Challenges in secondary prevention after acute myocardial infarction

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EURO PEAN
SO CIETY O F
CARDIOLOGY ®
Review
Challenges in secondary prevention
after acute myocardial infarction:
A call for action
European Journal of Preventive
Cardiology
0(00) 1–13
! The European Society of
Cardiology 2016
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/2047487316663873
ejpc.sagepub.com
Massimo F Piepoli1, Ugo Corrà2, Paul Dendale3, Ines Frederix4,
Eva Prescott5, Jean Paul Schmid6, Margaret Cupples7,
Christi Deaton8, Patrick Doherty9, Pantaleo Giannuzzi2,
Ian Graham10, Tina Birgitte Hansen11, Catriona Jennings12,
Ulf Landmesser13, Pedro Marques-Vidal14, Christiaan Vrints15,
David Walker16, Héctor Bueno17, Donna Fitzsimons18
and Antonio Pelliccia19
Abstract
Worldwide, each year more than 7 million people experience myocardial infarction, in which one-year mortality rates are
now in the range of 10%, but vary with patient characteristics. The consequences are even more dramatic: among
patients who survive, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary
events occur in those with a previous hospital discharge diagnosis of ischaemic heart disease.
The people behind these numbers spur this call for action. Prevention after myocardial infarction is crucial to reduce risk
and suffering. Evidence-based interventions include optimal medical treatment with anti-platelets and statins, achievement of blood pressure, lipid and blood glucose targets, and appropriate lifestyle changes.
The European Society of Cardiology and its constituent bodies are determined to embrace this challenge by developing a
consensus document in which the existing gaps for secondary prevention strategies are reviewed. Effective interventions
in relation to the patients, healthcare providers and healthcare systems are proposed and discussed. Finally, innovative
strategies in hospital as well as in outpatient and long-term settings are endorsed.
Keywords
Cardiovascular prevention, myocardial infarction, cardiac rehabilitation, risk factors, pharmacological therapy, exercise
training, healthcare systems
Received 29 May 2016; accepted 21 July 2016
14
1
Cardiac Department, Guglielmo da Saliceto Polichirurgico Hospital
AUSL Piacenza, Italy
2
Cardiology Rehabilitation Division, Scientific Institute of Veruno, Italy
3
Department of Cardiology, Jessa Hospital, Hasselt, Belgium
4
Heart Centre Hasselt, University of Hasselt, Belgium
5
Department of Cardiology, University of Copenhagen, Denmark
6
Department of Cardiology, Spital Tiefenau, Bern, Switzerland
7
Department of General Practice and Primary Care, Queen’s University
Belfast, UK
8
Florence Nightingale Foundation, Cambridge University Hospitals NHS
Foundation Trust, UK
9
Cardiovascular Health Department, University of York, UK
10
Trinity College, University of Dublin, Ireland
11
Zealand University Hospital, Roskilde, Denmark
12
Department of Cardiovascular Medicine, Imperial College London, UK
13
Department of Cardiology, Charite Universitätsmedizin Berlin,
Germany
Department of Internal Medicine, Lausanne University Hospital,
Switzerland
15
Department of Cardiology, University of Antwerp, Belgium
16
Department of Cardiology, East Sussex Healthcare NHS Trust, UK
17
Cardiology Department, Universidad Complutense de Madrid, Spain
18
University of Ulster, Belfast Trust Northern Ireland, UK
19
Institute of Sport Medicine and Science, Comitato Olimpico Nazionale
Italiano, Italy
This article is being co-published in the following journals: European
Journal of Preventive Cardiology, European Heart Journal – Acute
Cardiovascular Care and European Journal of Cardiovascular Nursing. To
request permission to re-use any part of this article, please contact SAGE
Publishing: http://online.sagepub.com/
Corresponding author:
Massimo F Piepoli, FESC Heart Failure Unit, Cardiac Department,
Guglielmo da Saliceto Polichirurgico Hospital AUSL Piacenza, I-29121
Piacenza, Italy.
