Models of preventive care in clinical practice to achieve

‘25 by 25’

Professor David A WoodGarfield Weston

Professor of Cardiovascular MedicineInternational Centre for Circulatory Health

Imperial College London United Kingdom

Guidelines

Implementation

Evaluation

Finland

Czech RepublicFrance

Germany

Hungary

Italy

Netherlands

SloveniaSpain

EUROASPIRE IV

Belgium

Ireland

UK

Greece

Poland

Latvia

Lithuania

Romania

Russia

Croatia

Bulgaria

CyprusTurkey

Serbia

Bosnia and Herzegovina Ukraine

Sweden

Eur J Prevent Cardiol 2015

Prevalence of smoking, obesity* and central obesity**

* BMI ≥ 30 kg/m²; **Waist circumference ≥ 88 cm for women and ≥ 102 cm for men

p=0.55

p=0.007

p=0.04

EUROASPIRE IIEUROASPIRE IIIEUROASPIRE IV

Prevalence of smoking by age and sex

Prevalence of raised BP*, elevated LDL-C** and diabetes***

* SBP/DBP ≥ 140/90 mmHg (≥ 140/80 mmHg for patients with diabetes); LDL ≥ 1.8 mmol/L (≥ 70 mg/dL);***Fasting glucose ≥ 7 mmol/L (≥ 126 mg/dL) for patients without history of diabetes

p=0.01

P<0.0001

p=0.0004

EUROASPIRE IIEUROASPIRE IIIEUROASPIRE IV

p=0.78

Cardiovascular protective drug therapies

P<0.0001EUROASPIRE IIEUROASPIRE IIIEUROASPIRE IV

P<0.0001

P<0.0001P<0.0001

Cardiopulmonary rehabilitation

“Cardiac rehabilitation is a branch of rehabilitation medicine dealing with

optimizing physical function in patients with cardiac disease or recent cardiac surgeries”

Wickipedia March 25th 2015

Cardiac rehab §°

95% CI Secondary prevention ¶

95% CI

Total mortality 0.80 0.68, 0.93 0.85 0.77, 0.94

CHD mortality 0.74 0.61, 0.90 - -

Myocardial re-infarction 0.79 0.57, 1.09 0.83 0.74, 0.94

§ Taylor R et al, Am J Med 2004; 116:682-692 ¶ Clark A M et al Annals of Internal Medicine 2005;143:659-672. °Heran B S, et al Cochrane Database of Systematic Reviews 2011

Randomised controlled trials of cardiac rehabilitation

Randomised controlled trials of secondary prevention

All cause mortalityTreatment Control Relative

Risk95% CI

Programmewith no exercise

4598 4604 0.87 0.76, 0.99

Programmewith exercise

2404 2251 0.88 0.74, 1.04

Exercise only 1165 1120 0.72 0.54, 0.95

Overall* 8167 7975 0.85 0.77, 0.94

*p=0.001

Clark A M et al Annals of Internal Medicine 2005;143:659-672

Treatment Control Relative Risk

95% CI

Programmewith no exercise

2787 2742 0.86 0.72, 1.03

Programmewith exercise

2075 1922 0.62 0.44, 0.87

Exercise only 1124 1073 0.76 0.57, 1.01

Overall* 5986 5737 0.83 0.74, 0.94*p=0.002

Clark A M et al Annals of Internal Medicine 2005;143:659-672

Randomised controlled trials of secondary prevention

Recurrent myocardial infarction

Cardiac rehabilitation+

Secondary prevention

Cardiac rehabilitation is a branch of rehabilitation medicine dealing with

optimizing physical function in patients with cardiac disease.

While the ‘glue’ of cardiac rehabilitation is exercise, programmes are evolving to

become comprehensive prevention centerswhere all aspects of

care are delivered.

Wickipedia March 25th 2015

Comprehensive prevention centers where all aspects of care are

delivered.

Wickipedia March 25th 2015

Lifestyle (smoking cessation, diet, physical activity) intervention, taking account of psycho-social factors, and using a behavioural approach Measuring, monitoring and managing other risk

factors (blood pressure, lipids and glucose) to target

Understanding of, and adherence with, cardioprotective drug therapies for life

SCORE: the European Risk Prediction System

1994199820033rd Joint European Societies Task Force

2004European Society of Cardiology

Score enabled HeartScore, an interactive tool

• 12 European cohort studies• wide geographic spread of

countries at different levels of cardiovascular risks

• 3-million person-years of observation

• 7,934 fatal cardiovascular events

Data from:

SCORE

Total risk assessment

SCORE

SCORE: the European Risk Prediction System

1994199820033rd Joint European Societies Task Force

2004European Society of Cardiology

Score enabled HeartScore, an interactive tool

• 12 European cohort studies• wide geographic spread of

countries at different levels of cardiovascular risks

• 3-million person-years of observation

• 7,934 fatal cardiovascular events

Data from:

SCORE

Total risk assessment

Total risk management

Lifestyle (smoking cessation, diet, physical activity) intervention, taking account of psycho-social factors, and using a behavioural approach Measuring, monitoring and managing other risk

factors (blood pressure, lipids and glucose) to target

Understanding of, and adherence with, cardioprotective drug therapies for life

Lancet 2008; 371: 1999-2012

EUROACTIONA European Society of Cardiology demonstration project:8 countries and 24 hospital and general practice centres

General hospitals and general practices

Dr Antonio Salvador, Cristina Buigues, Ana Bonet, Arancha Ruescas and Rosario Cuevas

