Ian Graham

1. Guidelines for the prevention of cardiovascular disease in Ireland- the way forward3 November 2010European 4th Joint Task Force Guidelines on CVD prevention in Clinical Practice:Targets, implementation and 5th Joint Task Force Guidelines 2012 Ian Graham Chairman JTF4, European Prevention Implementation Committee and IHF Council on CVD Prevention

2. Objectives of today’s meeting • Summarise current and future European CVD prevention Guidelines and implementation strategy (IG) • Summarise the role of the National Co-ordinator in the implementation process (SJ) • Guidelines in the context of National Policy (H McG) • The role of primary care (JC) • The role of the nurse (NF) • WORKSHOPS- 6.1 Perceived roles in implementation 6.2 Moving towards an integrated national strategy 6.3 Defining synergies and complementarity 6.4 Input into one page Irish Guideline 6.5 Suggestions for the 5th Joint Task Force

3. Outline • Objectives of meeting • General background • 4th Joint Task Force European Guidelines on CVD prevention • 5th Joint Guidelines • Implementation- some principles • European Prevention Implementation Committee Action Plan • Relations with the National Coordinators for CVD prevention

4. General Background

5. European Prevention implementation is complex- many players are involved • The EU- vital but no legislative framework • Individual Departments of Health- like their independence • ESC • EACPR • National Cardiac and other specialist and GP societies • Nurses and allied health professional, European and National • Educators- 1st 2nd & 3rd level • Industry- Pharma, Food, Exercise, Neutral It’s like herding cats!

6. No data < 30 30-50 50-70 70-100 100-150 150-200 > 200 Age standardised CHD mortality rates (under 65) in men & women

7. The European Heart Health Charter and the Guidelines on cardiovascular disease prevention • The European Heart Health Charter advocates the development and implementation of comprehensive health strategies, measures and policies at European, national, regional, and local level that promote cardiovascular health and prevent CVD • The Joint CVD prevention guidelines aim to assist physicians and other health professionals to fulfil their role in this endeavour, particularly with regard to achieving effective preventive measures in day-to-day clinical practice • They reflect the consensus arising from a multi-disciplinary partnership between the major European professional bodies represented

8. Implementation of CVD guidelines • Knowledge of JTF4 guidelines and what is likely in JTF5 • The gap between recommendations and clinical practice • Barriers to implementation • Strategies to improve implementation

9. Guidelines on Prevention Research SCORE,HeartScore Evidence based reviews Guidelines 94,98,03,07,12 EuroAspire E-SURF Audit Implementation PIC Nat. Co-ord EuroAction

10. European Guidelines on CVD PreventionFourth Joint European Societies’ Task Force on cardiovascular disease prevention in clinical practice Ian M Graham Chairman JTF4

13. 1. Introduction 2. Scope of the problem; past and future 3. Prevention strategies and policy issues 4. How to evaluate scientific evidence 5. Priorities, total risk estimation and objectives 6. Behaviour change and behavioural risk factors 7. Smoking 8. Nutrition, overweight and obesity 9. Physical activity 10. Blood pressure 11. Plasma lipids 12. Diabetes and metabolic syndrome 13. Psychosocial factors 14. Inflammation markers and haemostatic factors 15. Genetic factors 16. New imaging methods to detect asymptomatic individuals at high risk 17. Gender issues: CVD in women 18. Renal impairment as a risk factor in CVD 19. Cardioprotective drug therapy 20. Implementation strategies JTF4 on CVD PREVENTIONCONTENTS

14. What are the PRIORITIES for CVD prevention in clinical practice? • Patients with established atherosclerotic CVD • Asymptomatic individuals who are at increasedrisk of CVD because of 2.1 Multiple risk factors resulting in raised total CVD risk (≥5% SCORE 10-year risk of CVD death) 2.2 Diabetes type 2 and type 1 with microalbuminuria 2.3 Markedly increased single risk factors especially if associated with end-organ damage • Close relatives of subjects with premature atherosclerotic CVD or of those at particularly high risk

15. 0 3 5 140 5 3 0People who stay healthy tend to have certain characteristics: 0 No tobacco 3 Walk 3 km daily, or 30 mins any moderate activity 5 Portions of fruit and vegetables a day 140 Blood pressure less than 140 mm Hg systolic 130 5 Total blood cholesterol <5mmol/l 4.5, 4 3 LDL cholesterol <3 mmol/l 2.5, 2 0 Avoidance of overweight and diabetes

