Date Published: February 21, 2019
Publisher: Public Library of Science
Author(s): David Carballo, Nicolas Rodondi, Reto Auer, Sebastian Carballo, David Nanchen, Lorenz Räber, Roland Klingenberg, Pierre-Frédéric Keller, Dik Heg, Peter Jüni, Olivier Muller, Christian M. Matter, Thomas F. Lüscher, Stephan Windecker, Francois Mach, Baris Gencer, Yoshihiro Fukumoto.
Structured secondary cardiovascular prevention programs (SSCP) following acute coronary syndromes (ACS) may reduce major adverse cardiovascular events (MACE) through better adherence to post-ACS recommendations.
Through a prospective multicenter cohort study, we compared the outcomes of two sequential post-ACS patient cohorts, the initial one receiving standard care (SC) followed by one receiving additional interventions (SSCP) aimed at improving patient education as well as healthcare provider and hospital systems. The primary endpoint was MACE at one year. Secondary endpoints included adherence to recommended therapies, attendance to cardiac rehabilitation (CR) and successful achievement of cardiovascular risk factor (CVRF) targets.
In total, 2498 post-ACS patients from 4 Swiss university hospitals were included: 1210 vs 1288 in the SC and SSCP groups, respectively. The SSCP group demonstrated a significant increase in attendance to CR programs (RR 1.08, 95%CI 1.02–1.14, P = 0.006), despite not achieving the primary MACE endpoint (HR 0.97, 95%CI 0.77–1.22, P = 0.79). After age-stratification, significant reductions in cardiac death, MI and stroke events (HR 0.53, 95%CI 0.30–0.93, P for interaction = 0.016) were observed for SSCP patients ≤ 65 years old. The SSCP group also scored significantly better for the LDL cholesterol target (RR 1.07, 95%CI 1.02–1.13, P = 0.012), systolic blood pressure target (RR 1.06, 95%CI 1.01–1.13, P = 0.029) and physical activity (RR 1.10, 95%CI 1.01–1.20, P = 0.021).
The implementation of an SSCP post ACS was associated with an improvement in the control of CVRF and attendance to CR programs, and was also associated with significant reductions in cardiac death, MI and stroke at one year for patients ≤65years old.
The prognosis of acute coronary syndromes (ACS) has considerably improved in recent years with the implementation of recommended post-ACS therapies. In this regard, a better understanding of therapeutic strategies resulting from evidence-based clinical research has led to improvements in patient long-term medication compliance and clinical outcomes. In 2012, the European Society of Cardiology (ESC) issued guidelines recommending the implementation of national programs at the hospital level to monitor the quality of care of ACS patients, as well as the development of multidimensional programs based on motivational interviewing. In addition, participation in cardiac rehabilitation (CR) programs following hospital discharge is strongly recommended to improve patient lifestyle and long-term prognosis post-ACS.[4, 5] Despite all these measures, recent European observational data for ACS patients still point to poorly controlled targets, resulting in suboptimal reductions in the incidence of major adverse cardiovascular events (MACE) and participation in CR programs.[6, 7]
A total of 2498 patients were included, 1210 in the SC group (2009–2010) and 1288 in the ELIPS add-on group (2011–2012) (Fig 1). Mean age was 62.3±12.3 (the age distribution is illustrated in S1 Fig), 21.1% were women, 54.7% had STEMI, 40.2% NSTEMI and 5.0% unstable angina (Table 1). The reported use of educational ELIPS tools by healthcare providers was as follows: 68.6% for motivational interviewing, 54.5% for the wall chart, 68.7% for the use of educational brochures, 74.2% for the film provided on DVD, 52.7% for the website and 82.8% for the discharge medication card.
The ELIPS program was designed after investigating areas of the healthcare system that offered the greatest potential for improving the quality of care for ACS patients. Although the expected impact on clinical outcomes in the overall cohort was not observed, the implementation of the ELIPS program was associated with a significant improvement in participation in CR programs and control of cardiovascular risk factors. These results should encourage the pursuit of long-term, hospital-based, post-ACS secondary prevention programs.