Hospital General de Dr. Peset

Dr Jorge Navarro and Gemma Medez Perez

Centro de Salud de San Pau

Ambulatory nurse-coordinated multidisciplinary approach

The EUROACTION team in Boldrini Hospital, Thiene, Italy The EUROACTION nurse and

the lead GP in Hoensbroek, The Netherlands

Lifestyle change in families• No smoking• Saturated Fat: <10% total

Energy• Fruits and vegetables:

>400g/day• Fish: >20g/day• Oily Fish: >3 times/week• 30-45 minutes of physical

activity at 60–75% of the average maximum heart rate on four-five days of the week

• Weight reduction ≥ 5%• Waist <94 cm in men and

<80 cm in women

Smoking cessation

IncreasingPhysical activity

Healthy eating,Weight

management

Family based lifestyle programme

Sweden

Poland

Health promotion workshops

Gemona, Italy Valencia, Spain

Thiene, Italy

Halmstad, Sweden Valencia, Spain

Supervised hospital and home based physical activity

programme

One year assessment

Identification

Intervention

Randomisation

INT

PROGRAMME16 week hospital

1 year primary care

1965PATIENTS

UC

A CLUSTER RANDOMISED CONTROLLED TRIAL

Initial assessment

580SUB-SAMPLE

2179PATIENTS

2778PATIENTS

1632PARTNERS

910PARTNERS

626PARTNERS

2613PATIENTS

1999PATIENTS

1634PARTNERS

698PARTNERS

EUROACTION: HospitalSmoking cessation at one year in coronary patients who were smokers in the month

prior to their event

p = 0.06

+ 10% ( - 0.3% to + 21%)

EUROACTION + Intensive Smoking Cessation with

Varenicline

ItalyUK

Netherlands Spain

Eur Heart J 2014; 35: 1411-1420

Study Participants

N=696 Eligible patientsN=559 High-Risk patientsN=137 Vascular patients

EA+ ARMN=350 patients

N=276 High-Risk patientsN=74 Vascular patients

N=328 Baseline assessmentN=313 Participated in EA+

N=299 85.4%16-weeks assessment

USUAL CARE ARMN=346 patients

N=283 High-Risk patientsN=63 Vascular patients

N=288 83.2%16-weeks assessment

N=346 Primary endpoint N=335 Primary endpoint

Smoking abstinence for last 7 days confirmed by CO in breath < 10 ppmPRIMARY ENDPOINT

Odds Ratio (95% CI) = 4.52 (3.20 to 6.39)

Lancet 2008; 371: 1999-2012

EUROACTIONA European Society of Cardiology demonstration project:8 countries and 24 hospital and general practice centres

Proportions of patients achieving the European targets for a

healthy dietHospital General Practice

Intervention Usual Care

p = 0.005

p = 0.26

p = 0.13

p = 0.009

p = 0.004

p = 0.91

p = 0.04

Proportions of partners achieving the European targets for a

healthy dietHospital General Practice

p = 0.002

p = 0.42

p = 0.09

p = 0.31 p = 0.002

p = 0.98

p = 0.77

Intervention Usual Care

P = 0.002

General Practice+ 29% ( + 11% to + 48%)

Hospital+ 36% (+20% to + 51%)

P = 0.001

Proportion of patients achieving European Guidelines for physical

activity

Proportion of partners achieving European Guidelines for physical

activity

P = 0.06

General PracticeHospital

p = 0.03

+ 19% (- 0.6% to + 38%) + 27% (+ 4% to + 50%)

Proportion of patients achieving the European target for

blood pressure

P = 0.04

General PracticeHospital

p = 0.03

+ 17% (+ 2% to + 32%)+ 10% (+ 0.6% to + 20%)

Intervention Usual Care

Proportion of patients achieving European target for blood pressure

p = 0.04*

+ 17% (+ 0.5% to + 33%)

* random effects modelling

%

+ 19% (+ 1% to + 37%)

p = 0.04*

Patients without diabetes

Patients with diabetes

Proportion of patients on cardiovascular protective drug therapy

General PracticeHospital

Intervention Usual Care

p=0.28

p=0.16

p=0.26

p=0.53

p=0.04

p=0.06

p=0.91p=0.02

p=0.24

p=0.03

0.19

‘EUROACTION set a new standard for preventive

cardiology – in both secondary and primary prevention

TerminologyCardiac rehabilitation

Cardiovascular rehabilitationRehabilitation and secondary

preventionCardiac rehabilitation and

preventionCardiovascular prevention and

rehabilitation

NICE Guideline: MI - secondary prevention

Cardiac rehabilitation programme is defined as:

ExerciseHealth education and information

Psychology and social support

NICE Guideline: MI - secondary prevention

Cardiac rehabilitation does NOT include:Lifestyle changes after MI:

Smoking cessationChanging dietary regimen

Alcohol consumptionWeight managementDrug therapy after MI

TerminologyCardiac rehabilitation

Cardiovascular rehabilitationRehabilitation and secondary

preventionCardiac rehabilitation and

preventionCardiovascular prevention and

rehabilitation

Cardiac rehabilitation and secondary prevention for patients with

established atherosclerotic disease+

Primary prevention for asymptomatic individuals at high risk of developing CVD including patients with diabetes

mellitus, CKD and other high risk diseases

Primary

Prevention

Secondary

Prevention

Integrate secondary and primary prevention in one programme