Provision of dietary education in UK-based cardiac rehabilitation: a cross-sectional survey conducted in conjunction with the British Association for Cardiovascular Prevention and Rehabilitation

Dietary education is a core component of cardiac rehabilitation (CR). It is unknown how or what dietary education is delivered across the UK. We aimed to characterise practitioners who deliver dietary education in UK CR and determine the format and content of the education sessions. A fifty-four-item survey was approved by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) committee and circulated between July and October 2021 via two emails to the BACPR mailing list and on social media. Practitioners providing dietary education within CR programmes were eligible to respond. Survey questions encompassed: practitioner job title and qualifications, resources, and the format, content and individual tailoring of diet education. Forty-nine different centres responded. Nurses (65·1 %) and dietitians (55·3 %) frequently provided dietary education. Practitioners had no nutrition-related qualifications in 46·9 % of services. Most services used credible resources to support their education, and 24·5 % used BACPR core competencies. CR programmes were mostly community based (40·8 %), lasting 8 weeks (range: 2-25) and included two (range: 1-7) diet sessions. Dietary history was assessed at the start (79·6 %) and followed up (83·7 %) by most centres; barriers to completing assessment were insufficient time, staffing or other priorities. Services mainly focused on the Mediterranean diet while topics such as malnutrition and protein intake were lower priority topics. Service improvement should focus on increasing qualifications of practitioners, standardisation of dietary assessment and improvement in protein and malnutrition screening and assessment.

It needs more than a myocardial infarction to start exercising: the CoLaus|PsyCoLaus prospective study

BACKGROUND

Increased physical activity (PA) is recommended after an acute coronary event to prevent recurrences. Whether patients with acute coronary event actually increase their PA has not been assessed using objective methods such as accelerometer. We aimed to assess the subjectively and objectively measured physical activity (PA) levels of patients before and after an acute coronary event.

METHODS

Data from the three follow-up surveys of a prospective study conducted in Lausanne, Switzerland. Self-reported PA was assessed by questionnaire in the first (2009-2012) and second (2014-2017) follow-ups. Objective PA was assessed by a wrist-worn accelerometer in the second and third (2018-2021) follow-ups. Participants who developed an acute coronary event between each survey period were considered as eligible. PA levels were compared before and after the event, and changes in PA levels were also compared between participants who developed an acute event with three gender and age-matched healthy controls.

RESULTS

For self-reported PA, data from 43 patients (12 women, 64 ± 9 years) were used. No differences were found for all PA levels expressed in minutes/day before and after the event: moderate PA, median and [interquartile range] 167 [104-250] vs. 153 [109-240]; light PA: 151 [77-259] vs. 166 [126-222], and sedentary behaviour: 513 [450-635] vs. 535 [465-642] minutes/day. Comparison with gender- and age-matched healthy controls showed no differences regarding trends in reported PA. For accelerometer-assessed PA, data from 32 patients (16 women, 66 ± 9 years) were used. No differences were found for all PA levels expressed in minutes/day before and after the event: moderate PA: 159 [113-189] vs. 141 [111-189]; light PA: 95.8 [79-113] vs. 95.9 [79-117], and sedentary behaviour: 610 [545-659] vs. 602 [540-624]. Regarding the comparison with gender- and age-matched healthy controls, controls had an increase in accelerometer-assessed sedentary behaviour as % of day: multivariable adjusted average standard error 2.7 ± 0.6, while no increase was found for cases: 0.1 ± 1.1; no differences were found for the other PA levels.

CONCLUSION

Patients do not seem to change their PA levels after a first coronary event. Our results should be confirmed in larger samples.

Economic Burden Associated with the Treatment with a Cardiovascular Polypill in Secondary Prevention in Spain: Cost-Effectiveness Results of the NEPTUNO Study

Purpose

The aim of this study was to estimate health-care resources utilization, costs and cost-effectiveness associated with the treatment with CNIC-Polypill as secondary prevention of atherosclerotic cardiovascular disease (ASCVD) compared to other treatments, in clinical practice in Spain.

