Insights from the world of cardiology
Cardiovascular diseases (CVDs) are a single family of diseases with common antecedents requiring a holistic approach to prevention. This is the central theme of the new cardiovascular outcomes strategy for NHS England.1 Atherosclerosis is ubiquitous in the population, manifesting itself in different ways – acute coronary syndromes, transient cerebral ischaemia or claudication – but linked by a common pathology and underlying causes in terms of lifestyle and related risk factors. Many with one expression of this disease commonly suffer from another, and yet each is managed in silos of care through cardiology, stroke and vascular services, and while appropriate for acute disease, not so for prevention. All these patients require a professional lifestyle intervention, risk factor and therapeutic management to reduce risk of disease progression, the need for further hospitalisation, revascularisation, and, ultimately, prevention of recurrent events leading to greater life expectancy.
If true of manifest disease, it is even truer for the antecedents of atherosclerosis, namely hypertension, hypercholesterolaemia, diabetes and chronic kidney disease. These very terms also lead to silo approaches for risk factor assessment and management in primary prevention, now replaced by the new paradigm of total cardiovascular risk, central to the national Health Checks programme. Those at highest multi-factorial risk, including all those with type 2 diabetes mellitus, also require an integrated prevention programme, but are commonly signposted to silo services for smoking cessation, weight management, exercise referral schemes, as well as specialist clinics in hypertension, lipids and diabetes. Dividing the patient into all these specialist areas leads to uncoordinated care, multiple visits to different health professionals and services, which can offer confusing and contradictory advice.
The patient should be at the centre of preventive care, based on holistic assessment and management. As stated in the national strategy a “more coordinated and integrated approach is needed to assessment, treatment and care to improve outcomes”. The report recommends developing and evaluating service models to manage CVD as “a single family of diseases” applicable to both manifest atherosclerotic disease and those at high multi-factorial risk of developing this disease. In the context of prevention, distinguishing secondary from primary prevention is, to a large extent, artificial, as all patients require lifestyle, risk factor and therapeutic management to reduce their overall risk of developing, or having recurrent, disease.
MyAction is an innovative, nurse-led, multi-disciplinary programme, which manages cardiovascular disease as “a single family of diseases” and integrates secondary and primary prevention in one community-based service.2 It is founded on the principles of EUROACTION – a nurse-led, multi-disciplinary programme evaluated in a cluster randomised-controlled trial in hospital and general practice across eight European countries.3 MyAction accepts all patients with coronary artery disease, with transient cerebral ischaemia or minor stroke and with claudication. At the same time, MyAction takes high-risk patients identified through the Health Checks programme because of a CVD score of ≥20% over 10 years, diabetes or chronic kidney disease. The MyAction team comprises full-time specialist cardiac nurses, full-time dietitians and full-time physiotherapists or physical activity specialists, supported by a psychologist and a community cardiologist and led by a central team at Imperial College London. Patients are recruited together with their partners because there is concordance for lifestyle – smoking, eating habits and physical activity levels – and achieving healthy lifestyle changes is more likely if the intervention is offered to the whole household rather than the patient in isolation. The MyAction programme is located in community leisure centres, rather than hospital or general practice, as the facilities in these centres provide a more conducive health-promoting environment.
The concept of the MyAction programme meets the requirements of the new cardiovascular outcomes strategy to improve outcomes for people with or at risk of CVD. We are managing CVDs as a single family of diseases with common antecedents – through complete integration of secondary and primary prevention – a new paradigm for cardiovascular prevention compared with traditional service models of cardiac rehabilitation, limited to those following myocardial infarction or coronary revascularisation, and silo services for smoking cessation, weight management, exercise prescription, hypertension, lipids and diabetes. If we are to reduce premature mortality from CVD, reduce inequalities and improve quality of life we need to take an innovative holistic approach to cardiovascular prevention.
- Department of Health. Cardiovascular disease outcomes strategy: improving outcomes for people with or at risk of cardiovascular disease. London: DoH, 5th March 2013. Available from: https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy
- Connolly S, Holden A, Turner E et al. MyAction: an innovative approach to prevention of cardiovascular disease in the community. Br J Cardiol 2011;18:171–6. Available from: http://bjcardio.co.uk/2011/08/myactionaninnovativeapproachtothe
- Wood DA, Kotseva K, Connolly S et al.; on behalf of EUROACTION Study Group. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008;371:1999–2012.