16. JTF5 on CVD Prevention • Much shorter and more succinct • More explicit evidence base- ESC grading vs. GRADE • New approaches to risk estimation- total events, risk age • Targets similar- 1.8 mmol/l for LDL cholesterol? • There is time to influence them! • Will be launched at Europrevent Dublin, 3-5 May 2012

17. How big is the gap between recommendations and practice? Has there been an improvement over time?

18. Use of BP meds Total Chol All countries BP control BMI Obesity Diabetes Smoking

19. Utility of Guidelines • Guidelines alone are good for the vanity of the authors and bad for rain forests; they are a waste of time without a defined implementation strategy • Hence thePrevention Implementation Committee and other implementation efforts

20. “Said is not heard,heard is not understood,understood is not agreed upon,agreed is not applied,applied is not at all maintained.”Konrad Lorenz, 1903-1969 [Thank you, Ulrich Keil]

21. Barriers to implementationPearson 1996; European Guidelines 4th Joint Task Force 2007 • Patient (Person) • Physician • Health Care Settings • Community/Society

22. Barriers to implementation REACT study, Hobbs FDR, Erhardt L, Family Practice 2002 ESC CRT Market research survey, Graham I, EJCPR 2006 • Lack of patient compliance • Lack of time • Lack of budget • Lack of clarity (complicated, confusing, too much information) • Guidelines too general (do not fit my patient) • Unhelpful government health policies (assistance, remuneration, patient education)

23. SUMMARY:Key factors to increase usage of guidelines • Simple, clear, credible national guidelines • Sufficient time • Facilitatory government policy: -Defined prevention strategy -Reimbursement for health professionals -public awareness and education from school on • Multidisciplinary implementation strategy- with teeth

24. CVD Prevention Implementation An adapted structure for the future

25. The EUROPEAN PREVENTION IMPLEMENTATION COMMITTEE Terms of Reference • The ESC has delegated the implementation of the European Guidelines on CVD Prevention to the European Association Cardiovascular Prevention and Rehabilitation. Its Cardiovascular PreventionImplementation Committee fulfils that function. • Its role is to help to close the gap between science and practice for both in hospital and in primary care

26. PREVENTION IMPLEMENTATION COMMITTEEMembership Co-Chairs: Ian Graham & Pantaleo Giannuzzi Members • Prof Pantaleo Gianuzzi, EACPR President • Prof David Wood, EACPR Past-President • Prof Lars Ryden, recent Chair of the ESC European Affairs Committee • Prof Richard Hobbs, Chair Council on Cardiovascular Primary Care • Susanne Logstrup, EHN • Muriel Mioulet, ESC External Affairs Director • Sophie Squarta, ESC Head of Department for CVD Prevention • Sections representatives Cardiac rehabilitation - Hannah McGee Epidemiology & Public Health - Johan De Sutter Exercise Physiology - Martin Halle Prevention & Health Policy - Diego Vanuzzo Sports Cardiology - Dorian Dugmore Sducation Committee - Lale Tokgozoglu

27. Prevention Implementation Committee Action Plan

28. PREVENTION IMPLEMENTATION COMMITTEEACTIVITIES • Core activities • Define strategies to assist in Guideline implementation • Activities with the National Co-ordinators for CVD prevention

29. PIC – Suggested Core activities- Benchmarking – H. McGee Health Economic models – D. Wood & G. De Backer Industry projects – M. Halle & D. Dugmore Audit – E-SURF- Ian Graham Implementation research Political lobbying – L. Rydén “How to” manual – P. Giannuzzi Lay communications- Joep Perk (Apoteket), Lay Score/HeartScore

30. Strategies to improve implementationSophie Squarta, Lars Ryden,Ian Graham

31. Implementation strategies: European level • Publication of Guidelines in relevant journals • The Prevention Toolkit, comprising the Guidelines (paper and electronic), a slidekit and HeartScore stand alone • A defined dissemination strategy • Implementation Committees/Groups: Prevention Implementation Committee; Joint Prevention Committee; National Coordinators 5. Presentations at international conferences of the participating societies 6. Directly influencing EU health policy- for example through the Luxembourg Declaration and the European Health Charter- the product of a partnership between the EU, WHO, ESC and EHN

32. Implementation strategies: TOOLS • Guidelines: full text/ summary/pocket/one page/posters • HeartSore: The electronic, interactive risk estimation and guideline tool. On line and stand-alone, downloadable and on CD • The new Guideline Learning Tool- on-line interactive case-based learning • The e-toolkit: Guidelines, slides, HeartScore • E-SURF, the new and simplified risk factor audit

