european society of cardiology - professor david wood on ......a european society of cardiology...
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EUROACTIONEUROACTIONA European Society of Cardiology A European Society of Cardiology
Demonstration Project Demonstration Project in in
Preventive CardiologyPreventive Cardiology
FINAL RESULTSFINAL RESULTS
Professor David WoodProfessor David Woodon behalf of the EUROACTION Groupon behalf of the EUROACTION Group
8 countries 24 centres 9062 subjects8 countries 24 centres 9062 subjectsEUROACTIONEUROACTION
One year assessmentOne year assessment
Identification Identification
InterventionIntervention
RandomisationRandomisation
INTINT
PROGRAMMEPROGRAMME16 week hospital16 week hospital
1 year primary care1 year primary care
19651965PATIENTSPATIENTS
UCUC
A CLUSTER RANDOMISED A CLUSTER RANDOMISED CONTROLLED TRIALCONTROLLED TRIAL
Initial assessment Initial assessment 638638SUBSUB--SAMPLESAMPLE
21792179PATIENTSPATIENTS
29512951PATIENTSPATIENTS
16331633PARTNERSPARTNERS
898898PARTNERSPARTNERS
626626PARTNERSPARTNERS
28462846PATIENTSPATIENTS
19991999PATIENTSPATIENTS
16321632PARTNERSPARTNERS
698698PARTNERSPARTNERS
EUROACTIONEUROACTIONSubjectsSubjects
Hospital programmeHospital programmeCoronary patients & familiesCoronary patients & families•• ACS and stable angina pectorisACS and stable angina pectoris
General practice programmeGeneral practice programmeHigh risk patients & familiesHigh risk patients & families
•• SCORE ≥ 5% over 10 yearsSCORE ≥ 5% over 10 years•• Treated hypertension or Treated hypertension or dyslipidaemiadyslipidaemia
•• Diabetes mellitusDiabetes mellitus
EUROACTION EUROACTION Primary endpointsPrimary endpoints
• Proportions of patients and families achieving lifestyle, risk factor and therapeutic targets for cardiovascular disease
preventionLifestyle management: smoking (breath CO), diet, physical activityOther risk factor management:
Overweight/ obesity (BMI, waist circumference)Blood pressureTotal cholesterol and LDL cholesterolDiabetes
Cardioprotective drug therapies: anti-platelet, beta-blockers, ACE inhibitors/ARB’s, lipid lowering drugs
Goal: ZEROGoal: ZERO
SMOKINGSMOKING
PATIENTSPATIENTS
HospitalHospitalSmoking cessation at one year in Smoking cessation at one year in
coronary patients who were smokerscoronary patients who were smokers**
47
58
0
10
20
30
40
50
60
70
Intervention Usual Care
p = 0.06p = 0.06
7274
0102030405060708090
100
Intervention Usual Care
General PracticeGeneral PracticeNonNon--smoking at one year in high risk smoking at one year in high risk
patients patients
+ 0.8% (+ 0.8% (-- 13% to + 15%) 13% to + 15%)
p = 0.9p = 0.9**Smoking in month prior to index eventSmoking in month prior to index event
+ 10% ( + 10% ( -- 0.3% to + 21%) 0.3% to + 21%)
DIETDIET
GOALS:GOALS:
Saturated fat: <10% total energySaturated fat: <10% total energyFruit and vegetables: ≥400g/dayFruit and vegetables: ≥400g/day
Fish: ≥20g/dayFish: ≥20g/dayOily fish: ≥3 times/weekOily fish: ≥3 times/week
Proportions of patients achieving Proportions of patients achieving the European targets for a the European targets for a
healthy diethealthy diet
16
7972
55
8
67
3540
0102030405060708090
Saturated fat <10% of total
energy
Fruits andvegetables >400
g/day
Fish > 20 g/day Oily fish > 3times/week
HospitalHospital General PracticeGeneral Practice
11
8378
6
67
39
0102030405060708090
Fruits andvegetables >400
g/day
Fish > 20 g/day Oily fish > 3times/week
Intervention Intervention Usual CareUsual Care
p = 0.005p = 0.005p = 0.07p = 0.07
p = 0.13p = 0.13
p = 0.009p = 0.009
p = 0.004p = 0.004 p = 0.62p = 0.62
p = 0.04p = 0.04
Proportions of Proportions of partnerspartners achieving achieving the European targets for a the European targets for a
healthy diethealthy diet
20
8177
7
6654
0102030405060708090
Fruits and vegetables>400 g/day
Fish > 20 g/day Oily fish > 3times/week
HospitalHospital General PracticeGeneral Practicep = 0.002p = 0.002
p = 0.46p = 0.46
p = 0.05p = 0.05
p = 0.31p = 0.31 p = 0.002p = 0.002p = 0.68p = 0.68
