Q J Med 2004; 97: 127-131
QJM vol. 97 no. 3 (c) Association of Physicians 2004; all rights reserved.
Secondary prevention for coronary artery disease
From the 1Department of Cardiology, Ninewells Hospital, Dundee, 2Department of Cardiology, Perth Royal Infirmary, Perth, and 3Health Center, Dalkeith, UK
Received 3 October 2003 and in revised form 2 January 2004
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Summary |
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Background: Secondary prevention of coronary artery disease is effective in reducing morbidity and mortality, but deficiencies in implementation and prescription bias have been identified.
Aim: To assess progress in secondary prevention measures for coronary heart disease and whether there was a difference between patient subgroups with angina, post myocardial infarction or revascularization.
Design: Retrospective analysis.
Methods: Between 1997 and 2001, data were collected on prophylactic prescribing, demographic and lifestyle information, at baseline and 1 year following attendance at a hospital-based, cardiac-nurse-led out-patient clinic.
Results: Patients (n = 945) were entered into the database at hospital discharge and 619 (72%) attended at 1 year. Aspirin and statin prescribing increased, though ACE inhibitor use was less. Mean total cholesterol at baseline reduced to 4.92 ± 0.11 mmol/l (p < 0.001) in 2000, with a further reduction to 4.59 ± 0.08 mmol/l at the 1-year visit in 2001 (p < 0.001). The proportion of patients with total cholesterol < 5 mmol/l increased to 38% in 2000, reaching 70% in 2001. Smokers at baseline were similar at around 30%, although this had reduced to 10% in 2001 (p < 0.001). No change in weight was seen for patients with BMI 
30 (p = NS). No significant differences were seen between patient subgroups (p = NS).
Discussion: Secondary prevention measures are improving, especially in prophylactic prescribing, lipid management and smoking cessation, although scope for further improvement remains. No difference was seen between the patient subgroups. Lifestyle measures need to be addressed to gain maximum benefit in addressing overall cardiovascular risk.
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Introduction |
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Secondary prevention measures for coronary heart disease are effective in reducing coronary morbidity and mortality. These include prophylactic drug therapy (anti-platelet agents, beta-blockers, statins and ACE inhibitors), lifestyle changes and risk factor control (smoking cessation, dietary modification and weight reduction).1,2
The identification of coronary heart disease and future healthcare provision is a main priority in the National Service Framework.3 Multidisciplinary disease management programs improve the process of care, with reduced hospital admissions, improved quality of life and a reduction in mortality.4,5
European and UK surveys have previously highlighted deficiencies in secondary prevention implementation and the potential to reduce coronary morbidity and mortality through these measures.6–12 Furthermore, inequalities have been identified in effective implementation, with lower rates of statin prescribing in the elderly and for patients with angina and no previous infarction.13 Patients who have received coronary angiography have higher rates of aspirin and statin prescription, with coronary angioplasty being an independent predictor of receiving a statin.14
We aimed to assess whether there had been progress in secondary prevention measures over a 5-year period, for patients attending a hospital-based, cardiac-nurse-led out-patient clinic. Further, we aimed to identify whether differences existed between patient subgroups with angina, post myocardial infarction or post revascularization (coronary angioplasty and coronary artery bypass grafting).
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Methods |
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Patients with coronary heart disease (n = 945) received a baseline visit by a specialist cardiac rehabilitation nurse during in-patient hospital stay, and were invited to attend a nurse-led out-patient follow up clinic at 3 months and 1 year. A coronary heart disease cardiac rehabilitation and risk dataset, initiated at the end of 1996, was completed. Index diagnoses, at the time of the in-patient hospital stay, included angina, post myocardial infarction, post coronary angioplasty and post coronary artery bypass grafting. Data were collected over 5 years.
In addition to patient demographics, information was collected regarding aspirin, statins and ACE inhibitor prescription. Information regarding smoking status and number of cigarettes smoked was recorded, and BMI was calculated. Obesity was taken as BMI 30. Blood pressure was recorded, with targets defined as less than either 140/85 mmHg or 130/80 mmHg for diabetic patients. Blood samples were taken and analysed for total cholesterol concentrations. If necessary, patients were given lifestyle advice with regard to smoking cessation and healthy eating, and were encouraged to exercise by means of a brisk 30 min walk or equivalent every day. Data were recorded during the in-patient hospital stay and subsequent clinic visits at 3 months and 1 year.
Analysis
Quantitative variables are expressed as percentages and mean ± SEM. Intra- and inter-group analysis were by ECTA (Exact Contingency Table Analysis). Statistical significance was taken at the 5% level.
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Results |
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At hospital discharge, 945 patients were entered into the database. Of the index diagnoses, 187 (16%) patients had angina, 702 (59%) were post myocardial infarction, 83 (7%) were post coronary angioplasty and 212 (18%) were post coronary artery bypass grafting. Follow-up attendance was 740 (78%) patients at 3 months and 619 (72%) at 1 year. The majority were 60–75 years old (54%); 36% were < 60 years old and 10% were > 76 years old. There was no significant difference between the attendance and index groups. The proportion of patients in each age group was similar for each index diagnoses (p = NS).
