Elsevier

The Lancet

Volume 371, Issue 9629, 14–20 June 2008, Pages 1999-2012
The Lancet

Articles
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

https://doi.org/10.1016/S0140-6736(08)60868-5Get rights and content

Summary

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.

Funding

European Society of Cardiology through an unconditional educational grant from AstraZeneca.

Introduction

The scientific evidence for cardiovascular disease prevention is compelling;1 it shows that lifestyle intervention, risk factor management, and cardioprotective drugs can reduce cardiovascular morbidity and mortality in patients with established atherosclerotic disease and those at high risk (Systemic COronary Risk Evaluation [SCORE]) of developing the disease.1, 2 However, results of risk factor management in patients with coronary heart disease in the European Action on Secondary and Primary prevention through Intervention to Reduce Events (EUROASPIRE)3, 4, 5 study showed that cardiovascular disease prevention in routine clinical practice is inadequate. Most patients are not referred to a cardiac rehabilitation programme and less than a third attend.6 The EUROASPIRE4, 5 survey in 2000 described the management of coronary patients as a “collective failure of medical practice”. The EUROACTION model was developed by the European Society of Cardiology to help patients with coronary heart disease, high multifactorial risk, and diabetes outside specialist cardiac rehabilitation centres to achieve the lifestyle, risk factor, and therapeutic targets defined in the prevention guidelines in routine clinical practice.7 The aim of this study was to assess whether a nurse-coordinated, multidisciplinary, family-based, ambulatory, preventive cardiology programme (EUROACTION) in hospital and general practice could increase the proportions of patients and their families achieving the goals for cardiovascular disease prevention compared with usual care (panel).8

Section snippets

Study population

A matched, paired cluster-randomised controlled trial (figure 1) was done in 12 (six pairs) general hospitals in France, Italy, Poland, Spain, Sweden, and the UK, and 12 (six pairs) general-practice centres in Denmark, Italy, Poland, Spain, the Netherlands, and the UK. Hospitals and primary-care centres were randomly assigned to intervention or usual care. The trial started in April, 2003, and was completed in September, 2006.

Consecutive patients (men and women) were prospectively identified.

Results

Table 1 shows patients and their partners' demographics, participation, and 1-year assessments in hospital and general-practice centres. Table 2 shows the results of the initial assessments and the proportions of patients and their partners achieving lifestyle, risk factor, and drug targets for cardiovascular disease prevention. Figure 1 shows the trial profile.

Among patients with coronary heart disease who reported smoking in the month before their cardiac event, a higher proportion in the

Discussion

The EUROACTION preventive cardiology programme reduced the risk of cardiovascular disease compared with usual care mainly through lifestyle changes by families, who together made healthier food choices and became more physically active than before the intervention. This change led to some weight loss and, for high-risk patients, a reduction in central obesity. Blood pressure control was improved and for patients with coronary heart disease without the use of additional antihypertensive drugs.

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