Cardiovascular Disease Prevention and Rehabilitation Susan Connolly Consultant Cardiologist Imperial College Healthcar

1. Cardiovascular Disease Prevention and Rehabilitation Susan Connolly Consultant Cardiologist Imperial College Healthcare NHS Trust and NHLI, Imperial College, London, UK 10th June 2009

4. Cardiac Rehabilitation: WHO “co-ordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease”.

5. Who is eligible Post MI/ACS PCI/CABG Stable angina Valve Heart failure Cardiac Transplantation ICD

6. Who actually gets cardiac rehabilitation in the UK?

7. Why Does It Matter?

8. How does it work?

9. Why is Number of People Accessing CR so Low? (1) Inadequate provision Lack of funding and dedicated budget No dedicated tariff (now changing) Limited capacity has led to bias towards MI/CABG; stable angina pts often excluded those Generally unsupported by physician only ~5% programmes have dedicated cardiologist

10. Why is Number of People Accessing CR so Low? (2) Selective Uptake Those less likely to take up CR include women, the elderly and ethnic minorities Furthermore, those who are depressed, socially isolated and those who smoke are also less likely to attend

11. UK Developments: (1) Audit National Audit cardiac Rehabilitation Part of CCAD (e.g. like MINAP) BACR, BHF, Healthcare Commission, RCP, DOH Heart Team Has just published its second annual report

12. UK Developments: (2) National Standards

13. Changing Face of Cardiac Rehabilitation Secondary prevention increasingly integral component Menu-based approach Behavioural change strategies e.g. motivational interviewing, goal setting “Our health, our care, our say” – community-based CR

14. Primary Prevention

22. Conclusions Lifestyle of patients continues to be a major challenge with high prevalences of obesity and central obesity Coronary patients are managed more effectively overall than high risk individuals About half of all coronary and high risk individuals have a blood pressure above target Therapeutic control of blood pressure is similar in coronary and high risk individuals

24. Is it possible to improve the preventive cardiology care of such patients?

25. EUROACTION: A European Society of Cardiology demonstration project in preventive cardiology Aim To raise the standards of preventive cardiology in Europe by demonstrating that the recommended European and national lifestyle, risk factor and therapeutic goals in cardiovascular disease prevention are achievable and sustainable in everyday clinical practice.

26. EUROACTION Countries

27. Nurse-led multidisciplinary approach

28. The family approach

32. This is the LC where the Phase III programme runs & this is where the MyAction programme is running. It is our flagship site which received lottery funding in 1999 and is about to undergo further development. It provides an excellent opportunity to run this new integrated model in the community.This is the LC where the Phase III programme runs & this is where the MyAction programme is running. It is our flagship site which received lottery funding in 1999 and is about to undergo further development. It provides an excellent opportunity to run this new integrated model in the community.

33. Risk Factors: overweight and obesity blood pressure lipids glucose Therapeutic: prophylactic drug therapies psycho-social support Therapeutic: treatment of disease Prophylactic: protective or preventive The intervention programme focuses not only on risk factor management but also on lifestyle management. Therapeutic: treatment of disease Prophylactic: protective or preventive The intervention programme focuses not only on risk factor management but also on lifestyle management.

34. And of course, as in EUROACTION, their partners are also invited to join the programme. And of course, as in EUROACTION, their partners are also invited to join the programme.

35. Once recruited to the programme, the patient & partner undergo a multidisciplinary comprehensive assessment by the team, which includes….. From the IA, a behaviour change strategy & individual goal setting is set for each person. This is supported by a variety of resources…Once recruited to the programme, the patient & partner undergo a multidisciplinary comprehensive assessment by the team, which includes….. From the IA, a behaviour change strategy & individual goal setting is set for each person. This is supported by a variety of resources…

36. The programme is offered on an evening and weekday. Couples attend 8 sessions of the preventive cardiology programme, within a 16 week period. Programme includes: HP workshops (healthy eating, food labelling, benefits of ex., CVD risk management, medication, stress management) Smoking cessation programme led by the Nurse Weight management programme & dietary intervention led by Dietitian Community based supervised ex programme and home based exercise & physical activity plan led by Ex specialist Regular individual appointments with specialist nurse, PA specialist & dietitian to progress lifestyle, risk factor and therapeutic goals. Team meetings & regular reviews with cardiologists & GPs Review of progress in lifestyle & CVD risk management plan. Initiation of further investigation as required. Optimisation of prophylactic therapies Referral to other HP as appropriate (e.g. clinical psychologist, counsellor, etc.) The programme is offered on an evening and weekday. Couples attend 8 sessions of the preventive cardiology programme, within a 16 week period. Programme includes: HP workshops (healthy eating, food labelling, benefits of ex., CVD risk management, medication, stress management) Smoking cessation programme led by the Nurse Weight management programme & dietary intervention led by Dietitian Community based supervised ex programme and home based exercise & physical activity plan led by Ex specialist Regular individual appointments with specialist nurse, PA specialist & dietitian to progress lifestyle, risk factor and therapeutic goals. Team meetings & regular reviews with cardiologists & GPs Review of progress in lifestyle & CVD risk management plan. Initiation of further investigation as required. Optimisation of prophylactic therapies Referral to other HP as appropriate (e.g. clinical psychologist, counsellor, etc.)

37. Change in Mediterranean Diet Score (mean) between IA and EOP

41. Change in % with TC <4 and <5 mmol/L between IA and EOP

47. Vision For CVD Prevention Professional comprehensive multidisciplinary ambulatory preventive cardiology programmes should be available for all coronary and high risk patients ‘Prevention centres’