Email: [email protected]
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European Journal of Preventive Cardiology 0(00)
Disease burden
Worldwide, each year more than 7 million people
experience acute myocardial infarction (AMI),1 and
although substantial reductions in mortality have
been experienced in recent decades,2 one-year mortality
rates are still in the range of 10%,3 varying with patient
characteristics. In the Swedish SCAAR registry oneyear mortality rates were approximately 10% among
patients aged 70–79 years and 24% among patients
aged 80–90 years.4 The consequences of AMI are
more dramatic: among patients who survive a AMI,
20% suffer a second cardiovascular event in the first
year and approximately 50% of major coronary
events occur in those with a previous hospital discharge
diagnosis of AMI.5
While early events are related to ruptured coronary
plaques and associated thrombosis, the majority of
later events may be the result of coronary and systemic
atherosclerosis progression. Thus it is being increasingly appreciated that evidence-based long-term management of ischaemic heart disease (IHD) is critical to
achieve optimal reduction in mortality and morbidity.6
Prevention after AMI is a crucial part of this, and is
associated with improved prognosis7,8 with evidencebased interventions, such as optimal medical treatment,
appropriate lifestyle changes and cardiovascular risk
factor control.9 Importantly, the impact of lifestyle
change after AMI has a rapid onset: patients who
adhere to exercise and diet recommendations have a
54% lower risk and smokers who quit smoking a 43%
lower risk of recurrent events six months after AMI.10
Despite this compelling evidence, preventive care
post AMI remains sub-optimal. Cross-sectional data
from the serially conducted EUROASPIRE surveys
across Europe in both patients with established IHD
and people at high cardiovascular risk have demonstrated a high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of drug therapies
to achieve blood pressure and lipid goals. Most
recently, in the fourth survey of coronary patients,
after a median time of 1.35 years after their acute
event, 48.6% of patients who were smoking at the
time of their event persisted in smoking, little or no
physical activity was reported in nearly two thirds of
interviewees, over a third (37.6%) were obese, 42.7%
had blood pressure 140/90 mmHg (140/80 in people
with diabetes), 80.5% had low-density lipoprotein
(LDL) cholesterol 1.8 mmol/L and in those with diabetes, glucose control was relatively poor, with less than
half reaching the guideline target of haemoglobin A1c
(HbA1c) of <7.0%.11
Similarly, an Italian multicentre registry study performed in 2010–2012 showed in 11,706 patients from
163 large-volume coronary care units, that at six
months drug adherence was 90%, but the recommended
targets of blood pressure (<140/90 mmHg) were reached
in only 74%, LDL (<1.8 mmol/l) in 76%, HbA1c (<7%
in treated people with diabetes) in 45% and smoking
cessation only in 73% of the participant patients.12
Secondary prevention
Secondary prevention programmes, defined as the level
of preventive care focusing on early risk stratification,
use of referral services and initiation of treatment to
stop the progress of an established disease process,
are highly recommended in all IHD patients, to restore
quality of life, maintain or improve functional capacity
and prevent recurrence.13 Cardiac rehabilitation, operationally defined here as a structured multidisciplinary
intervention for cardiovascular risk assessment and
management, advice on physical activity, psychosocial
support and the appropriate prescription and adherence to cardioprotective drugs, is the most investigated
modality of secondary prevention interventions,14 its
core components in post-AMI patients well identified
(Table 1).15
Although traditionally divided into three phases
(e.g. inpatient, outpatient, long-term intervention), in
reality secondary prevention is a continuous lifelong process, a care pathway that follows the patient journey,
made up of key stages that need to occur to
enable patients to achieve the return to a normal life.16
Settings vary in different countries,17 according to local
and national regulations and experiences, involving residential, ambulatory community, or home-based programmes. While the objectives are identical to those
for outpatients, residential inpatient programmes are
specifically structured to provide more intensive and/or
complex interventions, reserved for high-risk patients.18
Preventive services in the community offer the opportunity to maintain the benefits in the long term,19
with potential for overcoming existing barriers to
healthcare such as distance, unfamiliarity and fear/distrust of hospitals, allowing the delivery of a programme
that is best placed (i.e. ‘tailored’) to meet individual needs. EUROACTION20 and GOSPEL21 interventions provided scientific evidence for a beneficial
long-term effect of community-based programmes.
The EUROACTION study tested a comprehensive,
nurse-led, family centred and multidisciplinary model
of preventive and rehabilitative care in eight countries
in Europe, and was subsequently set up as an integrated
community centred service in the UK (MyAction)
providing care for both vascular patients and those
at high cardiovascular risk, while the GOSPEL study
is an Italian long-term multifactorial educational
and behavioral intervention (coordinated by a cardiologist) after a standard rehabilitation programme following AMI.
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Table 1. Components of secondary prevention in post-AMI
patients.