11
7872
60
8
63
3742
0102030405060708090
Saturated fat <10% of total
energy
Fruits andvegetables >400
g/day
Fish > 20 g/day Oily fish > 3times/week
p = 0.71p = 0.71
Intervention Intervention Usual CareUsual Care
PHYSICAL ACTIVITYPHYSICAL ACTIVITY
Goal:Goal:3030--45 minutes of physical 45 minutes of physical activity at 60activity at 60––75% of the 75% of the
average maximum heart rate average maximum heart rate on fouron four--five days of the weekfive days of the week
20
54
0
10
20
30
40
50
60
Intervention Usual Care
P = 0.002P = 0.002
22
50
0
10
20
30
40
50
60
Intervention Usual Care
General PracticeGeneral Practice+ 29% ( + 11% to + 48%) + 29% ( + 11% to + 48%)
HospitalHospital+ 36% (+20% to + 51%) + 36% (+20% to + 51%)
P = 0.01 P = 0.01
Proportion of patients achieving Proportion of patients achieving European Guidelines for physical European Guidelines for physical
activityactivity
Caspersen and Powell physical activity Caspersen and Powell physical activity classification in patientsclassification in patients
General PracticeGeneral PracticeHospitalHospital
27
46
121410
46
18
26
0
10
20
30
40
50
60
Sedentary Irregularlyactive
Regularly activenot intensive
Regularly activeintensive
%
Intervention Intervention Usual CareUsual Care
7356
P=0.04P=0.04 P=0.09P=0.0972
50
22
50
1315 13
37
15
35
0
10
20
30
40
50
60
Sedentary Irregularlyactive
Regularly activenot intensive
Regularly activeintensive
%
Proportion of Proportion of partners partners achieving achieving European Guidelines for physical European Guidelines for physical
activityactivity
27
41
0
10
20
30
40
50
Intervention Usual Care
P = 0.06P = 0.06
General PracticeGeneral Practice+ 27% (+ 4% to + 50%)+ 27% (+ 4% to + 50%)
HospitalHospital
p = 0.03p = 0.03
25
44
0
10
20
30
40
50
Intervention Usual Care
+ 19% (+ 19% (-- 0.6% to + 38%)0.6% to + 38%)
WEIGHT AND SHAPEWEIGHT AND SHAPE
Goals:Goals:BMI <25 kg/m²BMI <25 kg/m²
WAIST <94cm menWAIST <94cm men<80cm women<80cm women
Proportion of patientsProportion of patients++achieving achieving ≥≥ 5% weight reduction5% weight reduction
General PracticeGeneral PracticeHospitalHospital
Intervention Intervention Usual Care SubUsual Care Sub--samplesample
13
19
0
10
20
Intervention Usual Care
+ 6% (+ 6% (-- 7% to + 19%)7% to + 19%)
P = 0.28*P = 0.28*
7
16
0
10
20
Intervention Usual Care
p = 0.005*p = 0.005*
+ 10% (+5% to + 16%)+ 10% (+5% to + 16%)
+ Patients with a BMI + Patients with a BMI ≥≥ 25 kg/m225 kg/m2
Proportion of patients achieving Proportion of patients achieving the ideal waist circumference the ideal waist circumference
15
23
0
10
20
30
40
Intervention Usual Care
p = 0.11p = 0.11
General PracticeGeneral PracticeHospitalHospital
p = 0.10p = 0.10
+ 8% (+ 8% (-- 2% to + 18%) 2% to + 18%)
22
31
0
10
20
30
40
Intervention Usual Care
+ 9% (+ 9% (-- 3% to + 20%)3% to + 20%)
Intervention Intervention Usual CareUsual Care
RISK FACTOR MANAGEMENTRISK FACTOR MANAGEMENT
Goals:Goals:Blood pressure <140/90 mmHgBlood pressure <140/90 mmHg(<130/85 mmHg in diabetes)(<130/85 mmHg in diabetes)
Total cholesterol <5 Total cholesterol <5 mmol/lmmol/l
LDL cholesterol <3 LDL cholesterol <3 mmol/lmmol/l
Diabetes: good Diabetes: good glycaemicglycaemic controlcontrol
Proportion of patients achieving Proportion of patients achieving the European target for the European target for
blood pressureblood pressure
P = 0.04P = 0.04
General PracticeGeneral PracticeHospitalHospital
p = 0.03p = 0.03
55
65
0
10
20
30
40
50
60
70
Intervention Usual Care
41
58
0
10
20
30
40
50
60
70
Intervention Usual Care
+ 17% (+ 2% to + 32%)+ 17% (+ 2% to + 32%)+ 10% (+ 0.6% to + 20%)+ 10% (+ 0.6% to + 20%)
Intervention Intervention Usual CareUsual Care
Proportion of patients achieving Proportion of patients achieving the European lipid targetsthe European lipid targets
General PracticeGeneral PracticeHospitalHospital
8178 7471
0102030405060708090
100
TC < 5 mmol/l LDL-C < 3 mmol/l
P=0.23P=0.23 P=0.07P=0.07TC + 7% ( TC + 7% ( --6% to + 19%) 6% to + 19%) LDLLDL--C + 7% ( 0.9% to + 15%)C + 7% ( 0.9% to + 15%)