33. Implementation strategies:National level 1.Adapt the European Guidelines to suit the local culture 2.Formation of a multidisciplinaryimplementation group: professional bodies, medical and other health professionals, basic scientists, educators, business people, politicians. Needs to be more than merely advisory: should inform and shape health policy 3. Multi-faceted communications using all available media to doctors, medical and para-medical students, and ultimately all adults and children, including schools

34. Forming a multidisciplinary implementation groupProcess- • The ESC asks National Cardiac Societies to nominate a National Co-ordinator to develop and lead the multidisciplinary implementation group which will develop- • National adaptation of guidelines if required • Partnerships between politicians, health professionals, educators and business • A defined communication strategy • An evaluation strategy • BUT it must have teeth. This requires high level political representation if it is not to be a talking-shop. Indeed… • This process has been variably successful. It is now proposed that there should be two national co-ordinators- one a cardiologist and one from the Department of Health/ Health Service Executive

35. Forming a multidisciplinary implementation group-IRELAND • IHF Council on CVD prevention established to facilitate the process • (Chair IG) • National Co-ordinators Siobhan Jennings and Mahon Varma • Project manager Bridget Claffrey • Workplan established including meetings with all stakeholders and this meeting • Aim to showcase Ireland as an exemplar of the development of an implementation strategy • Presentation to the ESC European Summit on CVD prevention, Nice 30 Nov 2010

36. SUMMARY • Objectives of meeting defined • General background • 4th Joint Task Force European Guidelines on CVD prevention • 5th Joint Guidelines • Implementation- some principles • European Prevention Implementation Committee Action Plan • Relations with the National Coordinators for CVD prevention • The strategy for Ireland

37. Thank you

38. Relations with the National Coordinators for CVD Prevention

39. PIC and the National Co-ordinators • Promotion of joint co-ordinators in each country representing Cardiology and the Department of Health • Contribute to benchmarking by updating the Mapping document • Individualised strategic advice to countries • Workshops especially for developing countries • Contribution and use of the “How to” manual • Advice to and from the Joint Prevention Alliance • Possibly to act as national co-ordinators for the pan- European audit

40. PIC, JPA and National Co-ordinators- Likely most effective actions? • Driving National alliances • Simpler Guideline materials • How-to manual • Benchmarking and audit • Lobbying EU policy

41. Discussion of JPA and PIC

42. PIC and Joint Prevention Alliance • It is suggested to reflect the importance of the JPC by re-naming it the JointPrevention Alliance • The partnership- JTF4/5 members- remains the same • The JPA will decide its own workplan: • Encourage Joint Guidelines dissemination by the partner bodies • Promote and co-ordinate Alliance events and workshops at specialist conferences • Provide information on networks within countries to aid in the co-ordination of implementation • Advise the PIC in all of its activities • Advise on & promote the “how-to” manual • Assist in development of guideline learning tool • Specific topics for lobbying

43. PIC – Suggested Core activities- to be prioritised • Benchmarking – H. McGee • “Call for Action” mapping document • EuroAspire III • Psyma survey report • Powerhouse Health Consumer report • EuroHeart WP5 • Health Economic models – D. Wood & G. De Backer • Demonstration projects – M. Halle & D. Dugmore • Audit – Epidemiology & Public Health section • Implementation research • Political lobbying – L. Rydén • “How to” manual – I. Graham & P. Giannuzzi • Lay communications-Joep Perk (Apoteket), Lay Score/HeartScore

44. JTF4 Guidelines on CVD Prevention in Clinical Practice 1. INTRODUCTION

45. JTF IV Guidelineson prevention of CVDFORMAT • Full text- far too long!- treat as a resource document. Summary boxes from the pocket guidelines to make navigation easier • Summary- still far too long! • Pocket guidelines- better, more accessible • Single page handout- summarizes the key points • The challenge- to keep the key points in the health professional’s mind- and on his/her desk!

46. JTF4 on CVD Prevention in Clinical Practice 3. PREVENTION STRATEGIES AND POLICY ISSUES

47. WHO report on the Prevention of CHD (and hence CVD) defined three components to preventive strategy: 1. Population 2. High risk 3. Secondary prevention • The prevention paradox- high risk individuals gain most from preventive measures- but most CVD deaths come from subjects with only mildly increased risk because they are so numerous • The three strategies should be complementary, not competitive • Policy is defined further in the Osaka declaration

48. JTF4 on CVD Prevention in Clinical Practice 5. PRIORITIES, TOTAL RISK ESTIMATION AND OBJECTIVES

49. JTF4 on CVD Prevention in Clinical Practice 20. IMPLEMENTATION STRATEGIES

50. Report from the EACPR EuroPRevent Congress