Patients and Methods

An observational, retrospective study was performed using medical records (economic results [healthcare perspective], NEPTUNO-study; BIG-PAC-database) of patients who initiated secondary prevention between 2015 and 2018. Patients were followed up to 2 years (maximum). Four cohorts were balanced with a propensity-score-matching (PSM): 1) CNIC-Polypill (aspirin+atorvastatin+ramipril), 2) Monocomponents (same separate drugs), 3) Equipotent (equipotent drugs) and 4) Other therapies ([OT], other cardiovascular drugs). Incidence of cardiovascular events, health-care resources utilization and healthcare and non-healthcare costs (2020 Euros) were compared. Incremental cost-effectiveness ratios per cardiovascular event avoided were estimated.

Results

After PSM, 1614 patients were recruited in each study cohort. The accumulated incidence of cardiovascular events during the 24-month follow-up was lower in the CNIC-Polypill cohort vs the other cohorts (19.8% vs Monocomponents: 23.3%, Equipotent: 25.5% and OT: 26.8%; p<0.01). During the follow-up period, the CNIC-Polypill cohort also reduced the health-care resources utilization per patient compared to the other cohorts, particularly primary care visits (16.6 vs Monocomponents: 18.7, Equipotent: 18.9 and OT: 21.0; p<0.001) and hospitalization days (2.3 vs Monocomponents: 3.4, Equipotent: 3.7 and OT: 4.0; p<0.001). The treatment cost in the CNIC-Polypill cohort was lower than that in the other cohorts (€4668 vs Monocomponents: €5587; Equipotent: €5682 and OT: €6016; p<0.001) (Difference: -€919, -€1014 and -€1348, respectively). Due to the reduction of cardiovascular events and costs, the CNIC-Polypill is a dominant alternative compared to the other treatments.

Conclusion

CNIC-Polypill reduces recurrent major cardiovascular events and costs, being a cost-saving strategy as secondary prevention of ASCVD.

Nurses' perspectives on the barriers to and facilitators of the implementation of secondary prevention for people with coronary heart disease: a qualitative descriptive study

OBJECTIVES

To identify the barriers to and facilitators of secondary prevention among people with coronary heart disease from the perspectives of nurses.

DESIGN

A qualitative descriptive design using face-to-face semistructured interviews.

SETTING

This study was conducted in China from October to November 2021.

PARTICIPANTS

Registered nurses who had experience conducting secondary prevention for coronary heart disease were purposively recruited. Twelve nurses from 10 hospitals participated in this study. The data were analysed using content analysis based on the Theoretical Domains Framework.

RESULTS

Based on the Theoretical Domains Framework, barriers to and facilitators of secondary prevention were identified within four key themes: nurse attributes (eg, knowledge and skills, motivation), patient characteristics (eg, age, education and economic conditions), the environmental context and resources (eg, organisational support, including financial support, clarity of responsibilities) and social influence (eg, economic development level, patient feedback).

CONCLUSIONS

This research highlights the importance of nurses' motivation for delivering preventive care. Organisations should provide adequate support and establish a quality management system to maintain the quality of secondary prevention.

An intensive, structured, mobile devices-based healthcare intervention to optimize the lipid-lowering therapy improves lipid control after an acute coronary syndrome

Aims

Despite the evidence, lipid-lowering treatment (LLT) in secondary prevention remains insufficient, and a low percentage of patients achieve the recommended LDL cholesterol (LDLc) levels by the guidelines. We aimed to evaluate the efficacy of an intensive, mobile devices-based healthcare lipid-lowering intervention after hospital discharge in patients hospitalized for acute coronary syndrome (ACS).

Methods and results

Ambiespective register in which a mobile devices-based healthcare intervention including periodic follow-up, serial lipid level controls, and optimization of lipid-lowering therapy, if appropriate, was assessed in terms of serum lipid-level control at 12 weeks after discharge. A total of 497 patients, of which 462 (93%) correctly adhered to the optimization protocol, were included in the analysis. At the end of the optimization period, 327 (70.7%) patients had LDLc levels ≤ 70 mg/dL. 40% of patients in the LDLc ≤ 70 mg/dL group were upgraded to very-high intensity lipid-lowering ability therapy vs. 60.7% in the LDLc > 70 mg/dL group, p < 0.001. Overall, 38.5% of patients had at least a change in their LLT. Side effects were relatively infrequent (10.7%). At 1-year follow-up, LDLc levels were measured by the primary care physician in 342 (68.8%) of the whole cohort of 497 patients. In this group, 71.1% of patients had LDLc levels ≤ 70 mg/dL.