Intervention Intervention Usual CareUsual Care
45
36 3532
0102030405060708090
100
TC < 5 mmol/l LDL-C < 3 mmol/l
Change in proportion of high risk Change in proportion of high risk patients achieving the European patients achieving the European
lipid targetslipid targetsLDL cholesterolLDL cholesterolTotal cholesterolTotal cholesterol
IA = initial assessment 1 YR = one year assessmentIA = initial assessment 1 YR = one year assessmentIntervention Intervention Usual CareUsual Care
22IA
32IA
361 YR 32
1 YR
0
10
20
30
40
50
Intervention Usual Care
26IA
36IA
361 YR
441 YR
0
10
20
30
40
50
Intervention Usual Care
Change in proportion of high risk Change in proportion of high risk patients achieving the European patients achieving the European
lipid targetslipid targetsLDL cholesterolLDL cholesterolTotal cholesterolTotal cholesterol
IA = initial assessment 1 YR = one year assessmentIA = initial assessment 1 YR = one year assessmentIntervention Intervention Usual CareUsual Care
22IA
32IA
361 YR 32
1 YR
05
101520253035404550
Intervention Usual Care
26IA
36IA
361 YR
441 YR
05
101520253035404550
Intervention Usual Care
Change in proportion of high risk Change in proportion of high risk patients achieving the European patients achieving the European
lipid targetslipid targetsLDL cholesterolLDL cholesterolTotal cholesterolTotal cholesterol
IA = initial assessment 1 YR = one year assessmentIA = initial assessment 1 YR = one year assessmentIntervention Intervention Usual CareUsual Care
22IA
32IA
361 YR 32
1 YR
05
101520253035404550
Intervention Usual Care
26IA
36IA
361 YR
441 YR
05
101520253035404550
Intervention Usual Care
+14%- 0.5%
+18%
-0%
+ 13% (+ 2% to + 23%) p = 0.025+ 13% (+ 2% to + 23%) p = 0.025 + 17% (+ 7% to + 27%) p = 0.008+ 17% (+ 7% to + 27%) p = 0.008
Proportion of patients with selfProportion of patients with self--reported diabetes mellitus which reported diabetes mellitus which
is controlledis controlled (HbA1c <7%)(HbA1c <7%)General PracticeGeneral PracticeHospital Hospital
Intervention Intervention Usual CareUsual Care
50
61
0102030405060708090
Intervention Usual Care
+ 11% (+ 11% (--13% to +34%)13% to +34%)
p = 0.29p = 0.29
65
80
0102030405060708090
Intervention Usual Care
+ 12% (+ 12% (-- 5% to + 29%)5% to + 29%)
p = 0.12p = 0.12
Distribution of HbA1c in Distribution of HbA1c in patients with diabetespatients with diabetes
General PracticeGeneral PracticeHospitalHospital
Intervention Intervention Usual CareUsual Care
HbA1cHbA1c HbA1cHbA1c
17
2324
36
29
21
29
21
0
10
20
30
40
50
< 6% 6-6.9% 7-7.9% >=8%
%
9
12
37
42
1520
40
25
0
10
20
30
40
50
< 6% 6-6.9% 7-7.9% >=8%
%
CARDIOPROTECTIVE DRUG CARDIOPROTECTIVE DRUG THERAPIESTHERAPIES
Proportion of patients on Proportion of patients on cardiovascular protective cardiovascular protective
drug therapydrug therapyGeneral PracticeGeneral PracticeHospitalHospital
Intervention Intervention Usual CareUsual Care
86
21
52
76
93
80
19
56
8092
0102030405060708090
100
Anti-plateletdrugs
Betablockers
ACEinhibitors
Caantagonists
Statins
p=0.28p=0.28
p=0.16p=0.16
p=0.26p=0.26
p=0.53p=0.53
p=0.04p=0.04
38
9
2917
3313 22
820161810
0102030405060708090
100
Anti-plateletdrugs
Diuretics B-blockers ACE CA Statins
p=0.06p=0.06
p=0.91p=0.91p=0.02p=0.02
p=0.24p=0.24
p=0.03p=0.03
0.190.19
LIMITATIONSLIMITATIONSStatistical power
o Statistical power was reduced because of patient numbers and heterogeneity in the differences between intervention and usual
care between countries
Under estimationo Usual care was being audited
o One quarter of usual care patients were clinically assessed at baseline
o One fifth of patients in usual care received cardiac rehabilitationOver estimation
o Selective drop out - patients in intervention did not attend at one year
CONCLUSIONSCONCLUSIONS
ConclusionsConclusions
EUROACTION has achieved its overall aim by raising standards of preventive cardiology careraising standards of preventive cardiology care
for coronary and high risk patients and their families in everyday clinical practice.
