Reducing CVD risks

A Five-year review of the Croi MyAction programme for CVD risk factor reduction points to its dramatic success and says it should act as a national template.

The innovative Croi MyAction cardiovascular disease community secondary prevention programme has had some key successes in reducing risk factors and improving patient outcomes in the population it serves.

Overall, high-risk individuals taking part in the programme scored major improvements in lifestyle targets and reduction in risk factors, leading to significant improvements in their cardiovascular health.

Croi MyAction, which is endorsed by the European Society of Cardiology, was established in 2009 and has targeted interventions of over 1,100 people in the west of Ireland who are at significant risk of heart attack, stroke and diabetes.

Under the programme, which is run in the west of Ireland, high-risk individuals are targeted with a special 12 to 16 week intervention and one-year follow up.

The nurse co-ordinated multidisciplinary programme, organised by the heart disease charity Croi, has aimed to overcome the difficulties in implementing prevention guidelines and the challenges involved in achieving CVD prevention in routine clinical practice.

The 2009 to 2014 review of the programme, carried out by Croi and NUI Galway-affiliated National Institute for Preventive Cardiology (NIPC), demonstrates that it has achieved outstanding and measurable improvements in cardiovascular health. The review found that Croi MyAction had:

• Achieved a smoking quit rate of 51%, which is associated with a 50% reduction in CVD events

• Achieved greater adherence to the Mediterranean diet (increase of four and a half units) linked to a 9% reduction in total mortality, CVD mortality and cancer

• An increase in physical activity targets from 13% to 52%, associated with a 20%-30% reduction in cardiovascular events

• Improved aerobic fitness of 1.5METs (metabolic equivalent), which is linked to a 15%-25% reduction in all-cause mortality

• An increase in achievement of blood pressure control targets from 55% to 73%, with a mean reduction of 8.6mmHg systolic and 3.7mmHg diastolic, which is linked to a 20% reduced risk for coronary heart disease and a 35% reduced risk for stroke

• An increase in achievement of cholesterol level targets from 39% to 70% with a mean reduction of total cholesterol from 0.73mmol/L and LDL cholesterol of 0.62mmol/L, linked to a 15% reduction in CVD mortality and non-fatal MI.

The My Action model, which is the template for the Croi scheme originated at Imperial College London, had a strong basis in the EURACTION study of 2008, which stressed the need for local community preventive cardiology programmes and the benefit of such nurse co-ordinated programmes.

The key components of Croi MyAction are lifestyle modification (smoking cessation, healthier food choices and physical activity); medical risk factors management through blood sugar, lipids and glucose control and, where appropriate, the prescription of cardioprotective medication.

The multidisciplinary team implementing the programme consists of a nurse specialist, dietitian, physiotherapist/exercise specialist, supported by a physician. Individuals at high risk of CHD, type 2 diabetes and stroke/TIA are referred to the programme through a series of pathways including GPs and hospital departments.

An important part of the programme is the involvement of the subject’s partner in the intervention process. Initially, patients and partners are seen as couples, but individually assessed by each multidisciplinary team member for factors including smoking, diet, activity levels, BMI, blood pressure and cardiac medication use.

The 16-week programme includes individualised follow-up, a weekly educational workshop and a supervised exercise session. There is also a weekly multidisciplinary team meeting to review lifestyle, risk factor and therapeutic goals including medication prescription as appropriate.

Commenting on the risk factor and treatment improvements affected by the programme, the review noted that:

• The smoking quit rate was in excess of the target set (35% at four weeks) by specialist smoking cessation services 

• There was a significant reduction in weight among participants by an average of 3.7kg and waist circumference by 4.9cm in men and 4.4cm in women at end of programme.

• There was an increase in physical activity uptake levels, with six in 10 patients achieving a target of 30 minutes of moderate aerobic activity five days per week, with a similar increase seen in partners.

The review also noted improvements in the Mediterranean diet score, an increase in the number of patients achieving cholesterol targets from 45% to 73% by the end of the programme and an increase in glycaemic control in those with diabetes, with an almost doubling of those achieving a HbA1c target of 48mmol/L at one year.

The review proposes that Croi MyAction should be considered by health service planners as a template for a national demonstration model that could integrate the care of all those at high CVD risk.

The report also recommends that greater emphasis should be placed on promoting healthy lifestyle in CVD management, particularly through multidisciplinary teams. 

It also calls for training for healthcare providers in addressing complex lifestyle behaviours, the delivery of prevention programmes in the community, the promotion of early diagnosis and treatment access for CVD risk, and for a formal economic analysis of the benefits of Croi MyAction to be undertaken.