London, UK - Results from the largest-ever Europe-wide preventive cardiology project, EUROACTION, have been published in the June 14, 2008 issue of the Lancet [1]. The data, which show that family-based nurse-led cardiovascular-rehabilitation programs successfully improve standards of preventive care, were first presented at the World Congress of Cardiology in Barcelona in 2006.

Lead investigator Dr David Wood (Imperial College London, UK) told heartwire: "The really big issue is the fact that the majority of patients in Europe with coronary disease are not offered any form of prevention and rehabilitation program, and there is huge variability in the provision of such programs [where they exist] across the continent. This raises the really important question that if cardiologists are performing life-saving interventions, why is this not being married to evidence-based prevention?" He notes that the European Society of Cardiology (ESC), together with the European Heart Network and WHO Europe, is trying to change this with its Heart Health Charter [2], a political initiative to raise awareness of CVD prevention at a European Union (EU) level.

If cardiologists are performing life-saving interventions, why is this not being married to evidence-based prevention?

In a Comment accompanying the publication of the results [3], Dr Dariush Mozaffarian (Harvard School of Medicine, Boston, MA) says: "EUROACTION shows that a multidisciplinary intervention that emphasizes established risk factors and treatments improves lifestyle and metabolic risk factors for CVD. Strengths include the team approach, family-based intervention, and assessment of both primary- and secondary-prevention populations." He adds that the emphasis on lifestyle "proved particularly crucial."

EUROACTION spanned eight countries—Denmark, France, Italy, the Netherlands, Poland, Spain, Sweden, and the UK—and 24 hospital and general practice (GP) centers in a cluster randomized trial. It addressed the cardiovascular health of more than 8500 patients—half of whom already had coronary heart disease (recruited in hospitals) and half of whom were deemed high risk (from GP practices)—and compared outcomes with "usual-care" patients. Advice was issued according to European preventive-cardiology guidelines published in 2003, and analysis was by intention to treat. The primary end points—measured at one year—were family-based lifestyle change; management of blood pressure, lipids, and blood glucose to target concentrations; and prescriptions of cardioprotective drugs.

Wood said the family inclusion was key to the initiative's success. "One of the central features of our program was the family-based intervention. Without exception, all other prevention programs have focused only on the patient in isolation. We argue that it is more appropriate to address lifestyle and other factors in the context of the family, and our results reinforce this. Those patients who made the greatest changes were associated with partners who made similarly large changes." Wood said his team is planning a separate publication specifically about the family-based-intervention side of their study.

The basis of EUROACTION was lifestyle change—ie, avoidance of tobacco, achievement of a healthy diet, and physical activity, which were all given equal weighting. The program was intentionally set up in busy general hospitals and general practices, outside specialist cardiac-rehabilitation centers, to provide a service for all coronary and high-risk patients in routine clinical practice. It was coordinated by nurses, because of evidence that such programs improve outcomes.

Significant improvements were observed after one year, not only in the EUROACTION patients but also in their partners, compared with patients treated by usual care and their partners, across a number of key lifestyle and risk factors. Significantly more hospital and high-risk patients met physical-activity targets, reached blood-pressure goals, and improved use of cardioprotective therapies compared with those receiving usual-care.

For diet, significant improvements were seen in all three areas—increasing consumption of fruits and vegetables, eating more oily fish, and reducing saturated fat intake—in the coronary patients. For the high-risk patients, only fruit and vegetable intake was significantly improved compared with usual-care patients.

Smoking cessation was not significantly improved in either group compared with usual-care patients, but the hospital patients "came quite close, with a p value of 0.06," Wood told heartwire.

For cardioprotective drugs, results varied. In the hospital patients, prescriptions for statins were significantly higher in the intervention group than in the usual-care group (p=0.04), and in general practices, patients in the intervention group were also more likely to get statins (p=0.03) and ACE inhibitors (p=0.02) than those in the usual-care groups.

The partners varied in their abilities to achieve targets but came out significantly better than the partners of the usual-care patients for a number of outcomes.

Even though significance was not achieved in some key areas, the trends were all in the right direction, Wood noted, adding that the study was underpowered. And the basic premise was that the six pairs of patients would all see changes in the same direction, he added.

Mozaffarian noted some limitations, such as the fact that some important dietary factors—eg, whole grain and trans fats—were not included and the intervention effects on partners were difficult to interpret because of a lack of baseline data.

The researchers agree. "Although these results are encouraging, there is scope for improvement." For instance, the smoking-cessation intervention, based on advice, reduced relapse in patients with CHD but had no effect on high-risk patients. And even though the protocol recommended use of smoking-cessation therapies, these were not used because of cost, they note.

Wood said the EUROACTION results show that "if patients are offered rehabilitation programs, a large majority will take it up. So it's not a problem with the patients, but with the profession. Shouldn't these patients be given every opportunity to benefit from the type of program we have succeeded in running and evaluating?"

He notes that there is currently a "huge variability in the provision of prevention and rehabilitation services across Europe. And even comparing large countries with strong economies can show a 100-fold difference—for example, Spain, where cardiac rehabilitation is almost nonexistent, compared with Germany."

It's not a problem with the patients, but with the profession.

And where specialist cardiac-rehab centers do exist, "they are completely unable to cope with the volume of patients requiring this service, and therefore they tend to concentrate on the very highest-risk and most complicated cases," he notes. "When what we really need is a more generalizable model of care that is easily accessible wherever patients are diagnosed and managed, appropriately adapted to the medical, cultural, and economic setting of each country, and that is one of the principles of the EUROACTION initiative."

To this end, the aim of the ESC is to try to translate the Heart Health Charter into soft law at the EU parliament level and to commission and council changes, Wood notes. "As part of that charter, we advocate the provision of preventive-cardiology services for both patients with established disease and those at high risk of developing it."