The proportion of patients on aspirin at baseline was 90% in 1997, increasing to 97% in 2000. There was no significant difference between the index diagnoses groups.
Statin prescriptions increased from 62% at baseline in 1997 to 66% in 2000 (Figure 1). At the 1 year visit, the proportion of statin use had increased from 70% in 1998 to 80% in 2001. This was associated with a reduction in the mean total cholesterol at baseline from 6.01 ± 0.08 mmol/l to 4.92 ± 0.11 mmol/l (p < 0.001), with a further reduction to 4.59 ± 0.08 mmol/l at the 1 year visit in 2001 (p < 0.001) (Figure 2). The proportion of patients with total cholesterol < 5 mmol/l increased from 21% in 1997 to 38% in 2000. This increased to 70% by the 1 year visit. The majority of patients on a statin were 60–75 years old. Statin prescription and target cholesterol levels were independent of index group (p = NS) and age (p = NS).
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ACE inhibitor use remained relatively static for 1997 to 1999 at around 40%, though use at the 1 year visit in 2000 increased to 46%. Baseline prescription had also increased to 46% during 2000, with a further increase to 59% at 1 year. There were no differences between the index groups (p = NS).
The proportion of patients smoking at baseline was similar at around 30%. At the 1-year follow up visit this had reduced from 29% in 1998 to 10% in 2001 (p < 0.001). Proportion of patients smoking less than 10 per day was ranged between 23–36% with a similar increase at 1 year to 68%. There was no significant difference between the index groups (p = NS).
The proportion of patients achieving blood pressure targets at baseline was relatively static at 75%, although this reduced for each visit, with 54% reaching target at 1 year in 2002. The diabetic subgroup included 121 patients (10%), of which 46% were at target blood pressure at discharge in 2000, with a further reduction at 1 year to 42%. There was no significant difference between the index groups (p = NS).
The proportion of patients with a BMI > 30 was static at around 20%, with no difference between the index groups or identifiable change in pattern with each year (p = NS).
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Discussion |
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Prophylactic prescribing and risk factor profile improved over our study period, although further implementation strategies are needed to modify risk factors further and to attain healthier lifestyles. Our data does not suggest any bias towards patients who have had a myocardial infarction or been revascularized, including the elderly population.
The non-attenders at the secondary prevention clinic highlight an area of concern. Although there was no obvious relation to the index diagnoses, this might well be a group that receives sub-optimal measures to reach targets. Our study includes the proportion of patients who attended the clinic both at baseline and 1 year, which may not be representative of the wider population. This, however, was representative across all the index diagnosis groups.
Our data are encouraging, with improved secondary prevention prescribing rates as compared to previous UK and European surveys.6,9 Mean total cholesterol values were reduced each year, with a greater proportion of patients reaching target levels < 5 mmol/l. With reductions seen over the clinic visits, this most likely reflects increased titration of statins, in addition to greater prescribing. ACE inhibitor prescribing rates are less than for aspirin and statins for patients with coronary heart disease, with the increase in 2000/2001 most likely representing the broadening evidence base following publication of the HOPE study and national clinical guidelines.1,15 The recently reported EUROPA study extends the benefits of ACE inhibitor use to include lower-risk patents with coronary artery disease, with a relative risk reduction of 20% over 5 years in the primary end-point of death, myocardial infarction or cardiac arrest. The study group included patients with previous coronary artery revascularization (54.7%) and patients with no history of myocardial infarction (35.1%). This latter group had a 12.1% relative risk reduction in the primary endpoint with an ACE inhibitor.16
Education regarding smoking appears to have reduced the total number of smokers with time by one third (10% continued smoking), an improvement compared to the reported 21% continued smoking at a median time of 1.4 years in EUROASPIRE II.9 Further, smokers have been able to cut the total number of cigarettes, with twice as many smoking under 10 per day after 1 year. There remains the possibility of self-reporting bias, however, as no objective measures were used such as exhaled air carbon monoxide detection.
With regard to blood pressure control, the decline in proportions reaching target appears to increase with clinic visits, with a proportion above target at 1 year similar to the 50% reported in EUROASPIRE II.9 This was also reflected in the diabetic subgroup. There did not appear to be a compliance issue with ACE inhibitors, aspirin or statins, though this may well reflect compliance with other anti-hypertensive treatment. It may reflect the diffuse and progressive nature of atherosclerosis, coupled with a resistance to adopt a healthier lifestyle. Furthermore blood pressure was recorded at a single point in time at the out-patient clinic, and therefore cannot exclude a ‘white coat’ effect, or be representative of ambulatory blood pressure recordings.
Weight control has remained poor over time, and there does not appear to be any effect on reduction with clinic visits, despite dietary advice and opportunities to attend a dietician. EUROASPIRE II reported that 31% of patients remained obese, though the baseline 14% is difficult to interpret, as weight was only recorded in a quarter of case notes.9 This would appear to highlight a general resistance among patients to adopting a healthier lifestyle. Though all patients were encouraged to take a brisk 30 min walk or equivalent every day, there were no objective measures of exercise and activity levels.
