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Home » Cardiac Health, Health

CVD prevention therefore is far from being done

Submitted by on 12 Apr 2018 – 17:10

For those of us in clinical practice, many real barriers that thwart effective preventive care, including lack of time, training, and dedicated personnel/resources and chronic under-funding, still continue to persist. A paradigm shift from provider-centred or disease-centred care to person-centred care is required but this will take courageous leadership, writes Dr Susan Connolly, Clinical Lead for Preventive Cardiology, Western Health and Social Care Trust

While there has been a decline in mortality rates of cardiovascular disease (CVD) in developed countries, it remains the main cause of death in men in all but 12 countries of Europe and the main cause of death in women in all but two. Worryingly there are even some signals that this decline in CVD mortality is starting to reverse possibly due to the obesity epidemic (and diabesity) that started approximately 30 years ago.

Furthermore, despite the wealth of effective preventive therapies at our disposal including newer more potent antithrombotics, blood pressure lowering drugs and high intensity statins (which are now mostly generic and thus very affordable), patients with established CVD remain at a significant risk for another cardiovascular event. Indeed recent research would suggest that less than 5 percent of the population have CVD but less than 40 percent of new cardiovascular events occur in this group (ie, constituting theses individuals’ second and third events and so forth).

This so-called ‘residual risk’ is attributable in part to the serious gap between guidelines and recommendations for optimal secondary prevention and that achieved in clinical reality. EUROASPIRE surveys which span a 20-year period in Europe are a damning indictment of secondary prevention standards in Europe demonstrating scant improvement in smoking prevalence and blood pressure control, continuing suboptimal lipid control and rising obesity, central obesity and diabetes levels in those who have had a CVD event. Moreover the surveys have repeatedly shown that only the minority of patients are accessing cardiac rehabilitation programmes, despite the compelling evidence for such programmes in reducing cardiovascular mortality. Standards in primary prevention are no better with recent EUROASPIRE data from surveys of high risk individuals (ie, those that have not yet developed CVD) showing a similarly grim picture.

CVD prevention therefore is far from being done. But for those of us in clinical practice, many real barriers that thwart effective preventive care, including lack of time, training, and dedicated personnel/resources and chronic underfunding, still continue to persist.

The World Health Organization (WHO) recognises three levels of prevention– the population strategy, and the primary prevention and secondary prevention strategies –but the distinction between primary and secondary prevention is arbitrary and all patients require the same professional lifestyle intervention, risk factor and therapeutic management to reduce their risk of disease progression, hospitalisations and revascularisation, and to improve their life expectancy.

Such an approach could be offered by a comprehensive integrated professional multidisciplinary CVD prevention programme that offers an ‘all-under-one-roof’ approach with the patient at the centre of care. We have shown this model to be effective through the seminal EUROACTION study, which was conducted as a cluster randomised-controlled trial of a nurse-coordinated multidisciplinary, family-based CVD prevention programme in hospital and general practice across eight European countries.

The programme used a behavioural approach to address lifestyle together with medical risk factor management and the use of cardio-protective medications. At the end of one year, the programme demonstrated healthier lifestyle changes and improvements in other risk factors for patients with coronary heart disease and those at high risk of CVD and their partners than those in usual care.

We subsequently removed the distinction between primary and secondary prevention by integrating care of patients with established CVD (coronary heart disease, peripheral arterial disease, TIA/minor stroke) and those who were at high multifactorial risk of developing CVD into one community-based CVD prevention programme (ie, a pan vascular prevention programme) which we called MyAction.

We piloted the feasibility of this approach and demonstrated that it achieved the same, or even better, outcomes as the EUROACTION trial, and the programme has since been successfully delivered in the borough of Westminster in London and also in Galway in partnership with Croí, the West of Ireland heart and stroke charity.

Formal analysis of the programme’s cost-effectiveness has been undertaken in both the NHS and Irish healthcare setting and the programme has been found not just to be cost-effective but cost saving. This is not surprising as there is mounting evidence that lifestyle modification reduces the incidence not only of CVD but also other chronic diseases such as cancer, chronic obstructive airways disease and cognitive dysfunction. Such individuals also live significantly longer and stay healthier longer, compressing morbidity closer to the end of their prolonged lives and costing less during their lifespan.

But acute cardiovascular care or ‘fire fighting’, by its nature, continues to demand the lion’s share of the health budget while prevention is still perceived in comparison as a ‘soft intervention’. Currently less than 2 percent of national healthcare budgets are assigned to health and well being despite the fact that the burden of non-communicable diseases are making modern healthcare unaffordable and unsustainable. A paradigm shift from provider-centred or disease-centred care to person-centred care is required but this will take courageous leadership – clinical and political – to drive forward an investment in evidence-based effective preventive services and models.

References:

1. Wood DA, Kotseva K, Connolly S, et al. 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. The Lancet 2008;371(9629):1999-2012.

2. Gibson I, Flaherty G, Cormican S, et al. Translating guidelines to practice: findings from a multidisciplinary preventive cardiology programme in the west of Ireland. Eur J PrevCardiol 2014;21(3):366-76

3. Connolly SB, Kotseva K, Jennings C et al. Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme. Heart, February 2017.