Interventions
Components
Risk factor
modification/
lifestyle
interventions
Preventive
medications
Management of
comorbidities
Psychosocial factors
Multidisciplinary
team follow-up
Patient/family
education
Socioeconomic
and healthcare
factors
Healthy diet
Physical activity
Weight control
Smoking cessation
Stop alcohol abuse
Antithrombotic therapies
Beta-blockers
ACE inhibitors/ARBs/
aldosterone antagonists
(if depressed left
ventricular function)
Statins
Obesity
Dyslipidaemia
Arterial hypertension
Diabetes
Heart failure
Arrhythmia/arrhythmia risk
Social isolation
Depression, stress, and anxiety
Sexual activity
Cardiologist
Primary care
Advanced practice nurse/
physician assistant
Other relevant medical
specialists
Other non-medical specialists
(e.g. physiotherapist,
psychologist, pharmacist,
dietician, vocational
specialist)
Plan of care
Education
Recognition of symptoms,
signs and symptoms
for urgent vs.
emergency evaluations
Risk factor control
Activating EMS
CPR training for
family members
Advanced directives
Access to health
insurance coverage
Access to healthcare providers
Disability
Social services
Social networks
Community services
Electronic personal health records
ACI: acute myocardial infarction; ACE: angiotensin-converting enzyme;
ARB: angiotensin receptor inhibitors; CPR: cardiopulmonary resuscitation; EMS: emergency medical system.
The existing health-economic literature supports
comprehensive secondary prevention as a relatively
more cost-effective intervention in IHD patients, in
comparison to invasive therapies or cardiac surgery.22
Given the current economic challenges in healthcare it
is noteworthy that in low and middle-income countries,
cardiac prevention has been demonstrated to be both
effective and cost-effective.23
Identification of gaps and potential
solutions in implementation
Despite the availability of suitable secondary prevention
programmes, only one third to one half of eligible
patients are referred24 or finally take up a preventive
programme.25 A plethora of research indicates that
patient, healthcare provider and/or health system-based
barriers all hold responsibility for this (Table 2).26
Patient-related gaps
Education and empowerment. Patients with IHD understand poorly their disease and perceive themselves as
having little control over its course, many lack interest
in prevention and/or feel embarrassed about participating in preventive group sessions. Most of them report
not receiving robust information and/or encouragement from physicians and other health professionals
regarding how to prevent recurrent events.27
Other factors, which hinder attendance, include lack
of social support, poor psychological wellbeing, inconvenient location with transport difficulties, competing
work commitments and financial cost.16
Inadequacies and time constraints related to education and counselling of patients before they leave hospital lead to deficiencies in implementation of preventive
care later on. Patients who have a clear understanding of
their after-hospital care instructions are 30% less likely
to be readmitted or to visit the emergency department
than patients who lack this information.28 Patients discharged from the hospital with a clear guideline-oriented
treatment recommendation, a checklist of measures to
ensure risk modification and lifestyle change provided in
the discharge letter, educated to care for themselves and
to know how or when to seek follow-up care, can better
understand the importance of this information and its
potential impact.29
A wide variety of techniques and combinations of
techniques has also been evaluated, but only self-monitoring of physical activity and action planning or
coping strategies targeting barriers seem to be helpful
(Table 3).30
Adherence to healthy lifestyle interventions. A systematic
review and meta-analysis of adherence to
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Table 2. Factors leading to therapeutic inertia in cardiovascular prevention, attributed to patient level, clinician/
health care provider level and healthcare system level.
Patient
Clinician/healthcare provider
Healthcare system
Medication side-effects
Too many medications
Cost of medications
Denial of disease
Denial of disease severity
Failure to initiate treatment
Failure to titrate to goal
Failure to set clear goals
Underestimation of patient need
Failure to identify and manage
comorbid conditions
Forgetfulness
Perception of low susceptibility
Insufficient time
Insufficient focus of emphasis on
goal attainment
Reactive rather than proactive
Poor communication skills
Lack of clinical guideline
Lack of care coordination
No visit planning
Lack of decision support
Poor communication between
physician and others involved
in a patient’s healthcare
provision
No disease registry
No active outreach
Absence of disease symptoms
Poor communication with
physician
Mistrust of physician
Depression, mental disease,
substance abuse
Low health literacy/poor awareness on value of preventive
measure
Shortage of time
Poor awareness on value of
preventive measure
Perverse incentives
Pressure to shorten length of
hospital stay
Healthcare systems focused on
acute care (hospital-based
health systems)
Lack of preventive structure
Poorly designed preventive
programmes/lack of quality
control
Table 3. Components of an optimal, standardised, patientcentred discharge process.
