% 80% p< p< p< p< % 60% 50% 40% 30% 20% 10% 0% Antiplatelets Beta-blockers ACE/ARB's Statins EUROASPIRE I 80.8% 56.0% 31.0% 18.1% EUROASPIRE II 83.6% 69.0% 49.2% 57.3% EUROASPIRE III 93.2% 85.5% 74.5% 87.0%

14 EUROASPIRE No change in prevalence of smoking and continuing adverse trends in prevalence of obesity and central obesity No change in blood pressure control despite increased use of anti-hypertensive medications Continuing improvement in lipid control Increasing prevalence of diabetes, both self reported and undetected, and deteriorating therapeutic control Increased use of anti-platelets, beta- blockers, ACE/ARB s and statins K Kotseva et al. Lancet 2009; 373:

15 EUROACTION A European Society of Cardiology demonstration project in preventive cardiology in patients with coronary heart disease and their families Specialists from the European Association for Cardiovascular Prevention and Rehabilitation, Council on Cardiovascular Nursing and Allied Health Professionals European Heart Network

16 EUROACTION Countries UK Sweden France Poland Spain Italy

17 EUROACTION Aim To raise the standards of preventive cardiology in Europe by demonstrating that the recommended European and national lifestyle, risk factor and therapeutic goals in cardiovascular disease prevention are achievable and sustainable in everyday clinical practice.

Nurse led multidisciplinary family based

families Comprehensive lifestyle and risk

18 Nurse led multidisciplinary family based preventive cardiology programme A cardiovascular prevention and rehabilitation programme for coronary patients and their families Comprehensive lifestyle and risk factor management Prescribing cardio-protective drug therapies

19 EUROACTION programme Multidisciplinary approach Health promotion workshop programme

20 The supervised exercise programme Halmstad, Sweden Valencia, Spain Thiene, Italy

21 EUROACTION materials

22 Smoking cessation at one year in coronary patients who were smokers* % p = Intervention *Smoking in month prior to index event Usual Care

23 Proportions of patients and partners achieving the European targets for a healthy diet Patients Partners p = Saturated fat < 10% of total energy p = p = Fruits and vegetables >400 g/day p = Fish > 20 g/day Oily fish > 3 times/week p = Saturated fat < 10% of total energy p = p = Fruits and vegetables >400 g/day p = Fish > 20 g/day Oily fish > 3 times/week 8

24 Proportion of patients and partners achieving European guidelines for physical activity Patients Partners p = p = Intervention Usual Care 0 Intervention Usual Care

25 Proportions of patients achieving weight and waist circumference targets % achieving 5% weight reduction* % achieving the ideal waist circumference** p = p = Intervention Usual Care 0 Intervention Usual Care *Patients with a BMI 25 kg/m2 **Waist <94cm men; <80cm women

26 % % % Proportion of patients achieving blood pressure*, lipids** and diabetes*** targets p= p= p=0.07 Blood pressure Total cholesterol LDL-cholesterol HbA1c<7% p= *BP < 140/90 mm Hg; <130/85 mm Hg in patients with diabetes; ** TC < 5 mmol/l, LDL-C < 3 mmol/l; *** in patients with diabetes

27 Proportion of patients on cardiovascular protective drug therapy p= Anti-platelet drugs p= Beta blockers p= ACE inhibitors p= Ca antagonists p= Statins

28 EUROACTION The multidisciplinary EUROACTION family based programme achieved significantly better lifestyle changes for coronary patients and partners in terms of a more healthy diet, and increased physical activity, compared to usual care The EUROACTION programme improved blood pressure, blood lipid and blood glucose control compared to usual care The EUROACTION programme increased prescribing for statins in coronary patients compared to usual care D Wood et al. Lancet 2008; 371:

29 Conclusions Guidelines are important prerequisite for implementing preventive cardiology care There is a gap between guidelines standards and clinical management and this gap is getting worst for lifestyle especially smoking and obesity Structured protocol based ambulatory programme can be more effective than usual care Professional comprehensive multidisciplinary ambulatory preventive cardiology programmes should be available for all coronary patients

Models of preventive care in clinical practice to achieve 25 by 25

Models of preventive care in clinical practice to achieve 25 by 25 Professor David A Wood Garfield Weston Professor of Cardiovascular Medicine International Centre for Circulatory Health Imperial College