A Mead

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-randomised controlled trial

BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary, family-based preventive cardiology programme could improve standards of preventive care in routine clinical practice. METHODS In a matched, cluster-randomised, controlled trial in eight European countries, six pairs of hospitals and six pairs of general practices were assigned to an intervention programme (INT) or usual care (UC) for patients with coronary heart disease or those at high risk of developing cardiovascular disease. The primary endpoints-measured at 1 year-were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescription of cardioprotective drugs. Analysis was by intention to treat. The trial is registered as ISRCTN 71715857. FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC, respectively. In patients with coronary heart disease who smoked in the month before the event, 136 (58%) in the INT and 154 (47%) in the UC groups did not smoke 1 year afterwards (difference in change 10.4%, 95% CI -0.3 to 21.2, p=0.06). Reduced consumption of saturated fat (196 [55%] vs 168 [40%]; 17.3%, 6.4 to 28.2, p=0.009), and increased consumption of fruit and vegetables (680 [72%] vs 349 [35%]; 37.3%, 18.1 to 56.5, p=0.004), and oily fish (156 [17%] vs 81 [8%]; 8.9%, 0.3 to 17.5, p=0.04) at 1 year were greatest in the INT group. High-risk individuals and partners showed changes only for fruit and vegetables (p=0.005). Blood-pressure target of less than 140/90 mm Hg was attained by both coronary (615 [65%] vs 547 [55%]; 10.4%, 0.6 to 20.2, p=0.04) and high-risk (586 [58%] vs 407 [41%]; 16.9%, 2.0 to 31.8, p=0.03) patients in the INT groups. Achievement of 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% (2.4 to 23.0, p=0.02) in favour of INT. In the hospital group, prescriptions for statins were higher in the INT group (810 [86%] vs 794 [80%]; 6.0%, -0.5 to 11.5, p=0.04). In general practices in the intervention groups, angiotensin-converting enzyme inhibitors (297 [29%] INT vs 196 [20%] UC; 8.5%, 1.8 to 15.2, p=0.02) and statins (381 [37%] INT vs 232 [22%] UC; 14.6%, 2.5 to 26.7, p=0.03) were more frequently prescribed. INTERPRETATION To achieve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to individual countries, which are accessible by all hospitals and general practices caring for coronary and high-risk patients.

Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial

AIM The EUROACTION PLUS trial measured the effectiveness of a nurse-led preventive cardiology programme (EUROACTION) offering intensive smoking cessation PLUS optional varenicline for persistent high CVD risk smokers to reduce overall cardiovascular risk compared with usual care (UC) in general practice (GP). METHODS AND RESULTS A parallel group randomized controlled trial in 20 GP in Italy, Netherlands, Spain, and UK. Six hundred and ninety-six current smokers, (137 vascular disease and 559 high total CVD risk), were randomized 350 to EUROACTION PLUS (EA+) and 346 to UC. Specially, trained nurses offered the EUROACTION preventive cardiology programme addressing smoking cessation, diet, physical activity, and risk factor management to reduce overall cardiovascular risk. The primary endpoint was 7 day point prevalence of self-reported abstinence (validated breath carbon monoxide <10 p.p.m.) at 16 weeks. Secondary outcomes included dietary habits, physical activity, weight, blood pressure (BP), lipid, and glucose management. One hundred and seventy-seven (51%) EA+ patients (91% opted to use varenicline) were abstinent vs. 63 (19%) in UC; OR 4.52 (95% CI: 3.20-6.39). The Mediterranean diet score of ≥9 in 149 (52%) EA+ patients vs. 97 (37%) in UC; OR 1.84 (95% CI: 1.31-2.59). Physical activity target achieved in 46 (16%) EA+ patients vs. 19 (7%) in UC; OR 2.48 (95% CI: 1.41-4.36). Target BP (<140/90 mm Hg) achieved in 150 (52%) EA+ patients vs. 112 (43%) in UC, OR 1.47 (95% CI: 1.05-2.06) with no difference in antihypertensive drugs. There were no differences in management of cholesterol or glucose. CONCLUSIONS The EUROACTION preventive cardiology programme in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with UC. REC reference: 09/H0402/85; EudraCT number: 2009-012451-18; http://www.controlled-trials.com/ISRCTN22073647, 12 February 2014, date last accessed.

EUROACTION: A European Society of Cardiology demonstration project in preventive cardiology. A cluster randomised controlled trial of a multi-disciplinary preventive cardiology programme for coronary patients, asymptomatic high risk individuals and their families. Summary of design, methodology and outcomes

There is substantial scientific evidence that professional lifestyle intervention on smoking, diet and physical activity, together with control of blood pressure, cholesterol and glycaemia, and selective use of prophylactic drug therapies (aspirin and other anti-platelet therapies, beta-blockers, ACE inhibitors or A-II receptor blockers, lipid-lowering drugs and anticoagulants) can reduce cardiovascular morbidity and mortality in patients with established coronary disease, and can also reduce the risk of developing atherosclerotic disease in high risk individuals. The joint European Societies guidelines on prevention of cardiovascular disease (CVD) define priorities for preventive cardiology in clinical practice 1. The first is patients with established atherosclerotic cardiovascular disease. The second is high risk individuals from the general population with hypertension, dyslipidaemia, diabetes, or a combination of these and other risk factors which puts them at high multifactorial risk of developing CVD. The third is the families (first degree blood relatives) of both coronary patients and high-risk individuals.