Conclusion

An intensive, structured, mobile devices-based healthcare intervention after an ACS is associated with more than 70% of patients reaching the LDLc levels recommended by the clinical guidelines. In patients with LDLc measured at 1-year follow-up, 71.1% had LDLc levels ≤ 70 mg/dL.

Does Connected Health Technology Improve Health-Related Outcomes in Rural Cardiac Populations? Systematic Review Narrative Synthesis

Individuals living in rural areas are more likely to experience cardiovascular diseases (CVD) and have increased barriers to regular physical activity in comparison to those in urban areas. This systematic review aimed to understand the types and effects of home-based connected health technologies, used by individuals living in rural areas with CVD. The inclusion criteria included technology deployed at the participant’s home and could be an mHealth (smart device, fitness tracker or app) or telehealth intervention. Nine electronic databases were searched across the date range January 1990–June 2021. A total of 207 full texts were screened, of which five studies were included, consisting of 603 participants. Of the five studies, four used a telehealth intervention and one used a form of wearable technology. All interventions which used a form of telehealth found a reduction in overall healthcare utilisation, and one study found improvements in CVD risk factors. Acceptability of the technologies was mixed, in some studies barriers and challenges were cited. Based on the findings, there is great potential for implementing connected health technologies, but due to the low number of studies which met the inclusion criteria, further research is required within rural areas for those living with cardiovascular disease.

The varied role, scope of practice, and education of cardiovascular nurses in ESC-affiliated countries: an ACNAP survey

AIMS

Cardiovascular disease burden is increasing globally, pressuring nursing staff to deliver high-quality care across a diverse range of treatment areas. As such, an evaluation of the educational preparation of nurses is needed. To determine the current role, scope of practice, education level, and needs of cardiovascular nurses working across the European Society of Cardiology (ESC)-affiliated countries.

METHODS AND RESULTS

A short survey was distributed in paper (EuroHeartCare 2018) or electronic format to nurses delivering cardiovascular care. A total of 876 cardiovascular nurses from 26 ESC-affiliated countries completed the survey. Most respondents (79%), were educated to at least bachelor level, with 46% having a masters or doctorate, and were highly motivated to continue their educational development. Despite this, a large number (44.3%) of respondents believed they were not fully prepared for their job. The main areas where further education was requested included acute care in cardiovascular disease (CVD) and CVD risk factor management. Face-to-face courses/training were the most requested delivery mode, followed by E-learning-which appears to be underutilized in this population. Awareness of the existing curricula for cardiovascular nurse education was minimal, and therefore these resources require further promotion and implementation.

CONCLUSIONS

This international sample of cardiovascular nurses was generally educated to degree level and motivated to improve their cardiovascular knowledge. Many believed they were underprepared for their role, highlighting the need for increased investment in education. This should be focused on specific needs and delivered using a face-to-face, E-learning, or blended-learning format. Furthermore, increased signposting of existing resources is required.

Treatment target achievement after myocardial infarction and ischaemic stroke: cardiovascular risk factors, medication use, and lifestyle: the Tromsø Study 2015-16

AIMS

To investigate European guideline treatment target achievement in cardiovascular risk factors, medication use, and lifestyle, after myocardial infarction (MI) or ischaemic stroke, in women and men living in Norway.