Earlier randomized controlled trials have shown improvements in secondary prevention with multidisciplinary programmes.4,5,7 Regarding lifestyle measures, Campbell et al. found no significant improvement in smoking cessation at 1 year.7 This was also found by Murchie et al., however, 1 year improvements for both diet and physical activity were not found to be sustained at 4 years, compared to control groups.5 Both studies reported improvements in blood pressure targets, though a higher target of 160/90 mmHg was accepted. Perhaps unsurprisingly, medical treatment would appear to be easier to change than lifestyle.
A greater collaboration between primary and secondary care is required to further optimize secondary prevention. A more community-based approach to the management of secondary prevention has been suggested,17 with advanced practice nurses and community health workers providing more accessible care as part of the multidisciplinary team.18 With the increasing evidence base for use of pharmacological secondary prevention influencing prescribing habits, there appears to be a greater need in the community for further health promotion towards lifestyle changes in a multicultural society. Further, with more primary prevention studies providing more evidence for lipid-lowering and ACE inhibitor use,19–21 this adds further economic strain in addressing cardiovascular risk.
Conclusions
Secondary prevention prophylactic prescribing of aspirin, ACE inhibitors and statins is improving. Secondary prevention clinics further increase the proportion of patients reaching target cholesterol levels, but scope remains for further improvement. No difference in prophylactic prescribing or risk factor profile was seen between patient groups with angina, post myocardial infarction or post revascularization. Healthcare promotion remains key, with links between the community, and both primary and secondary care, to gain maximum benefit in addressing overall cardiovascular risk.
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Acknowledgments |
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This work was conducted with the support of the Tayside Clinical Governance Committee. We are indebted to Dr F. Daly, who provided statistical input (Senior Lecturer, Dept of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK). Appreciation to NGD, LB and VT in setting up the cardiac rehabilitation and risk factor database.
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Footnotes |
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Address correspondence to Dr A.L. McLeod, Specialist Registrar in Cardiology, Department of Cardiology, Ninewells Hospital, Dundee, DD1 9SY. e-mail: a.mcleod{at}ed.ac.uk
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References |
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TopSummaryIntroductionMethodsResultsDiscussionReferences |
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1. Scottish Intercollegiate Guidelines Network. SIGN guideline number 41: Secondary prevention of coronary heart disease following myocardial infarction—a national clinical guideline. Edinburgh, SIGN, 2000.
2. Scottish Intercollegiate Guidelines Network. SIGN guideline number 51: management of stable angina—a national clinical guideline. Edinburgh, SIGN, 2001.
3. Department of Health. National service framework for coronary heart disease. London, Department of Health, 2000.
4. McAlister FA, Lawson FME, Teo KK, Armstrong PW. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. Br Med J 2001; 323:957–62.
5. Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care. Br Med J 2003; 326:84.
6. Bowker TJ, Clayton TC, Ingham J, McLennan NR, Hobson HL, Pyke SD, Schofield B, Wood DA. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996; 75:334–42.
7. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. Br Med J 1998; 316:1430–4.
8. Flanagan DE, Cox P, Paine D, Davies J, Armitage M. Secondary prevention of coronary heart disease in primary care: a healthy heart initiative. Q J Med 1999; 92:245–50.
9. EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001; 22:554–72
10. EUROASPIRE I and II Group. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet 2001; 357:995–1001.[CrossRef][Web of Science][Medline]
11. Brady AJ, Oliver MA, Pittard JB. Secondary prevention in 24, 431 patients with coronary heart disease: survey in primary care. Br Med J 2001; 322:1463.
12. Carroll K, Majeed A, Firth C, Gray J. Prevalence and management of coronary heart disease in primary care: population-based cross-sectional study using a disease register. J Public Health Med 2003; 1:29–35.
13. Reid FD, Cook DG, Whincup PH. Use of statins in the secondary prevention of coronary heart disease: is treatment equitable? Heart 2002; 88:15–19.
14. Steg PG, Iung B, Feldman LJ, Cokkinos D, Deckers J, Fox KA, Keil U, Maggioni AP. Impact of availability and use of coronary interventions on the prescription of aspirin and lipid lowering treatment after acute coronary syndromes. Heart 2002; 88:20–4.
15. Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342:145–53.
16. Fox KM. EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003; 362:782–8.[CrossRef][Web of Science][Medline]
17. Riley J. The nurse as expert practitioner in global cardiovascular risk management. Heart 2003; 89(Suppl. 2):ii33–4.[Medline]
18. Allen JK, Scott LB. Alternative models in the delivery of primary and secondary prevention programs. J Cardiovasc Nurs 2003; 18:150–6.[Medline]
19. Sever PS, Dahlof B, Poulter NR, et al., ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003; 361:1149–58.[CrossRef][Web of Science][Medline]
20. Shepherd J, Blauw GJ, Murphy MB, et al., PROSPER study group. PROspective Study of Pravastatin in the Elderly at Risk. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360:1623–30.[CrossRef][Web of Science][Medline]
21. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360:7–22.[CrossRef][Web of Science][Medline]
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