Creating a clear follow-up plan, coordinating appointments
for clinician follow-up, post-discharge testing, and transportation arrangements
Giving the patient a written discharge plan at the time of
discharge, explaining the reason for hospitalisation and information about medications
Assessing the patient’s understanding of his/her diagnosis, of
the clinical tests and evaluations performed in the hospital, of
the discharge plan, including medications, lifestyle changes, (in
case, by asking the patient to explain the discharge plan in his
or her own words in order to identify and resolve barriers to
understanding)
Educating the patient about recognition of cardiac symptoms,
problem-solving strategies, and review appointments plans
Providing hospital contact details, and telephone contacts
after discharge to address concerns
Sending the discharge summary to the physicians and other
services responsible for the patient’s care after discharge
together with contact details of relatives and healthcare providers where appropriate
cardioprotective medicines in more than 350,000
patients found low adherence in both individuals at
high cardiovascular risk (66%) and in patients with
cardiovascular disease (CVD) (50%) a median of two
years after initiation of a prescription.31 This results in
worse outcomes and higher healthcare costs.32,33 The
reasons for non-adherence are complex and influenced
by factors including demography, socioeconomic factors, health systems factors, intensity of follow-up,
time since last provider visit, adverse effects of therapy,
complex medication regimens and health literacy
(Table 2). For these reasons, the healthcare provider
should assess not only adherence to medication, but
also identify reasons, and promote adherence according
to established principles (Table 4). In this aspect, the
active role of the pharmacist should be encouraged: in
the UK, the new pharmacist-led medicines optimisation
clinic is a model of implementation of the contribution
of the pharmacist to support patients post-myocardial
infarction (MI).
A Cochrane review34 of interventions to improve
medication adherence advised drawing on the support
of allied professionals such as nurses and pharmacists
to deliver complex interventions, which may include
telephone follow-up, interim appointments and monitoring of repeat prescriptions. Drawing on the support
of non-professional people within the social context of
the patient, such as spouses, other family members,
carers or other key figures, and lay groups in the community, may prove to be a cost-effective way to
improve adherence. However, the review acknowledged
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Piepoli et al.
5
Table 4. Adherence factors.
‘Agree’ rather than ‘dictate’ a drug regimen and tailor it to
personal lifestyle and needs
Provide advice regarding benefits and possible adverse effects
of medications, and duration and timing of doses
Consider patients’ habits and preferences, encourage selfmonitoring, use of cues and technologies to act as reminders
Reduce dosage demands to the lowest feasible level and simplify the dosing regimen when possible
Ask patients in a non-judgemental way how the medication
works
Back up verbal instructions with clear written instructions
Implement repetitive monitoring and feedback and regular
review of medicines to minimise polypharmacy
Introduce trained nurses or physician assistants if needed and
feasible
Promoting the active role of the pharmacist in assessing drug
adherence and in encouraging patients to discuss their medicines and any concerns they may have about them
Involve the partner, other family member or carer in the
patient’s treatment
In case of persistent non-adherence, offer multisession or
combined behavioural intervention
that such interventions may be difficult to replicate in
everyday clinical care due to cost and availability of
personnel.
Adherence to preventive pharmacological therapy. Adherence
to medication is low in individuals at high risk and
in patients with CVD, resulting in worse outcomes
and higher healthcare costs.11 Non-adherence is multifactorial and is influenced by demographic and socioeconomic factors, time since last provider visit, adverse
effects of therapy and complex medication regimens
(Table 2). For these reasons, the healthcare provider
should assess not only adherence to medication, but
also identify reasons, and promote adherence according
to established principles35,36 (Table 4).
Furthermore, the development in many patients of
real or presumed ‘drug intolerance’ should be considered, and how quick the physicians label patient as
such may severely disadvantage post-MI patients.
The post-MI patients may also present with several
comorbidities, which need multiple treatments, sometimes in conflict with each other. The role of the physician is also trying to simplify the treatment regimen to
the lowest acceptable level, with repetitive monitoring
and feedback. The use of the polypill and combination
therapy to increase adherence to drug therapy may be
considered.