Preventive Cardiology: A practical manual

BACKGROUND AND MULTIDISCIPLINARY FAMILY BASED CARDIOVASCULAR ASSESSMENT 1. Rationale for preventive cardiology programmes 2. The nurse-led multidisciplinary team 3. Identification and recruitment 4. Comprehensive multidisciplinary family based cardiovascular assessment APPLICATION OF THE ASSESSMENT FINDINGS TO MANAGE LIFESTYLE AND CARDIOVASCULAR RISK FACTORS 5. Changing lifestyles 6. Smoking cessation 7. Principles of dietary intervention 8. Physical activity and exercise 9. Principles of managing weight loss 10. Blood pressure, cholesterol and glucose 11. Cardioprotective drug therapies 12. Erectile dysfunction 13. The Health Promotion Workshop Programme 14. Data management, quality assurance and audit

145 EUROACTION PLUS: a randomised controlled trial on preventive cardiology programme plus intensive smoking cessation with Varenicline for vascular and high CVD risk smokers and their partners—principal results

Aim The aim of the EUROACTION PLUS trial was to determine if the nurse-led preventive cardiology programme in primary care, with an intensive smoking intervention including the optional use of Varenicline, could achieve more effective smoking abstinence among persistent smokers with either established vascular disease, or at high risk of developing cardiovascular disease and to reduce overall cardiovascular risk compared to usual care (UC). Methods EUROACTION PLUS (EA PLUS) was a randomised controlled intervention trial carried out in general practices across 4 European countries: Italy, The Netherlands, Spain and the UK. Vascular patients and people at high risk of developing cardiovascular disease who were current smokers were individually randomised to receive either a professional smoking cessation intervention, which included the optional use of Varenicline, delivered in the context of the nurse-led EUROACTION preventive cardiology programme, or their usual care. The primary outcome was the proportion of non-smokers (7-day prevalence of non-smoking) validated by breath CO (<10 ppm) in intervention compared to usual care at 16 weeks. The secondary outcomes included the proportions of patients achieving the Joint European Societies lifestyle, risk factor and therapeutic targets for cardiovascular disease prevention. Results 696 patients were recruited: 350 randomised to EA PLUS and 346 to UC. 85% EA PLUS and 83% UC returned at 16 weeks. For the primary endpoint 51% of patients in the EA PLUS arm were abstinent compared to 19% in UC at 16 weeks; OR 4.52 (95% CI 3.20 to 6.39, p<0.0001). In partners, the 7-day point prevalence of abstinence was significantly higher in EA PLUS (73% vs 37%) compared to UC, OR 4.7 (95% CI 1.9 to 11.5, p<0.001). 52.3% of patients in EA PLUS achieved a Mediterranean diet score ≥9, compared to 37.3% in UC (p<0.001). 16.2% in EA PLUS achieved the physical activity target compared to 7.2% in UC (p=0.002) with a significantly higher proportion achieving the METSmax target (Chester Step test): 37.8% in EA PLUS vs 27.3% in UC (p=0.04). Blood pressure target (<140/90 (130/80 diabetes or vascular disease) was significantly higher in EA PLUS (52% vs 43%; OR 1.47, p=0.03) than UC but there were no differences in lipid or glucose management. Prescribing of cardiopr0tective medication was similar in both arms except for lipid lowering drugs; EA PLUS 53% vs UC (45%, p=0.06); high CVD risk individuals 48% EA PLUS vs 39% UC p=0.04). Conclusion This European trial has demonstrated that the EUROACTION nurse-led preventive cardiology programme, with an intensive smoking cessation intervention including optional Varenicline, helps more vascular and high risk patients, together with their partners, to stop smoking and better achieve the other European lifestyle and blood pressure targets for cardiovascular disease prevention than usual medical care.

EUROACTION: A European Society of Cardiology demonstration project in preventive cardiology.: A cluster randomised controlled trial of a multi-disciplinary preventive cardiology programme for coronary patients, asymptomatic high risk individuals and their

There is substantial scientific evidence that professional lifestyle intervention on smoking, diet and physical activity, together with control of blood pressure, cholesterol and glycaemia, and selective use of prophylactic drug therapies (aspirin and other anti-platelet therapies, beta-blockers, ACE inhibitors or A-II receptor blockers, lipid-lowering drugs and anticoagulants) can reduce cardiovascular morbidity and mortality in patients with established coronary disease, and can also reduce the risk of developing atherosclerotic disease in high risk individuals. The joint European Societies guidelines on prevention of cardiovascular disease (CVD) define priorities for preventive cardiology in clinical practice 1. The first is patients with established atherosclerotic cardiovascular disease. The second is high risk individuals from the general population with hypertension, dyslipidaemia, diabetes, or a combination of these and other risk factors which puts them at high multifactorial risk of developing CVD. The third is the families (first degree blood relatives) of both coronary patients and high-risk individuals.