EUROACTIONEUROACTIONA European DemonstrationA European Demonstration

Project in Preventive CardiologyProject in Preventive Cardiology

Implications of EUROACTION Implications of EUROACTION for preventive cardiologyfor preventive cardiology

Professor David WoodProfessor David Woodon behalf of the EUROACTION Groupon behalf of the EUROACTION Group

EUROACTIONEUROACTION8 countries 24 centres 8657 subjects8 countries 24 centres 8657 subjects

GeneralisableGeneralisable model of model of preventive cardiology carepreventive cardiology care

Includes all priority Includes all priority patient groupspatient groups

Coronary patients and their families

Relatives of coronary patients with premature CHD

Healthy individuals at high multifactorial risk (SCORE > 5% over 10 years) of developing

CVD, or hypertension/dyslipidaemia, or diabetes, and their families

Index event of patients attending Index event of patients attending initial assessment by genderinitial assessment by gender

MenMen

18%

31%

51%

AMI

UA

SA

41%

14%

45% AMI

UA

SA

WomenWomen

30%

36% 34%SCORE

BP &LipidsDiabetes

Classification of high risk patientsClassification of high risk patients

Equity of access to preventive Equity of access to preventive cardiology programmescardiology programmes

Participation & CompletionParticipation & Completion

HospitalHospital Primary CarePrimary Care

Patients Partners

Participated in EuroActionprogramme

1060 (67%)

637(77%)

438(69%)

Completed EuroAction programme

895(84%)

Patients Partners

Participated in EuroActionprogramme

943(87%)

233(74%)*

225(97%)*

Completed EuroAction programme

888(94%)

**of those who agreed to participateof those who agreed to participate

The FamilyThe Family approachapproach

Proportions of patients achieving Proportions of patients achieving the European targets for a the European targets for a

healthy diethealthy dietGeneral PracticeGeneral PracticeHospitalHospital

16

55

7255

8

54

3540

0102030405060708090

Saturated fat <10% of total

energy

Fruits andvegetables >400

g/day

Fish > 20 g/day Oily fish > 3times/week

11

56

78

6

4639

0102030405060708090

Fruits andvegetables >400

g/day

Fish > 20 g/day Oily fish > 3times/week

p = 0.005p = 0.005

p = 0.26p = 0.26

p = 0.13p = 0.13

p = 0.009p = 0.009

p = 0.004p = 0.004

p = 0.91p = 0.91

p = 0.04p = 0.04

Intervention Intervention Usual CareUsual Care

Proportions of partners achieving Proportions of partners achieving the European targets for a the European targets for a

healthy diethealthy diet

20

52

77

7

4554

0102030405060708090

Fruits and vegetables>400 g/day

Fish > 20 g/day Oily fish > 3times/week

HospitalHospital General PracticeGeneral Practicep = 0.002p = 0.002

p = 0.42p = 0.42

p = 0.09p = 0.09

p = 0.31p = 0.31 p = 0.002p = 0.002

p = 0.98p = 0.98

11

55

7260

8

5137

42

0102030405060708090

Saturated fat <10% of total

energy

Fruits andvegetables >400

g/day

Fish > 20 g/day Oily fish > 3times/week

p = 0.77p = 0.77

Intervention Intervention Usual CareUsual Care

NurseNurse--led led multidisciplinary teamsmultidisciplinary teams

Cardiovascular prevention nursesDieticians

PhysiotherapistsCardiologists

General practitioners

NurseNurse--led multiled multi--disciplinary disciplinary hospital and primary care teamshospital and primary care teams

Comprehensive lifestyleComprehensive lifestylerisk factor and therapeutic risk factor and therapeutic

interventionintervention

Lifestyle: tobacco, healthy eating and Lifestyle: tobacco, healthy eating and physical activityphysical activity

Other risk factors: overweight and obesity, blood pressure, lipids and glucose

Cardioprotective drug therapies

Proportion of patients achieving Proportion of patients achieving European Guidelines for physical European Guidelines for physical

activityactivity

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 = 0.001 P = 0.001

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%)

Comprehensive lifestyleComprehensive lifestylerisk factor and therapeutic risk factor and therapeutic

interventionintervention

Lifestyle: tobacco, healthy eating and physical activity

Other risk factors: overweight and obesity, Other risk factors: overweight and obesity, blood pressure, lipids and glucoseblood pressure, lipids and glucose