Finally, medicines optimisation may also mean deprescribing: physicians should also evaluate when to
stop and de-prescribe medicines: for example, there is
National Institute for Health and Care Excellence
(NICE) recommendation for stopping long-term betablockers post-MI in patients who do not have heart
failure or other specific indication.37
Healthcare provider gaps
Healthcare providers’ knowledge and motivation. In the
description of the core curriculum for the cardiologist,
the European Society of Cardiology (ESC) defines in
detail the knowledge needed in regard to secondary prevention, including evaluation and management of cardiovascular risk, as well as the provision of appropriate
prevention to CVD patients.38 However, it is questionable
whether such requirements are part of the curriculum of
most cardiologists or specialist allied health professionals
trained in Europe. This gap in knowledge and motivation
also apply to general practitioners (GPs) and noncardiology healthcare professionals and need to be
closed, by specific educational training.
Furthermore, for decades, much attention and many
resources have been directed at encouraging physicians
and providers to shift care as much as possible away
from costly inpatient hospital stays towards less expensive outpatient treatment.39 Among the most important
metrics for gauging the success of this endeavour is
the shortening of the hospital length of stay, early
discharge even directly from intensive care units,
although real savings have not been proved.40 This
leaves a limited amount of time for information and
education. In addition, it does not allow for optimisation of risk stratification and secondary prevention
therapy, particularly medication dose titration prior
to hospital discharge.
Risk stratification. Risk stratification is the prerequisite
for improving care management. Because the risk of
events decreases with time, early assessment (e.g. infarct
size and resting left ventricular function) is crucial
before discharge.41 Current guidelines recommend
evaluation of metabolic risk markers during the index
admission, such as fitness level, body mass index, LDL
cholesterol, fasting glucose level.13
Post-discharge plan. Strategies effective to increase uptake
include not only patient education and empowerment
(see section on Education and empowerment above)
but also, at post-hospital discharge, the development
of gender-tailored sessions, structured follow-up via
either telephone call or visit by a healthcare professional or both, a specific programme for older patients
and planned early appointments to programmes.42–44
Awareness and communication among health professionals in
acute care and in primary care. The transfer of the specialist’s knowledge to the community team remains a major
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challenge, as only about half of the GPs use guidelines
in everyday practice and knowledge of treatment goals
is often insufficient.45 Delayed communication or inaccuracies in information transfer among healthcare professionals has substantial implications for continuity of
care, patient safety, patient and clinician satisfaction
and resource use.46
Educational meetings, audit and feedback, with local
opinion leaders and access to computer decision support devices can lead to improved continuity of care.47
Regular review and provision of patient education in
primary care leads to improved adherence to lifestyle
advice (more physical activity, better diet), reduced
symptoms, improved quality of life and reduced mortality.48 In the UK, the clinical indicators of GPs’ performance in chronic disease monitoring include
checklists relating to medication and risk factor control, and engagement in this process is incentivised by
financial reward.49
Healthcare systems gaps
Patients consistently cite physicians and other healthcare
providers as the main sources of encouragement for subsequent participation in preventive programmes.30
Unfortunately, several factors negatively influence current referral rates.
Availability
of
structured
secondary
prevention
programme. The lack of prevention centres constitutes
an obstacle to the implementation of rehabilitation programmes in many European areas but particularly in
less advantaged regions.50
Referral to structured secondary prevention intervention. Lack
of referral is an important impediment to participation
in preventive programmes. The presence of interhospital variability in referral rates suggests that several
healthcare system factors might have a strong influence,
including insurance coverage, hospital characteristics
(dimension, geographical location) and other unidentified factors.50 Limited financial incentives for the
physician to implement preventive measures and the
pressures of competing workload priorities may negatively influence current referral rates.51
Various strategies can address the lack of referral
and improve enrolment (Figure 1).52 Systematic processes such as automatic referral and liaison systems to
connect cardiac patients with the preventive programme
have been developed and can increase referral rates by
more than 50%.53 Evidence is emerging to suggest that
mechanisms to support automatic patient referral via
electronic health records or discharge protocols are
effective in increasing referral. Strength of physician
endorsement for referring cardiac patients is a pivotal
step to improve participation and its associated
improved outcomes after AMI.53
Performance indicators. The lack of benefit from some
interventions (e.g. RAMIT trial)54 highlights the need
for quality and minimum standards in the delivery of
preventive programmes. Audit and control of the programmes should include information about the core
components and their implementation, results with clinical outcomes and patient satisfaction. Benchmarking
against local, regional and national standards provides
measures of performance and quality for commissioners
and services providers.15 Accountability measures,
including referral performance/quality indicators (e.g.
percentage of cardiac patients referred to programmes)
and financial incentives for centres performing well on
the quality indicators should increase physicians’ willingness to refer and improve the delivery of prevention.
