European Society of Cardiology - Professor David Wood on ......A European Society of Cardiology Demonstration Project in Preventive Cardiology FINAL RESULTS Professor David Wood on

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



16331633PARTNERSPARTNERS







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


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


g/day


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


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


g/day


p = 0.71p = 0.71


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


P = 0.002P = 0.002

22

50

0

10

20

30

40

50

60


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

%


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


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


+ 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


Intervention Intervention Usual Care SubUsual Care Sub--samplesample

13

19

0

10

20


+ 6% (+ 6% (-- 7% to + 19%)7% to + 19%)

P = 0.28*P = 0.28*

7

16

0

10

20


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


p = 0.11p = 0.11


p = 0.10p = 0.10

+ 8% (+ 8% (-- 2% to + 18%) 2% to + 18%)

22

31

0

10

20

30

40


+ 9% (+ 9% (-- 3% to + 20%)3% to + 20%)


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


p = 0.03p = 0.03

55

65

0

10

20

30

40

50

60

70


41

58

0

10

20

30

40

50

60

70


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


Proportion of patients achieving Proportion of patients achieving the European lipid targetsthe European lipid targets


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%)


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


26IA

36IA

361 YR

441 YR

0

10

20

30

40

50





22IA

32IA

361 YR 32

1 YR

05

101520253035404550


26IA

36IA

361 YR

441 YR

05

101520253035404550





22IA

32IA

361 YR 32

1 YR

05

101520253035404550


26IA

36IA

361 YR

441 YR

05

101520253035404550


+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


50

61

0102030405060708090


+ 11% (+ 11% (--13% to +34%)13% to +34%)

p = 0.29p = 0.29

65

80

0102030405060708090


+ 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



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


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.


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


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


The EUROACTION programme increasedprescribingprescribing for statins in coronary

patients and for ACE inhibitors and statinsin high risk people compared to usual care


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

Documents

European Society of Cardiology - Professor David Wood on ......A European Society of Cardiology Demonstration Project in Preventive Cardiology FINAL RESULTS Professor David Wood on