ConclusionsConclusions
The nursenurse--led multidisciplinaryled multidisciplinaryEUROACTION familyfamily based programme
achieved significantly better lifestyle changeslifestyle changes for coronary and high risk
patients and partnerspartners in terms of a more healthy diethealthy diet, and increased physical physical
activityactivity, compared to usual care
ConclusionsConclusions
The EUROACTION programme improvedimproved coronary and high risk
patients:
blood pressureblood pressure controlcontrol compared to usual care
blood lipid controlblood lipid control compared to usual careblood glucose controlblood glucose control in patients with
diabetes mellitus
ConclusionsConclusions
The EUROACTION programme increasedprescribingprescribing for statins in coronary
patients and for ACE inhibitors and statinsin high risk people compared to usual care
ConclusionsConclusions
EUROACTION has set new standards of preventive cardiology care new standards of preventive cardiology care for coronary and high risk patients and their
families in everyday clinical practice
EUROACTIONEUROACTION
Steering GroupSteering GroupProfessor Guy de Backer, Professor Dirk De Bacquer , Professor Martin Buxton, Professor Ian Graham, Mr Alan
Howard, Dr Kornelia Kotseva, Ms Susanne Logstrup, Professor Hannah McGee, Ms Muriel Mioulet, Dr Karen Smith, Professor David Thompson, Professor David Wood
National Co-ordinators &
Primary Care Leaders
EUROACTIONEUROACTIONSteering Group Steering Group
National CoNational Co--ordinators and Primary Care ordinators and Primary Care Leads Leads
Dr Troels Thomsen (National co-ordinator) Dr Kim Brockelmann (Primary Care leader) Denmark Denmark Dr Catherine Monpere (National co-ordinator) FranceFrance Professor Paolo Fioretti (National co-ordinator) Dr Alessandro Desideri
(Deputy Co-ordinator) Professor Silvio Brusaferro (Primary Care leader) Italy Italy Professor Andrzej Pajak (National co-
ordinator) Dr Piotr Jankowski (Deputy Co-ordinator) Professor Tomasz Grodzicki (Primary Care leader) Poland Poland Professor Jose
de Velasco (National co-ordinator) Dr Antonio Maiques(Primary Care leader) Spain Spain Professor Joep Perk (National
co-ordinator) Sweden Sweden Assoc. Professor Trudy van derWeijden (Primary Care leader) The NetherlandsThe Netherlands Professor David Wood (National co-ordinator) Dr Jonathan Morrell
(Primary Care leader) United KingdomUnited Kingdom
EUROACTIONEUROACTIONCoCo--ordinating and Data Management Centreordinating and Data Management Centre
Cardiovascular Medicine, National Heart and Lung Institute, Medical Faculty, Imperial College, London, UK
Dr Kornelia Kotseva (senior clinical research fellow) Dr Susan Connolly (consultant cardiologist) Ms Catriona Jennings (study nurse co-ordinator)
Ms Alison Mead (chief dietician) Ms Jennifer Jones (superintendent physiotherapist) Ms Annie Holden (physical activity specialist) Mr Kamal
Pandya (data manager) Ms Sally Graves (research administrator) Professor Ole Faergeman Professor David Wood (Chairman)
Statistical CentreStatistical Centre Department of Public Health, Ghent University, Ghent,
Belgium Professor Dirk De Bacquer, Professor Guy De Backer (Chairman)
Laboratory CentreLaboratory CentreDepartment of Pathological Biochemistry, Royal Infirmary,
Glasgow, ScotlandProfessor Jim Shephard (Chairman)
EUROACTIONEUROACTIONA European Society of Cardiology demonstration project in preventive
cardiology solely sponsored
by an unconditional educational grant from
Astra Zeneca
www.escardio.org/euroactionwww.escardio.org/euroaction