Furthermore, the appropriate prescription of evidence-based medications (e.g. lipid-lowering drugs,
antiplatelets) the titration of vasodilators, such as
angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers are well recognised performance indicators.15
Table 5 enumerates some examples of interventions
on a patient, provider and system level.
The way ahead: embracing current
challenges
In-hospital or acute intervention
This represents the earliest intervention, beginning
immediately after the acute event during the hospital
stay, and it should be given as high a priority as initial
acute care. Acknowledging the formally shared responsibilities of all professionals involved in the cardiac
patient’s care (i.e. nurses, GPs, intensivists, acute invasive cardiologists and cardiovascular surgeons) provides the first avenue. However, convincing all acute
care clinicians remains challenging and is related to
both the individual professional and the healthcare
organisation.55 Poor knowledge regarding the benefits
of the early initiation of secondary prevention could be
a possible explanation. This underscores the need to
increase awareness and to provide information regarding the available evidence. As a collaborative initiative,
the European Association for Cardiovascular
Prevention and Rehabilitation (EACPR), Acute
Cardiovascular Care Association (ACCA) and Council
on Cardiovascular Nursing and Allied Professions
(CCNAP) elaborated videos on the benefits and challenges of secondary prevention after AMI (http://escar
dio.org/The-ESC/Communities/European-Associationfor-Cardiovascular-Prevention-&-Rehabilitation-%28
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Figure 1. Strategies to address the lack of referral and improve enrolment in cardiovascular secondary prevention programme.
Piepoli et al.
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Table 5. Examples of cardiovascular preventive intervention at patient, provider and system level (adapted from Nieuwlaat et al.47).
Example of intervention
Patient-level interventions
Patient decision aids
Self-management
Provider-level interventions
Continuing education meetings
Audit and feedback
Educational outreach visits
Local opinion leaders
Computer-assisted clinical decision support
Organizational/system-level interventions
Clinical pathways
Financial incentives
Legislation-based smoking bans
Description
Effect
Tools that help people become involved in
decision-making by providing information about the options and outcomes of
a treatment, and clarifying personal
values
60% increase in accuracy of
patient’s risk perception
30% reduction in post-menopausal hormone use
20% reduction in discretionary
surgery
49% reduction in thrombotic
events in self-management of
vitamin K antagonist
56% reduction in heart failure
hospitalisations in selfmanagement of heart failure
Patients monitoring themselves, and
making medication dosing decisions,
with healthcare provider back-up
Conferences, lectures, workshops, seminars, symposia, and courses for health
professionals
Any summary of clinical performance over
a specified period of time, given in a
written, electronic or verbal format
Visits by a trained person to health professionals. ‘Face-to-face’ visits, also
referred to as academic detailing
Healthcare professionals considered by
colleagues as ‘educationally influential’
Automated clinical decision advice, based
on individual patient data
6–10% increase in uptake of
recommended care
Structured multidisciplinary care plans
used by health services to detail essential steps in the care of patients with a
specific clinical problem
42% reduction of in-hospital
complications for patients
undergoing an intervention,
primarily surgery
12% improvement of documentation in medical records
Potential improvement in practice, but effects on patient
outcomes are unknown
Financial reward for professionals for
affecting behaviour, including for a specified time period of work; for each
service, episode or visit; for a patient or
specific population; for providing a prespecified level or providing a change in
activity or quality of care
Legislative smoking bans and restrictions
affecting populations
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5–16% increase in the uptake of
recommended diagnostic and
therapeutic strategies
5.6–21% increase in uptake of
recommended care
12% increase in uptake of recommended care
Modest effects on process of
care for a range of management issues
Reduction in admissions for
acute coronary syndromes,
related to improvements in
first-hand and second-hand
smoking exposure
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EACPR%29/European-Association-for-Cardiovascular-Prevention-Rehabilitation).
programmes, based on the existing guidelines and position papers for different patient populations.58
Early outpatient prevention programmes:
core delivery rehabilitation
Focus on the identification of frailty syndrome post-AMI and
high-risk patients. Patients with frailty syndrome, that
is, older than 65 years, characterised by vulnerability
to stress-related factors and a decrease in physiological
reserves,59 suffer more often from AMI (15.4% vs.