Cardioprotective drug therapies

Proportion of patients achieving Proportion of patients achieving the European target for the European target for

blood pressureblood pressure(< 140/90 mm Hg [<130/85 mm Hg in patients with diabetes mellitu(< 140/90 mm Hg [<130/85 mm Hg in patients with diabetes mellitus])s])

General PracticeGeneral PracticeHospitalHospital

P = 0.04P = 0.04 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% (+ 32% to + 2%)+ 17% (+ 32% to + 2%)+ 10% (+ 20% to + 0.6%)+ 10% (+ 20% to + 0.6%)

Intervention Intervention Usual CareUsual Care

Therapeutic control of Therapeutic control of blood pressureblood pressure

General PracticeGeneral PracticeHospitalHospitalNo drugs: + 14% (+ 33% to No drugs: + 14% (+ 33% to -- 4%) 4%) Drugs: + 8 % (+19% to Drugs: + 8 % (+19% to -- 4%)4%)

No drugs: +17% (+32% to +4%) No drugs: +17% (+32% to +4%) Drugs: + 17% (+ 33% to +2%) Drugs: + 17% (+ 33% to +2%)

52

65

35

45

0%

10%

20%

30%

40%

50%

60%

70%

No drugs Drugs

InterventionIntervention

Usual CareUsual Care

52

79

47

64

0%10%20%30%40%50%60%70%80%90%

No drugs Drugs

p = 0.10 no drugsp = 0.10 no drugsp = 0.14 with drugsp = 0.14 with drugs

p = 0.02 no drugsp = 0.02 no drugsp = 0.04 with drugsp = 0.04 with drugs

Comprehensive lifestyleComprehensive lifestylerisk factor and therapeutic risk factor and therapeutic

interventionintervention

Lifestyle: tobacco, healthy eating and physical activity

Other risk factors: overweight and obesity, blood pressure, lipids and glucose

CardioprotectiveCardioprotective drug therapiesdrug therapies

Proportion of patients on Proportion of patients on cardiovascular protective cardiovascular protective

drug therapydrug therapyHospitalHospital General PracticeGeneral Practice

86

21

52

76

93

67

18

51

6874

0102030405060708090

100

Anti-plateletdrugs

Betablockers

ACEinhibitors

Caantagonists

Statins

p=0.004p=0.004

p=0.02p=0.02

p=0.98p=0.98

p=0.51p=0.51

p=0.002p=0.002

38

9

2917

3313 23

820161910

0102030405060708090

100

Anti-plateletdrugs

Diuretics B-blockers ACE CA Statins

p=0.07p=0.07

p=0.90p=0.90

p=0.03p=0.03

p=0.21p=0.21

p=0.03p=0.03

Intervention Intervention Usual CareUsual Care

Cluster Randomised Control TrialCluster Randomised Control TrialStatistical 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

EUROACTION has set a new benchmark for standards of preventive a new benchmark for standards of preventive

cardiology care 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)

TheThe LondonLondonCoCo--ordinatingordinating TeamTeam

• Dr Kornelia Kotseva, Senior Research Fellow

• Dr Susan Connolly, Consultant Cardiologist

• Ms Catriona Jennings, Nurse Co-ordinator

• Ms Sally Graves , Study Administrator, Study Administrator

• Ms Alison Mead, Dietitian

• Ms Jenni Jones, Physiotherapist

• Ms Annie Holden, Physical Activity Expert

• Mr Kamal Pandya, Data Manager

Dr Troels ThomsenNational Co-ordinato

DenmarkDenmark

• Dr Troels Thomsen, National Co-ordinator

• Dr Kim Brockelmann, Primary Care Lead

• Sundhedscenteret, Skanderborg

• Dr Lisbeth Rosborg, Principal Investigator

• Susanne Holck Mogensen

• General Practice, Gasvej, Horsens

• Dr Henrik Zanoni, Principal Investigator

• Lene Henriksen

FranceFranceDr Catherine Monpere, National Co-ordinator Institut Hospitalier Jacques CartierDr Bertrand Cormier, Principal Investigator Mme Evelyne Brandon Anne-Claire DarcyValerie BourniortAlberto Chivite LarzabelCentre Hospitalier Yves Le FollDr Benoit Moquet, Principal InvestigatorFrancoise Langlais