METHODS AND RESULTS

In the population-based Tromsø Study 2015-16 (attendance 65%), 904 participants had previous validated MI and/or stroke. Cross-sectionally, we investigated target achievement for blood pressure (<140/90 mmHg, <130/80 mmHg if diabetes), LDL cholesterol (<1.8 mmol/L), HbA1c (<7.0% if diabetes), overweight (body mass index (BMI) <25 kg/m2, waist circumference women <80 cm, men <94 cm), smoking (non-smoking), physical activity (self-reported >sedentary, accelerometer-measured moderate-to-vigorous ≥150 min/week), diet (intake of fruits ≥200 g/day, vegetables ≥200 g/day, fish ≥200 g/week, saturated fat <10E%, fibre ≥30 g/day, alcohol women ≤10 g/day, men ≤20 g/day), and medication use (antihypertensives, lipid-lowering drugs, antithrombotics, and antidiabetics), using regression models. Proportion of target achievement was for blood pressure 55.2%, LDL cholesterol 9.0%, HbA1c 42.5%, BMI 21.1%, waist circumference 15.7%, non-smoking 86.7%, self-reported physical activity 79%, objectively measured physical activity 11.8%, intake of fruit 64.4%, vegetables 40.7%, fish 96.7%, saturated fat 24.3%, fibre 29.9%, and alcohol 78.5%, use of antidiabetics 83.6%, lipid-lowering drugs 81.0%, antihypertensives 75.9%, and antithrombotics 74.6%. Only 0.7% achieved all cardiovascular risk factor targets combined. Largely, there was little difference between the sexes, and in characteristics, medication use, and lifestyle among target achievers compared to non-achievers.

CONCLUSION 

Secondary prevention of cardiovascular disease was suboptimal. A negligible proportion achieved the treatment target for all risk factors. Improvement in follow-up care and treatment after MI and stroke is needed.

The ICF Classification System to Assess Risk Factors for CVD in Secondary Prevention after Ischemic Stroke and Intracerebral Hemorrhage

Background and objectives: Patients with a history of prior stroke have a high risk for subsequent cardiovascular events (CVD). Therefore, the implementation of an effective strategy to reduce risk factors and thereby improve secondary prevention outcomes is crucial in this patient population. The aim of this study was to determine differences in the incidence of risk factors for recurrent CVD events based on clinical type of prior stroke and to characterize them using the ICF (International Classification of Functioning, Disability and Health) classification system. Materials and Methods: The incidence of risk factors for recurrent CVD events were retrospectively analyzed in 109 patients with a history of ischemic stroke (IS) and 80 patients with a history of intracerebral hemorrhage (ICH) within 14 days poststroke. Results: Atrial fibrillation/flutter (p = 0.031), >70% carotid artery stenosis (p = 0.004), blood pressure >140/90 mmHg (p = 0.025), blood HbA1c levels >7% (p = 0.002), smoking (p = 0.026) and NSAID (nonsteroidal anti-inflammatory drug) use (p < 0.001) were significantly more common in patients with a history of ischemic stroke. However, liver function test abnormalities were observed more commonly in patients with a history of hemorrhagic stroke (p = 0.025). Conclusions: The incidence and type of risk factors for recurrent CVD events vary according to the clinical type of prior stroke. The ICF classification system is a useful tool for evaluating these risk factors. This may help reduce the risk of subsequent CVD events.

Optimising implementation of European guidelines on cardiovascular disease prevention in clinical practice: what is needed?

Cardiovascular disease is a model example of a preventable condition for which practice guidelines are particularly important. In 2016, the joint task force created by the European Society of Cardiology (ESC) together with 10 other societies released the new version of the European guidelines on cardiovascular disease prevention. To facilitate the implementation of the ESC guidelines, a dedicated prevention implementation committee has been established within the European Association of Preventive Cardiology. The paper will first explore potential barriers to the guidelines’ implementation. It then develops a discussion that seeks to inform the future development of the committee’s work, including a new definition of the guidelines’ stakeholders (health policy-makers, healthcare professionals and health educators, patient organisations, entrepreneurs and the general public), future activities within four specific areas: strengthening awareness of the guidelines among stakeholders; supporting organisational changes to facilitate the guidelines’ implementation; motivating stakeholders to utilise the guidelines; and present ideas on new implementation strategies. Providing multifaceted cooperation between healthcare professionals, healthcare management executives and health policy-makers, the novel approach proposed in this paper should contribute to a wider use of the 2016 ESC guidelines and produce desired effects of less cardiovascular disease morbidity and mortality. Furthermore, the solutions presented within the paper may constitute a benchmark for the implementation of practice guidelines in other medical disciplines.