7.4%), with increased mortality and hospitalisation
risk after the index cardiac event.60 Future efforts
need to focus on improved frailty identification, and
to adapt/intensify prevention programmes, by adjusting
medical therapies, modifying dosages and rehabilitative
protocols. Several prognostic scores were developed
specifically to identify the post-AMI patients being at
highest risk for future adverse events (the Global
Registry of Acute Coronary Events (GRACE) score
and ACHTUNG-Rule).61
As mentioned above, patient uptake and adherence
proves to be particularly challenging, and innovative
strategies are urgently needed to address this problem.
There are clearly some programmes that do better than
others, at engaging patients in prevention, which creates a further opportunity to learn from others in regional or clinical networks.
Telecommunication technologies. Recent developments in
telecommunications have enabled the advent of new
preventive delivery strategies, supplementing conventional centre-based services to expand their capabilities
and to address the broad and extensive range of barriers preventing cardiac patients from participating.
As such, cardiac telemedicine was introduced, that is,
a comprehensive mHealth mode of care delivery, as
a personalised prevention tool for cardiac patients
to manage their own recovery and to prevent recurrent
events remotely.56 The optimal programme consists
of several modules devoted to monitoring, coaching,
e-learning, social interaction and two-way communication with the caregiver.57
Adapted preventive programmes and community services.
Adapted preventive cardiology programmes, such as
nurse-coordinated and family-based care, can be valuable
alternatives to traditional inpatient and/or outpatient
programmes.20 Professionals in primary care are essential
for this task as they often have detailed knowledge of an
individual’s social, medical and/or cultural background.
This applies especially for the disadvantaged groups
(poor, less educated and older people), who are most
likely to drop out.
New models of individualised interventions. Efforts are
waged to individualise programmes based on patient
stratification to maximise clinical benefit and optimise
safety. This can be achieved by prescribing patientspecific and tailored programmes, based on differing
combinations of cardiovascular risk factors, underlying
cardiac disease processes and/or exercise modifiers.
Currently, the EXPERT (EXercise Prescription in
Everyday practice & Rehabilitative Training) flowchart
project, combining the collaborative work and knowledge of more than 35 experts (out of 11 European
countries) in the rehabilitation of chronic internal diseases is being elaborated. It aims to aid future physicians in defining such individualised training
Long-term prevention
Long-term adherence to healthy lifestyles and medications. It
constitutes a joint lifelong effort of patient, primary
care physician, nurse, therapist and cardiologist. In
this era of an ever increasing CVD epidemic, most current cardiac centres do not have the capacity to deliver
long-term supervised and centre-based prevention to all
eligible patients. One model might be to transfer
resources from short-duration residential services
to longer-duration outpatient services of lesser intensity, designed for lower-risk patients, but of larger
number. A successful example already implemented
in routine clinical practice for low-risk patients is
the EUROACTION model: all aspects of a healthy
lifestyle, comprehensive risk factor management and
appropriate use of cardioprotective drugs are
addressed, without the use of specialised hospital or
community facilities.20 In other countries, such as
Italy, sport-medicine specialists, operating in selected
community-based sport medicine centres, in collaboration with specially trained physiotherapists, have
developed dedicated programmes for exercise-based
rehabilitation, follow-up and care in low-risk patients.
Home-based programmes can be equally effective as
centre based62 and tele-interventions can be efficacious
in both the medium and long term, encouraging largescale deployment of innovative models of care
delivery.63
Finally, a fixed dose combination tablet (also called
polypill) was shown to improve adherence compared to
separate medications.64 However, potential adverse
effects of a single drug component cannot be specifically
corrected and therefore may also affect the treatment
adherence to the other components.
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10
European Journal of Preventive Cardiology 0(00)
Pharmacological strategies to strengthen long-term secondary
prevention. Recent progress in drug strategies have
widened the possibility in CVD prevention. Three
issues in particular are considered here: (a) enhanced
lipid-lowering therapy in addition to statins, according
to the evidence of the efficacy of monoclonal antibodies
targeted to proprotein convertase subtilisin/kexin type
9 (PCSK9)65 and of the ezetimibe added therapy;66 (b)
enhanced antithrombotic therapy in which new options
have been demonstrated to be particularly effective in
further reducing coronary events, such as prolonged up
to 30 months (in contrast to recommended 12 months)
after acute coronary events dual antiplatelet therapy
(DAPT),67 and in particular the combination of aspirin
and ticagrelor,68 and the addition of new anticoagulants, such as rivaroxaban, to DAPT;69 (c) enhanced
blood pressure control to improve outcome, as shown
by new strategies involving spironolactone add-on therapy in resistant hypertension,70 amiloride plus hydrochlorothiazide in patients requiring a diuretic71 and
finally by a research protocol in which a lower blood
pressure target of 120 mmHg in patients at high cardiovascular risk was associated with higher survival.72
These advances open new possibilities in long-term
secondary prevention after AMI. However, the cost is
high, from both a clinical perspective (potential serious
side-effects) and from an economic perspective, to make
it unlikely that these pharmacological strategies will be
widely indicated for reducing residual risk in the near
future. For this reason, identification of the highest-risk
patients is pertinent, that is, those who are most likely
to benefit from very intense preventive therapy.