ItalyItalyProfessor Paolo Fioretti, National Co-ordinatorDr Alessandro Desideri , National Co-ordinatorProfessor Silvio Brusaferro, Primary Care LeadDr Bortolo Martini, Principal InvestigatorDr Enzo ApolloniMarila MeroniRudi LonghiValeria MunarettoAnna Sartori SforzaAnna d’AdamDr Carlo Sponzilli, Principal InvestigatorSonia VivanDr Beppino Colle, Principal InvestigatorDr Massimiliano RugoloTilla GurisattiDr Mario Casini Principal InvestigatorDr Fabrizio Gangi, Lead GPDaniela Gurisatti

The NetherlandsThe Netherlands• Associate Professor Trudy van derWeijden (National Co-ordinator and Primary Care Lead)• Health care centre Hoensbroek• Dr Martijn van Nunen (Principal Investigator)• Dr Bem Bruls • Jasja Janssen• Health Care Centre Neerbeek• Dr Mieke Winten-Huisman (Principal Investigator)• Dr Marc Eyck (Principal Investigator) • Renee Van De Heuvel• Claudia Geesing

PolandPolandProfessor Andrzej Pajak, National Co-ordinatorDr Piotr Jancowsky, National Co-ordinatorProfessor Tomasz Grodzicki, Primary Care LeadDr Isabella Kielbalska, Principal InvestigatorDr Jacek Nowak, Principal InvestigatorRenata WolfhautEwa DojkaAnna NowackaUrzula BielaAnna RakDr Elzbieta kluczewska, Principal InvestigatorDr Arkadiusz KaletaDr Slavomir Surowiec Dr Krystyna Pajak, Principal InvestigatorDr Joanna Sładek-RatajewiczBarbara Waligóra Irena Smarzyńska Dr Maria Fornal, Principal InvestigatorHelena KamińskaBarbara Wojtanis

SpainSpainProfessor Jose de Velasco National CoProfessor Jose de Velasco National Co--ordinatorordinatorDr Antonio Dr Antonio MaiquesMaiques PrmaryPrmary Care LeadCare LeadHospital General Dr Hospital General Dr PesetPeset ValenciaValenciaDr Antonio Salvador Principal InvestigatorDr Antonio Salvador Principal InvestigatorDr Ricardo Dr Ricardo SalomSalomCristina Cristina BuiguesBuiguesAna BonetAna BonetArancha RuescasArancha RuescasRosario CuevasRosario CuevasHospital General Alicante Hospital General Alicante Dr Dr FransiscoFransisco SogorbSogorb Principal InvestigatorPrincipal InvestigatorIsabel LilloIsabel LilloMonica Gonzalez GutierrezMonica Gonzalez GutierrezCentro de Salud San Pau, ValenciaCentro de Salud San Pau, ValenciaDrDr Jorge Jorge Navarro Principal InvestigatorNavarro Principal InvestigatorGemma Gemma MéndezMéndez Pérez Pérez Centro de Centro de SaludSalud de de ManisesManisesRocioRocio Marco Marco CrespoCrespo

SwedenSwedenProfessor Joep Perk, National Co-ordinatorMedicinkliniken Halmstad SjukhusDr Peter Hardhammar, Principal InvestigatorDr Per Anders Johansson, Principal InvestigatorLisa AnderssonGunilla SternhedenJessica AnderssonUlla PalmkvistElin SvenssonMedicinkliniken Uddevalla sjukhus Dr Klas Bunner, Principal InvestigatorYvonne Brandstrom

UKUKProfessor David Wood, National Co-ordinatorDr Jonathan Morrell, Primary Care LeadDr Punit Ramrakha, Principal InvestigatorRob HarteveldtChristine RallisonDonna ChabanneJenny OttawayLesley SimpsonDr Brian Gould, Principal InvestigatorDr Nikhil Parchuri, Principal InvestigatorAngie SutcliffeDr Michal ZabojszczDr Tim Gietzen, Principal InvestigatorSjouke AshtonDr Ian McNaughton, Principal InvestigatorShirley Colvin

EUROACTIONEUROACTIONA European Society of Cardiology demonstration project in preventive

cardiology solely sponsored

by an unconditional educational grant from

AstraZeneca

www.escardio.org/euroactionwww.escardio.org/euroaction