Moving forward and improving care delivery
The role of the government. National legislation regarding
preventive programmes is absent in 54 % of the participating countries to the European Cardiac Rehabilitation
Inventory Survey (ECRIS).17 Legislation provides an
imperative to make available and to optimise services,
and needs to be extended to all countries if citizens of
Europe are to be treated equitably. The national societies of cardiology are therefore encouraged to lobby their
respective governments to promote this. The role of the
ESC in relation to advocacy at a European level is crucial for setting standards and for promoting good practice among its members.
The role of the health insurance industry. As noted by
ECRIS, in 46% of European countries, patients covered the total cost for the long-term intervention, while
in 18% of countries, patients received a small financial
support from patient clubs and private health insurance
companies. Given the well established clinical benefits
of the long-term persistence of a healthy lifestyle in
secondary prevention, efforts to convince the health
insurance industry to support long-term prevention
programmes are justified. Higher reimbursement to systems that provide high-value evidence-based care and
incentives for individuals with persistent adherence to
healthy lifestyle changes should be encouraged.
The role of professional organisations. Numerous professional national and European-wide organisations such
as the ESC, EACPR, ACCA and CCNAP are committed to the different facets of secondary prevention
after AMI. They have an important cross-fertilising
role in sharing expertise and in supporting colleagues
to develop better services. By collaborative efforts in
establishing professional guidelines, cutting-edge scientific research and implementing initiatives that encourage good clinical practice; they play a pivotal role in
assuring the flourishing of secondary prevention. As an
example, the EACPR, the ESC and the Heart Failure
Association of the ESC support the preventive cardiology, sports cardiology and exercise based rehabilitation – from set-up to new frontiers course (https://
www.escardio.org/static_file/Escardio/Subspecialty/
HFA/Education/EACPR_HFA_Exercise%20Training
%20Programme%202015.pdf). This course enabled
secondary prevention experts to accelerate their knowledge sharing with colleagues in the field.
Need for further research
Future research should focus on cost-effectiveness
evaluations of novel care delivery strategies, to inform
policy makers how limited healthcare resources should
be allocated. Each nation and European partners
should look to audit their own services against clinical
minimum standards in delivery and outcomes. The
development of action plans by the different individual
stakeholders to move forward and improve care delivery is urgently needed.
Author contribution
MFP and UC contributed to the conception and design of the
work and drafted the manuscript. All authors critically
revised the manuscript and gave final approval and agree to
be accountable for all aspects of work ensuring integrity and
accuracy.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of
interest with respect to the research, authorship, and/or publication of this article: Dr Piepoli reports having received consulting/speaking fees from Novartis and Servier. Dr. Bueno
reports having received consulting/speaking fees from
Abbott, Astra-Zeneca, Bayer, BMS-Pfizer, Daichii-Sankyo,
Downloaded from cpr.sagepub.com by guest on September 12, 2016
Piepoli et al.
11
Eli-Lilly, Ferrer, Novartis, Servier, and research grants from
Astra-Zeneca.
This document was produced in the framework of the ESC
Secondary Prevention after Myocardial Infarction
Programme, developed by the European Association for
Cardiovascular Prevention and Rehabilitation (EACPR),
the Acute Cardiovascular Care Association (ACCA) and
the Council on Cardiovascular Nursing and Allied
Professions (CCNAP).
10.
11.
Funding
This paper was produced in the framework of the ESC
Prevention of CVD Programme, led by the European
Association
for
Cardiovascular
Prevention
and
Rehabilitation (EACPR) in collaboration with the Acute
Cardiovascular Care Association (ACCA) and the Council
on Cardiovascular Nursing and Allied Professions
(CCNAP), which is supported by unrestricted educational
grants. The author(s) received no financial support for the
research, authorship, and/or publication of this article.
12.
13.
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